Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis

Brooke Levis; Andrea Benedetti; John P.A. Ioannidis; Ying Sun; Zelalem Negeri; Chen He; Yin Wu; Ankur Krishnan; Parash Mani Bhandari; Dipika Neupane; Mahrukh Imran; Danielle B. Rice; Kira E. Riehm; Nazanin Saadat; Marleine Azar; Jill Boruff; Pim Cuijpers; Simon Gilbody; Lorie A. Kloda; Dean McMillan; Scott B. Patten; Ian Shrier; Roy C. Ziegelstein; Sultan H. Alamri; Dagmar Amtmann; Liat Ayalon; Hamid R. Baradaran; Anna Beraldi; Charles N. Bernstein; Arvin Bhana; Charles H. Bombardier; Gregory Carter; Marcos H. Chagas; Dixon Chibanda; Kerrie Clover; Yeates Conwell; Crisanto Diez-Quevedo; Jesse R. Fann; Felix H. Fischer; Leila Gholizadeh; Lorna J. Gibson; Eric P. Green; Catherine G. Greeno; Brian J. Hall; Emily E. Haroz; Khalida Ismail; Nathalie Jetté; Mohammad E. Khamseh; Yunxin Kwan; Maria Asunción Lara; Shen Ing Liu; Sonia R. Loureiro; Bernd Löwe; Ruth Ann Marrie; Laura Marsh; Anthony McGuire; Kumiko Muramatsu; Laura Navarrete; Flávia L. Osório; Inge Petersen; Angelo Picardi; Stephanie L. Pugh; Terence J. Quinn; Alasdair G. Rooney; Eileen H. Shinn; Abbey Sidebottom; Lena Spangenberg; Pei Lin Lynnette Tan; Martin Taylor-Rowan; Alyna Turner; Henk C. van Weert; Paul A. Vöhringer; Lynne I. Wagner; Jennifer White; Kirsty Winkley; Brett D. Thombs

doi:10.1016/j.jclinepi.2020.02.002

Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis

Brooke Levis, Andrea Benedetti, John P.A. Ioannidis, Ying Sun, Zelalem Negeri, Chen He, Yin Wu, Ankur Krishnan, Parash Mani Bhandari, Dipika Neupane, Mahrukh Imran, Danielle B. Rice, Kira E. Riehm, Nazanin Saadat, Marleine Azar, Jill Boruff, Pim Cuijpers, Simon Gilbody, Lorie A. Kloda, Dean McMillanScott B. Patten, Ian Shrier, Roy C. Ziegelstein, Sultan H. Alamri, Dagmar Amtmann, Liat Ayalon, Hamid R. Baradaran, Anna Beraldi, Charles N. Bernstein, Arvin Bhana, Charles H. Bombardier, Gregory Carter, Marcos H. Chagas, Dixon Chibanda, Kerrie Clover, Yeates Conwell, Crisanto Diez-Quevedo, Jesse R. Fann, Felix H. Fischer, Leila Gholizadeh, Lorna J. Gibson, Eric P. Green, Catherine G. Greeno, Brian J. Hall, Emily E. Haroz, Khalida Ismail, Nathalie Jetté, Mohammad E. Khamseh, Yunxin Kwan, Maria Asunción Lara, Shen Ing Liu, Sonia R. Loureiro, Bernd Löwe, Ruth Ann Marrie, Laura Marsh, Anthony McGuire, Kumiko Muramatsu, Laura Navarrete, Flávia L. Osório, Inge Petersen, Angelo Picardi, Stephanie L. Pugh, Terence J. Quinn, Alasdair G. Rooney, Eileen H. Shinn, Abbey Sidebottom, Lena Spangenberg, Pei Lin Lynnette Tan, Martin Taylor-Rowan, Alyna Turner, Henk C. van Weert, Paul A. Vöhringer, Lynne I. Wagner, Jennifer White, Kirsty Winkley, Brett D. Thombs

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

30 Scopus citations

Abstract

Objectives: Depression symptom questionnaires are not for diagnostic classification. Patient Health Questionnaire-9 (PHQ-9) scores ≥10 are nonetheless often used to estimate depression prevalence. We compared PHQ-9 ≥10 prevalence to Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) major depression prevalence and assessed whether an alternative PHQ-9 cutoff could more accurately estimate prevalence. Study Design and Setting: Individual participant data meta-analysis of datasets comparing PHQ-9 scores to SCID major depression status. Results: A total of 9,242 participants (1,389 SCID major depression cases) from 44 primary studies were included. Pooled PHQ-9 ≥10 prevalence was 24.6% (95% confidence interval [CI]: 20.8%, 28.9%); pooled SCID major depression prevalence was 12.1% (95% CI: 9.6%, 15.2%); and pooled difference was 11.9% (95% CI: 9.3%, 14.6%). The mean study-level PHQ-9 ≥10 to SCID-based prevalence ratio was 2.5 times. PHQ-9 ≥14 and the PHQ-9 diagnostic algorithm provided prevalence closest to SCID major depression prevalence, but study-level prevalence differed from SCID-based prevalence by an average absolute difference of 4.8% for PHQ-9 ≥14 (95% prediction interval: −13.6%, 14.5%) and 5.6% for the PHQ-9 diagnostic algorithm (95% prediction interval: −16.4%, 15.0%). Conclusion: PHQ-9 ≥10 substantially overestimates depression prevalence. There is too much heterogeneity to correct statistically in individual studies.

Original language	English (US)
Pages (from-to)	115-128.e1
Journal	Journal of Clinical Epidemiology
Volume	122
DOIs	https://doi.org/10.1016/j.jclinepi.2020.02.002
State	Published - Jun 2020

Keywords

Depression prevalence
Individual participant data meta-analysis
PHQ-9
SCID

ASJC Scopus subject areas

Epidemiology

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10.1016/j.jclinepi.2020.02.002

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Levis, B., Benedetti, A., Ioannidis, J. P. A., Sun, Y., Negeri, Z., He, C., Wu, Y., Krishnan, A., Bhandari, P. M., Neupane, D., Imran, M., Rice, D. B., Riehm, K. E., Saadat, N., Azar, M., Boruff, J., Cuijpers, P., Gilbody, S., Kloda, L. A., ... Thombs, B. D. (2020). Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis. Journal of Clinical Epidemiology, 122, 115-128.e1. https://doi.org/10.1016/j.jclinepi.2020.02.002

Levis, B, Benedetti, A, Ioannidis, JPA, Sun, Y, Negeri, Z, He, C, Wu, Y, Krishnan, A, Bhandari, PM, Neupane, D, Imran, M, Rice, DB, Riehm, KE, Saadat, N, Azar, M, Boruff, J, Cuijpers, P, Gilbody, S, Kloda, LA, McMillan, D, Patten, SB, Shrier, I, Ziegelstein, RC, Alamri, SH, Amtmann, D, Ayalon, L, Baradaran, HR, Beraldi, A, Bernstein, CN, Bhana, A, Bombardier, CH, Carter, G, Chagas, MH, Chibanda, D, Clover, K, Conwell, Y, Diez-Quevedo, C, Fann, JR, Fischer, FH, Gholizadeh, L, Gibson, LJ, Green, EP, Greeno, CG, Hall, BJ , Haroz, EE, Ismail, K, Jetté, N, Khamseh, ME, Kwan, Y, Lara, MA, Liu, SI, Loureiro, SR, Löwe, B, Marrie, RA, Marsh, L, McGuire, A, Muramatsu, K, Navarrete, L, Osório, FL, Petersen, I, Picardi, A, Pugh, SL, Quinn, TJ, Rooney, AG, Shinn, EH, Sidebottom, A, Spangenberg, L, Tan, PLL, Taylor-Rowan, M, Turner, A, van Weert, HC, Vöhringer, PA, Wagner, LI, White, J, Winkley, K & Thombs, BD 2020, 'Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis', Journal of Clinical Epidemiology, vol. 122, pp. 115-128.e1. https://doi.org/10.1016/j.jclinepi.2020.02.002

@article{df9b9b148a7041ff962d8dd0a5d24fdf,

title = "Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis",

abstract = "Objectives: Depression symptom questionnaires are not for diagnostic classification. Patient Health Questionnaire-9 (PHQ-9) scores ≥10 are nonetheless often used to estimate depression prevalence. We compared PHQ-9 ≥10 prevalence to Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) major depression prevalence and assessed whether an alternative PHQ-9 cutoff could more accurately estimate prevalence. Study Design and Setting: Individual participant data meta-analysis of datasets comparing PHQ-9 scores to SCID major depression status. Results: A total of 9,242 participants (1,389 SCID major depression cases) from 44 primary studies were included. Pooled PHQ-9 ≥10 prevalence was 24.6% (95% confidence interval [CI]: 20.8%, 28.9%); pooled SCID major depression prevalence was 12.1% (95% CI: 9.6%, 15.2%); and pooled difference was 11.9% (95% CI: 9.3%, 14.6%). The mean study-level PHQ-9 ≥10 to SCID-based prevalence ratio was 2.5 times. PHQ-9 ≥14 and the PHQ-9 diagnostic algorithm provided prevalence closest to SCID major depression prevalence, but study-level prevalence differed from SCID-based prevalence by an average absolute difference of 4.8% for PHQ-9 ≥14 (95% prediction interval: −13.6%, 14.5%) and 5.6% for the PHQ-9 diagnostic algorithm (95% prediction interval: −16.4%, 15.0%). Conclusion: PHQ-9 ≥10 substantially overestimates depression prevalence. There is too much heterogeneity to correct statistically in individual studies.",

keywords = "Depression prevalence, Individual participant data meta-analysis, PHQ-9, SCID",

author = "Brooke Levis and Andrea Benedetti and Ioannidis, {John P.A.} and Ying Sun and Zelalem Negeri and Chen He and Yin Wu and Ankur Krishnan and Bhandari, {Parash Mani} and Dipika Neupane and Mahrukh Imran and Rice, {Danielle B.} and Riehm, {Kira E.} and Nazanin Saadat and Marleine Azar and Jill Boruff and Pim Cuijpers and Simon Gilbody and Kloda, {Lorie A.} and Dean McMillan and Patten, {Scott B.} and Ian Shrier and Ziegelstein, {Roy C.} and Alamri, {Sultan H.} and Dagmar Amtmann and Liat Ayalon and Baradaran, {Hamid R.} and Anna Beraldi and Bernstein, {Charles N.} and Arvin Bhana and Bombardier, {Charles H.} and Gregory Carter and Chagas, {Marcos H.} and Dixon Chibanda and Kerrie Clover and Yeates Conwell and Crisanto Diez-Quevedo and Fann, {Jesse R.} and Fischer, {Felix H.} and Leila Gholizadeh and Gibson, {Lorna J.} and Green, {Eric P.} and Greeno, {Catherine G.} and Hall, {Brian J.} and Haroz, {Emily E.} and Khalida Ismail and Nathalie Jett{\'e} and Khamseh, {Mohammad E.} and Yunxin Kwan and Lara, {Maria Asunci{\'o}n} and Liu, {Shen Ing} and Loureiro, {Sonia R.} and Bernd L{\"o}we and Marrie, {Ruth Ann} and Laura Marsh and Anthony McGuire and Kumiko Muramatsu and Laura Navarrete and Os{\'o}rio, {Fl{\'a}via L.} and Inge Petersen and Angelo Picardi and Pugh, {Stephanie L.} and Quinn, {Terence J.} and Rooney, {Alasdair G.} and Shinn, {Eileen H.} and Abbey Sidebottom and Lena Spangenberg and Tan, {Pei Lin Lynnette} and Martin Taylor-Rowan and Alyna Turner and {van Weert}, {Henk C.} and V{\"o}hringer, {Paul A.} and Wagner, {Lynne I.} and Jennifer White and Kirsty Winkley and Thombs, {Brett D.}",

note = "Publisher Copyright: {\textcopyright} 2020 Elsevier Inc.",

year = "2020",

month = jun,

doi = "10.1016/j.jclinepi.2020.02.002",

language = "English (US)",

volume = "122",

pages = "115--128.e1",

journal = "Journal of Clinical Epidemiology",

issn = "0895-4356",

publisher = "Elsevier USA",

}

TY - JOUR

T1 - Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence

T2 - individual participant data meta-analysis

AU - Levis, Brooke

AU - Benedetti, Andrea

AU - Ioannidis, John P.A.

AU - Sun, Ying

AU - Negeri, Zelalem

AU - He, Chen

AU - Wu, Yin

AU - Krishnan, Ankur

AU - Bhandari, Parash Mani

AU - Neupane, Dipika

AU - Imran, Mahrukh

AU - Rice, Danielle B.

AU - Riehm, Kira E.

AU - Saadat, Nazanin

AU - Azar, Marleine

AU - Boruff, Jill

AU - Cuijpers, Pim

AU - Gilbody, Simon

AU - Kloda, Lorie A.

AU - McMillan, Dean

AU - Patten, Scott B.

AU - Shrier, Ian

AU - Ziegelstein, Roy C.

AU - Alamri, Sultan H.

AU - Amtmann, Dagmar

AU - Ayalon, Liat

AU - Baradaran, Hamid R.

AU - Beraldi, Anna

AU - Bernstein, Charles N.

AU - Bhana, Arvin

AU - Bombardier, Charles H.

AU - Carter, Gregory

AU - Chagas, Marcos H.

AU - Chibanda, Dixon

AU - Clover, Kerrie

AU - Conwell, Yeates

AU - Diez-Quevedo, Crisanto

AU - Fann, Jesse R.

AU - Fischer, Felix H.

AU - Gholizadeh, Leila

AU - Gibson, Lorna J.

AU - Green, Eric P.

AU - Greeno, Catherine G.

AU - Hall, Brian J.

AU - Haroz, Emily E.

AU - Ismail, Khalida

AU - Jetté, Nathalie

AU - Khamseh, Mohammad E.

AU - Kwan, Yunxin

AU - Lara, Maria Asunción

AU - Liu, Shen Ing

AU - Loureiro, Sonia R.

AU - Löwe, Bernd

AU - Marrie, Ruth Ann

AU - Marsh, Laura

AU - McGuire, Anthony

AU - Muramatsu, Kumiko

AU - Navarrete, Laura

AU - Osório, Flávia L.

AU - Petersen, Inge

AU - Picardi, Angelo

AU - Pugh, Stephanie L.

AU - Quinn, Terence J.

AU - Rooney, Alasdair G.

AU - Shinn, Eileen H.

AU - Sidebottom, Abbey

AU - Spangenberg, Lena

AU - Tan, Pei Lin Lynnette

AU - Taylor-Rowan, Martin

AU - Turner, Alyna

AU - van Weert, Henk C.

AU - Vöhringer, Paul A.

AU - Wagner, Lynne I.

AU - White, Jennifer

AU - Winkley, Kirsty

AU - Thombs, Brett D.

PY - 2020/6

Y1 - 2020/6

N2 - Objectives: Depression symptom questionnaires are not for diagnostic classification. Patient Health Questionnaire-9 (PHQ-9) scores ≥10 are nonetheless often used to estimate depression prevalence. We compared PHQ-9 ≥10 prevalence to Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) major depression prevalence and assessed whether an alternative PHQ-9 cutoff could more accurately estimate prevalence. Study Design and Setting: Individual participant data meta-analysis of datasets comparing PHQ-9 scores to SCID major depression status. Results: A total of 9,242 participants (1,389 SCID major depression cases) from 44 primary studies were included. Pooled PHQ-9 ≥10 prevalence was 24.6% (95% confidence interval [CI]: 20.8%, 28.9%); pooled SCID major depression prevalence was 12.1% (95% CI: 9.6%, 15.2%); and pooled difference was 11.9% (95% CI: 9.3%, 14.6%). The mean study-level PHQ-9 ≥10 to SCID-based prevalence ratio was 2.5 times. PHQ-9 ≥14 and the PHQ-9 diagnostic algorithm provided prevalence closest to SCID major depression prevalence, but study-level prevalence differed from SCID-based prevalence by an average absolute difference of 4.8% for PHQ-9 ≥14 (95% prediction interval: −13.6%, 14.5%) and 5.6% for the PHQ-9 diagnostic algorithm (95% prediction interval: −16.4%, 15.0%). Conclusion: PHQ-9 ≥10 substantially overestimates depression prevalence. There is too much heterogeneity to correct statistically in individual studies.

AB - Objectives: Depression symptom questionnaires are not for diagnostic classification. Patient Health Questionnaire-9 (PHQ-9) scores ≥10 are nonetheless often used to estimate depression prevalence. We compared PHQ-9 ≥10 prevalence to Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) major depression prevalence and assessed whether an alternative PHQ-9 cutoff could more accurately estimate prevalence. Study Design and Setting: Individual participant data meta-analysis of datasets comparing PHQ-9 scores to SCID major depression status. Results: A total of 9,242 participants (1,389 SCID major depression cases) from 44 primary studies were included. Pooled PHQ-9 ≥10 prevalence was 24.6% (95% confidence interval [CI]: 20.8%, 28.9%); pooled SCID major depression prevalence was 12.1% (95% CI: 9.6%, 15.2%); and pooled difference was 11.9% (95% CI: 9.3%, 14.6%). The mean study-level PHQ-9 ≥10 to SCID-based prevalence ratio was 2.5 times. PHQ-9 ≥14 and the PHQ-9 diagnostic algorithm provided prevalence closest to SCID major depression prevalence, but study-level prevalence differed from SCID-based prevalence by an average absolute difference of 4.8% for PHQ-9 ≥14 (95% prediction interval: −13.6%, 14.5%) and 5.6% for the PHQ-9 diagnostic algorithm (95% prediction interval: −16.4%, 15.0%). Conclusion: PHQ-9 ≥10 substantially overestimates depression prevalence. There is too much heterogeneity to correct statistically in individual studies.

KW - Depression prevalence

KW - Individual participant data meta-analysis

KW - PHQ-9

KW - SCID

UR - http://www.scopus.com/inward/record.url?scp=85082494030&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85082494030&partnerID=8YFLogxK

U2 - 10.1016/j.jclinepi.2020.02.002

DO - 10.1016/j.jclinepi.2020.02.002

M3 - Article

C2 - 32105798

AN - SCOPUS:85082494030

SN - 0895-4356

VL - 122

SP - 115-128.e1

JO - Journal of Clinical Epidemiology

JF - Journal of Clinical Epidemiology

ER -

Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis

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