Accuracy of the PHQ-2 Alone and in Combination With the PHQ-9 for Screening to Detect Major Depression: Systematic Review and Meta-analysis

Depression Screening Data (DEPRESSD) PHQ Collaboration

doi:10.1001/jama.2020.6504

Accuracy of the PHQ-2 Alone and in Combination With the PHQ-9 for Screening to Detect Major Depression: Systematic Review and Meta-analysis

Depression Screening Data (DEPRESSD) PHQ Collaboration

Research output: Contribution to journal › Article › peer-review

Abstract

Importance: The Patient Health Questionnaire depression module (PHQ-9) is a 9-item self-administered instrument used for detecting depression and assessing severity of depression. The Patient Health Questionnaire-2 (PHQ-2) consists of the first 2 items of the PHQ-9 (which assess the frequency of depressed mood and anhedonia) and can be used as a first step to identify patients for evaluation with the full PHQ-9.

Objective: To estimate PHQ-2 accuracy alone and combined with the PHQ-9 for detecting major depression.

Data Sources: MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, and Web of Science (January 2000-May 2018).

Study Selection: Eligible data sets compared PHQ-2 scores with major depression diagnoses from a validated diagnostic interview.

Data Extraction and Synthesis: Individual participant data were synthesized with bivariate random-effects meta-analysis to estimate pooled sensitivity and specificity of the PHQ-2 alone among studies using semistructured, fully structured, or Mini International Neuropsychiatric Interview (MINI) diagnostic interviews separately and in combination with the PHQ-9 vs the PHQ-9 alone for studies that used semistructured interviews. The PHQ-2 score ranges from 0 to 6, and the PHQ-9 score ranges from 0 to 27.

Results: Individual participant data were obtained from 100 of 136 eligible studies (44 318 participants; 4572 with major depression [10%]; mean [SD] age, 49 [17] years; 59% female). Among studies that used semistructured interviews, PHQ-2 sensitivity and specificity (95% CI) were 0.91 (0.88-0.94) and 0.67 (0.64-0.71) for cutoff scores of 2 or greater and 0.72 (0.67-0.77) and 0.85 (0.83-0.87) for cutoff scores of 3 or greater. Sensitivity was significantly greater for semistructured vs fully structured interviews. Specificity was not significantly different across the types of interviews. The area under the receiver operating characteristic curve was 0.88 (0.86-0.89) for semistructured interviews, 0.82 (0.81-0.84) for fully structured interviews, and 0.87 (0.85-0.88) for the MINI. There were no significant subgroup differences. For semistructured interviews, sensitivity for PHQ-2 scores of 2 or greater followed by PHQ-9 scores of 10 or greater (0.82 [0.76-0.86]) was not significantly different than PHQ-9 scores of 10 or greater alone (0.86 [0.80-0.90]); specificity for the combination was significantly but minimally higher (0.87 [0.84-0.89] vs 0.85 [0.82-0.87]). The area under the curve was 0.90 (0.89-0.91). The combination was estimated to reduce the number of participants needing to complete the full PHQ-9 by 57% (56%-58%).

Conclusions and Relevance: In an individual participant data meta-analysis of studies that compared PHQ scores with major depression diagnoses, the combination of PHQ-2 (with cutoff ≥2) followed by PHQ-9 (with cutoff ≥10) had similar sensitivity but higher specificity compared with PHQ-9 cutoff scores of 10 or greater alone. Further research is needed to understand the clinical and research value of this combined approach to screening.

Original language	English
Pages (from-to)	2290-2300
Number of pages	11
Journal	JAMA
Volume	323
Issue number	22
DOIs	https://doi.org/10.1001/jama.2020.6504
Publication status	Published - 9 Jun 2020

Bibliographical note

© 2020 American Medical Association. This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy. Further copying may not be permitted; contact the publisher for details.

Keywords

Adult
Depressive Disorder, Major/classification
Female
Humans
Interviews as Topic
Male
Mass Screening/methods
Patient Health Questionnaire
ROC Curve
Sensitivity and Specificity

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R5.PHQ-2 IPDMA - JAMA - MANUSCRIPT - 2020-04-07
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Cite this

@article{eb5587f1a0ef4586bf993dc6c4be4838,

title = "Accuracy of the PHQ-2 Alone and in Combination With the PHQ-9 for Screening to Detect Major Depression: Systematic Review and Meta-analysis",

abstract = "Importance: The Patient Health Questionnaire depression module (PHQ-9) is a 9-item self-administered instrument used for detecting depression and assessing severity of depression. The Patient Health Questionnaire-2 (PHQ-2) consists of the first 2 items of the PHQ-9 (which assess the frequency of depressed mood and anhedonia) and can be used as a first step to identify patients for evaluation with the full PHQ-9.Objective: To estimate PHQ-2 accuracy alone and combined with the PHQ-9 for detecting major depression.Data Sources: MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, and Web of Science (January 2000-May 2018).Study Selection: Eligible data sets compared PHQ-2 scores with major depression diagnoses from a validated diagnostic interview.Data Extraction and Synthesis: Individual participant data were synthesized with bivariate random-effects meta-analysis to estimate pooled sensitivity and specificity of the PHQ-2 alone among studies using semistructured, fully structured, or Mini International Neuropsychiatric Interview (MINI) diagnostic interviews separately and in combination with the PHQ-9 vs the PHQ-9 alone for studies that used semistructured interviews. The PHQ-2 score ranges from 0 to 6, and the PHQ-9 score ranges from 0 to 27.Results: Individual participant data were obtained from 100 of 136 eligible studies (44 318 participants; 4572 with major depression [10%]; mean [SD] age, 49 [17] years; 59% female). Among studies that used semistructured interviews, PHQ-2 sensitivity and specificity (95% CI) were 0.91 (0.88-0.94) and 0.67 (0.64-0.71) for cutoff scores of 2 or greater and 0.72 (0.67-0.77) and 0.85 (0.83-0.87) for cutoff scores of 3 or greater. Sensitivity was significantly greater for semistructured vs fully structured interviews. Specificity was not significantly different across the types of interviews. The area under the receiver operating characteristic curve was 0.88 (0.86-0.89) for semistructured interviews, 0.82 (0.81-0.84) for fully structured interviews, and 0.87 (0.85-0.88) for the MINI. There were no significant subgroup differences. For semistructured interviews, sensitivity for PHQ-2 scores of 2 or greater followed by PHQ-9 scores of 10 or greater (0.82 [0.76-0.86]) was not significantly different than PHQ-9 scores of 10 or greater alone (0.86 [0.80-0.90]); specificity for the combination was significantly but minimally higher (0.87 [0.84-0.89] vs 0.85 [0.82-0.87]). The area under the curve was 0.90 (0.89-0.91). The combination was estimated to reduce the number of participants needing to complete the full PHQ-9 by 57% (56%-58%).Conclusions and Relevance: In an individual participant data meta-analysis of studies that compared PHQ scores with major depression diagnoses, the combination of PHQ-2 (with cutoff ≥2) followed by PHQ-9 (with cutoff ≥10) had similar sensitivity but higher specificity compared with PHQ-9 cutoff scores of 10 or greater alone. Further research is needed to understand the clinical and research value of this combined approach to screening.",

keywords = "Adult, Depressive Disorder, Major/classification, Female, Humans, Interviews as Topic, Male, Mass Screening/methods, Patient Health Questionnaire, ROC Curve, Sensitivity and Specificity",

author = "{Depression Screening Data (DEPRESSD) PHQ Collaboration} and Brooke Levis and Ying Sun and Chen He and Yin Wu and Ankur Krishnan and Bhandari, {Parash Mani} and Dipika Neupane and Mahrukh Imran and Eliana Brehaut and Zelalem Negeri and Fischer, {Felix H} and Andrea Benedetti and Thombs, {Brett D} and Liying Che and Alexander Levis and Kira Riehm and Nazanin Saadat and Marleine Azar and Danielle Rice and Jill Boruff and Lorie Kloda and Pim Cuijpers and Simon Gilbody and John Ioannidis and Dean McMillan and Scott Patten and Ian Shrier and Roy Ziegelstein and Ainsley Moore and Dickens Akena and Dagmar Amtmann and Bruce Arroll and Liat Ayalon and Hamid Baradaran and Anna Beraldi and Charles Bernstein and Arvin Bhana and Charles Bombardier and Buji, {Ryna Imma} and Peter Butterworth and Gregory Carter and Marcos Chagas and Juliana Chan and Chan, {Lai Fong} and Dixon Chibanda and Rushina Cholera and Kerrie Clover and Aaron Conway and Jaime Delgadillo and {van der Feltz-Cornelis}, Christina",

note = "{\textcopyright} 2020 American Medical Association. This is an author-produced version of the published paper. Uploaded in accordance with the publisher{\textquoteright}s self-archiving policy. Further copying may not be permitted; contact the publisher for details. ",

year = "2020",

month = jun,

day = "9",

doi = "10.1001/jama.2020.6504",

language = "English",

volume = "323",

pages = "2290--2300",

journal = "JAMA",

issn = "0098-7484",

publisher = "American Medical Association",

number = "22",

}

TY - JOUR

T1 - Accuracy of the PHQ-2 Alone and in Combination With the PHQ-9 for Screening to Detect Major Depression

T2 - Systematic Review and Meta-analysis

AU - Depression Screening Data (DEPRESSD) PHQ Collaboration

AU - Levis, Brooke

AU - Sun, Ying

AU - He, Chen

AU - Wu, Yin

AU - Krishnan, Ankur

AU - Bhandari, Parash Mani

AU - Neupane, Dipika

AU - Imran, Mahrukh

AU - Brehaut, Eliana

AU - Negeri, Zelalem

AU - Fischer, Felix H

AU - Benedetti, Andrea

AU - Thombs, Brett D

AU - Che, Liying

AU - Levis, Alexander

AU - Riehm, Kira

AU - Saadat, Nazanin

AU - Azar, Marleine

AU - Rice, Danielle

AU - Boruff, Jill

AU - Kloda, Lorie

AU - Cuijpers, Pim

AU - Gilbody, Simon

AU - Ioannidis, John

AU - McMillan, Dean

AU - Patten, Scott

AU - Shrier, Ian

AU - Ziegelstein, Roy

AU - Moore, Ainsley

AU - Akena, Dickens

AU - Amtmann, Dagmar

AU - Arroll, Bruce

AU - Ayalon, Liat

AU - Baradaran, Hamid

AU - Beraldi, Anna

AU - Bernstein, Charles

AU - Bhana, Arvin

AU - Bombardier, Charles

AU - Buji, Ryna Imma

AU - Butterworth, Peter

AU - Carter, Gregory

AU - Chagas, Marcos

AU - Chan, Juliana

AU - Chan, Lai Fong

AU - Chibanda, Dixon

AU - Cholera, Rushina

AU - Clover, Kerrie

AU - Conway, Aaron

AU - Delgadillo, Jaime

AU - van der Feltz-Cornelis, Christina

N1 - © 2020 American Medical Association. This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy. Further copying may not be permitted; contact the publisher for details.

PY - 2020/6/9

Y1 - 2020/6/9

N2 - Importance: The Patient Health Questionnaire depression module (PHQ-9) is a 9-item self-administered instrument used for detecting depression and assessing severity of depression. The Patient Health Questionnaire-2 (PHQ-2) consists of the first 2 items of the PHQ-9 (which assess the frequency of depressed mood and anhedonia) and can be used as a first step to identify patients for evaluation with the full PHQ-9.Objective: To estimate PHQ-2 accuracy alone and combined with the PHQ-9 for detecting major depression.Data Sources: MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, and Web of Science (January 2000-May 2018).Study Selection: Eligible data sets compared PHQ-2 scores with major depression diagnoses from a validated diagnostic interview.Data Extraction and Synthesis: Individual participant data were synthesized with bivariate random-effects meta-analysis to estimate pooled sensitivity and specificity of the PHQ-2 alone among studies using semistructured, fully structured, or Mini International Neuropsychiatric Interview (MINI) diagnostic interviews separately and in combination with the PHQ-9 vs the PHQ-9 alone for studies that used semistructured interviews. The PHQ-2 score ranges from 0 to 6, and the PHQ-9 score ranges from 0 to 27.Results: Individual participant data were obtained from 100 of 136 eligible studies (44 318 participants; 4572 with major depression [10%]; mean [SD] age, 49 [17] years; 59% female). Among studies that used semistructured interviews, PHQ-2 sensitivity and specificity (95% CI) were 0.91 (0.88-0.94) and 0.67 (0.64-0.71) for cutoff scores of 2 or greater and 0.72 (0.67-0.77) and 0.85 (0.83-0.87) for cutoff scores of 3 or greater. Sensitivity was significantly greater for semistructured vs fully structured interviews. Specificity was not significantly different across the types of interviews. The area under the receiver operating characteristic curve was 0.88 (0.86-0.89) for semistructured interviews, 0.82 (0.81-0.84) for fully structured interviews, and 0.87 (0.85-0.88) for the MINI. There were no significant subgroup differences. For semistructured interviews, sensitivity for PHQ-2 scores of 2 or greater followed by PHQ-9 scores of 10 or greater (0.82 [0.76-0.86]) was not significantly different than PHQ-9 scores of 10 or greater alone (0.86 [0.80-0.90]); specificity for the combination was significantly but minimally higher (0.87 [0.84-0.89] vs 0.85 [0.82-0.87]). The area under the curve was 0.90 (0.89-0.91). The combination was estimated to reduce the number of participants needing to complete the full PHQ-9 by 57% (56%-58%).Conclusions and Relevance: In an individual participant data meta-analysis of studies that compared PHQ scores with major depression diagnoses, the combination of PHQ-2 (with cutoff ≥2) followed by PHQ-9 (with cutoff ≥10) had similar sensitivity but higher specificity compared with PHQ-9 cutoff scores of 10 or greater alone. Further research is needed to understand the clinical and research value of this combined approach to screening.

AB - Importance: The Patient Health Questionnaire depression module (PHQ-9) is a 9-item self-administered instrument used for detecting depression and assessing severity of depression. The Patient Health Questionnaire-2 (PHQ-2) consists of the first 2 items of the PHQ-9 (which assess the frequency of depressed mood and anhedonia) and can be used as a first step to identify patients for evaluation with the full PHQ-9.Objective: To estimate PHQ-2 accuracy alone and combined with the PHQ-9 for detecting major depression.Data Sources: MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, and Web of Science (January 2000-May 2018).Study Selection: Eligible data sets compared PHQ-2 scores with major depression diagnoses from a validated diagnostic interview.Data Extraction and Synthesis: Individual participant data were synthesized with bivariate random-effects meta-analysis to estimate pooled sensitivity and specificity of the PHQ-2 alone among studies using semistructured, fully structured, or Mini International Neuropsychiatric Interview (MINI) diagnostic interviews separately and in combination with the PHQ-9 vs the PHQ-9 alone for studies that used semistructured interviews. The PHQ-2 score ranges from 0 to 6, and the PHQ-9 score ranges from 0 to 27.Results: Individual participant data were obtained from 100 of 136 eligible studies (44 318 participants; 4572 with major depression [10%]; mean [SD] age, 49 [17] years; 59% female). Among studies that used semistructured interviews, PHQ-2 sensitivity and specificity (95% CI) were 0.91 (0.88-0.94) and 0.67 (0.64-0.71) for cutoff scores of 2 or greater and 0.72 (0.67-0.77) and 0.85 (0.83-0.87) for cutoff scores of 3 or greater. Sensitivity was significantly greater for semistructured vs fully structured interviews. Specificity was not significantly different across the types of interviews. The area under the receiver operating characteristic curve was 0.88 (0.86-0.89) for semistructured interviews, 0.82 (0.81-0.84) for fully structured interviews, and 0.87 (0.85-0.88) for the MINI. There were no significant subgroup differences. For semistructured interviews, sensitivity for PHQ-2 scores of 2 or greater followed by PHQ-9 scores of 10 or greater (0.82 [0.76-0.86]) was not significantly different than PHQ-9 scores of 10 or greater alone (0.86 [0.80-0.90]); specificity for the combination was significantly but minimally higher (0.87 [0.84-0.89] vs 0.85 [0.82-0.87]). The area under the curve was 0.90 (0.89-0.91). The combination was estimated to reduce the number of participants needing to complete the full PHQ-9 by 57% (56%-58%).Conclusions and Relevance: In an individual participant data meta-analysis of studies that compared PHQ scores with major depression diagnoses, the combination of PHQ-2 (with cutoff ≥2) followed by PHQ-9 (with cutoff ≥10) had similar sensitivity but higher specificity compared with PHQ-9 cutoff scores of 10 or greater alone. Further research is needed to understand the clinical and research value of this combined approach to screening.

KW - Adult

KW - Depressive Disorder, Major/classification

KW - Female

KW - Humans

KW - Interviews as Topic

KW - Male

KW - Mass Screening/methods

KW - Patient Health Questionnaire

KW - ROC Curve

KW - Sensitivity and Specificity

U2 - 10.1001/jama.2020.6504

DO - 10.1001/jama.2020.6504

M3 - Article

C2 - 32515813

SN - 0098-7484

VL - 323

SP - 2290

EP - 2300

JO - JAMA

JF - JAMA

IS - 22

ER -