The validity of the patient health Questionnaire-9 to screen for depression in patients with type-2 diabetes mellitus in non-communicable diseases clinics in Malawi

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Abstract

Background

Depression is a global problem, affecting populations worldwide, but is too often under-diagnosed. The identification of depression among patients with diabetes is important because depression is prevalent in this group and can complicate diabetes management.

Objectives

The aim of the study was to determine the sensitivity and specificity of the PHQ-9 in the detection of depression among patients with type-2 diabetes mellitus attending non-communicable diseases (NCD) clinics in Malawi.

Methods

We conducted a validation study of the Patient Health Questionnaire (PHQ-9) among 323 patients with type-2 diabetes mellitus who attended two NCD clinics in one of the 28 districts of Malawi. The participants were screened consecutively using the nine-item PHQ-9 in Chichewa by a research assistant and completed a diagnostic interview using the Structured Clinical Interview for DSM-IV (SCID) for depression with a mental health clinician. We evaluated both content validity based on expert judgement and criterion validity of the Patient Health Questionnaire (PHQ-9) based on performance against the SCID. The PHQ-9 cutpoint that maximized sensitivity plus specificity was selected to report test characteristics.

Results

Using the SCID for depression, the prevalence of minor or major depression was 41% (133/323). The internal consistency estimate for the PHQ-9 was 0.83, with an area under the receiver operator curve (AUC) of 0.93 (95% CI, [0.91–0.96]). Using the optimal cut-point of ≥9, the PHQ-9 had a sensitivity of 64% and a specificity of 94% in detecting both minor and major depression, with likelihood ratio-positive = 10.1 and likelihood ratio negative =0.4 as well as overall correct classification (OCC) rate of 81%.

Conclusions

This is the first validation study of the PHQ-9 in NCD clinics in Malawi. Depression was highly prevalent in this sample. The PHQ-9 demonstrated reasonable accuracy in identifying cases of depression and is a useful screening tool in this setting. Health care workers in NCD clinics can use the PHQ-9 to identify depression among their patients with those having a positive screen followed up by additional diagnostic assessment to confirm diagnosis.

Trial registration

PACTR201807135104799. Retrospectively registered on 12 July 2018.

Electronic supplementary material

The online version of this article (10.1186/s12888-019-2062-2) contains supplementary material, which is available to authorized users.

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Most cited references 33

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The PHQ-9

Kurt Kroenke, Robert L Spitzer, Janet B W Williams (2001)

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Depression, chronic diseases, and decrements in health: results from the World Health Surveys

Saba Moussavi, Somnath Chatterji, Emese Verdes … (2007)

Depression is an important public-health problem, and one of the leading causes of disease burden worldwide. Depression is often comorbid with other chronic diseases and can worsen their associated health outcomes. Few studies have explored the effect of depression, alone or as a comorbidity, on overall health status. The WHO World Health Survey (WHS) studied adults aged 18 years and older to obtain data for health, health-related outcomes, and their determinants. Prevalence of depression in respondents based on ICD-10 criteria was estimated. Prevalence values for four chronic physical diseases--angina, arthritis, asthma, and diabetes--were also estimated using algorithms derived via a Diagnostic Item Probability Study. Mean health scores were constructed using factor analysis and compared across different disease states and demographic variables. The relation of these disease states to mean health scores was determined through regression modelling. Observations were available for 245 404 participants from 60 countries in all regions of the world. Overall, 1-year prevalence for ICD-10 depressive episode alone was 3.2% (95% CI 3.0-3.5); for angina 4.5% (4.3-4.8); for arthritis 4.1% (3.8-4.3); for asthma 3.3% (2.9-3.6); and for diabetes 2.0% (1.8-2.2). An average of between 9.3% and 23.0% of participants with one or more chronic physical disease had comorbid depression. This result was significantly higher than the likelihood of having depression in the absence of a chronic physical disease (p<0.0001). After adjustment for socioeconomic factors and health conditions, depression had the largest effect on worsening mean health scores compared with the other chronic conditions. Consistently across countries and different demographic characteristics, respondents with depression comorbid with one or more chronic diseases had the worst health scores of all the disease states. Depression produces the greatest decrement in health compared with the chronic diseases angina, arthritis, asthma, and diabetes. The comorbid state of depression incrementally worsens health compared with depression alone, with any of the chronic diseases alone, and with any combination of chronic diseases without depression. These results indicate the urgency of addressing depression as a public-health priority to reduce disease burden and disability, and to improve the overall health of populations.

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Optimal cut-off score for diagnosing depression with the Patient Health Questionnaire (PHQ-9): a meta-analysis.

Laura Manea, Simon Gilbody, Dean McMillan (2012)

The brief Patient Health Questionnaire (PHQ-9) is commonly used to screen for depression with 10 often recommended as the cut-off score. We summarized the psychometric properties of the PHQ-9 across a range of studies and cut-off scores to select the optimal cut-off for detecting depression. We searched Embase, MEDLINE and PsycINFO from 1999 to August 2010 for studies that reported the diagnostic accuracy of PHQ-9 to diagnose major depressive disorders. We calculated summary sensitivity, specificity, likelihood ratios and diagnostic odds ratios for detecting major depressive disorder at different cut-off scores and in different settings. We used random-effects bivariate meta-analysis at cutoff points between 7 and 15 to produce summary receiver operating characteristic curves. We identified 18 validation studies (n = 7180) conducted in various clinical settings. Eleven studies provided details about the diagnostic properties of the questionnaire at more than one cut-off score (including 10), four studies reported a cut-off score of 10, and three studies reported cut-off scores other than 10. The pooled specificity results ranged from 0.73 (95% confidence interval [CI] 0.63-0.82) for a cut-off score of 7 to 0.96 (95% CI 0.94-0.97) for a cut-off score of 15. There was major variability in sensitivity for cut-off scores between 7 and 15. There were no substantial differences in the pooled sensitivity and specificity for a range of cut-off scores (8-11). The PHQ-9 was found to have acceptable diagnostic properties for detecting major depressive disorder for cut-off scores between 8 and 11. Authors of future validation studies should consistently report the outcomes for different cut-off scores.

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Author and article information

Contributors

Michael Udedi:

ORCID: http://orcid.org/0000-0001-8769-4313

mphatsoudedi@yahoo.co.uk

Adamson S. Muula: amuula@medcol.mw

Robert C. Stewart: robcstewart@mac.com

Brian W. Pence: bpence@unc.edu

Journal

Journal ID (nlm-ta): BMC Psychiatry

Journal ID (iso-abbrev): BMC Psychiatry

Title: BMC Psychiatry

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-244X

Publication date (Electronic): 27 February 2019

Publication date PMC-release: 27 February 2019

Publication date Collection: 2019

Volume: 19

Electronic Location Identifier: 81

Affiliations

[1 ]ISNI 0000 0001 2113 2211, GRID grid.10595.38, Department of Mental Health, , University of Malawi, College of Medicine, ; P/Bag 360, Chichiri, Blantyre, 3 Malawi

[2 ]GRID grid.415722.7, Department of Clinical Services, , Ministry of Health, ; P. O. Box 30377, Capital City, Lilongwe, 3 Malawi

[3 ]ISNI 0000 0001 2113 2211, GRID grid.10595.38, Department of Public Health, , University of Malawi, College of Medicine, ; P/Bag 360, Chichiri, Blantyre, 3 Malawi

[4 ]ISNI 0000 0001 2113 2211, GRID grid.10595.38, Africa Center of Excellence in Public Health and Herbal Medicine, , University of Malawi, College of Medicine, ; P/Bag 360, Chichiri, Blantyre, 3 Malawi

[5 ]ISNI 0000000122483208, GRID grid.10698.36, Epidemiology Department, , University of North Carolina at Chapel Hill Gillings School of Global Public Health, ; 135 Dauer Dr, Chapel Hill, NC 27599 USA

Author information

Michael Udedi http://orcid.org/0000-0001-8769-4313

Article

Publisher ID: 2062

DOI: 10.1186/s12888-019-2062-2

PMC ID: 6391834

PubMed ID: 30813922

SO-VID: 3b4071b5-5f96-4bb5-8d97-7ff0622d353a

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 18 September 2018

Date accepted : 18 February 2019

Funding

Funded by: FundRef http://dx.doi.org/10.13039/100004440, Wellcome Trust;

Award ID: DEL-15-01

Award Recipient : Michael Udedi

Custom metadata

ScienceOpen disciplines: Clinical Psychology & Psychiatry

Keywords: phq-9,validation,non communicable diseases,depression,diabetes mellitus,malawi

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ScienceOpen disciplines: Clinical Psychology & Psychiatry

Keywords: phq-9, validation, non communicable diseases, depression, diabetes mellitus, malawi

The validity of the patient health Questionnaire-9 to screen for depression in patients with type-2 diabetes mellitus in non-communicable diseases clinics in Malawi

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Abstract

Background

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Methods

Results

Conclusions

Trial registration

Electronic supplementary material

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Measurement of Glucocorticoid Receptor Signaling in Major Depression

Most cited references 33

The PHQ-9

Depression, chronic diseases, and decrements in health: results from the World Health Surveys

Optimal cut-off score for diagnosing depression with the Patient Health Questionnaire (PHQ-9): a meta-analysis.

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