PHQ-9 & GAD-7 Data in a National Survey about COVID-19 Restrictions in Australia

Research paper Title

Patient Health Questionnaire 9 (PHQ-9) and General Anxiety Disorder 7 (GAD-7) data contributed by 13,829 respondents to a national survey about COVID-19 restrictions in Australia.

Background

While the Patient Health Questionnaire 9 (PHQ-9) and General Anxiety Disorder 7 (GAD-7) are frequently used in mental health research, few studies have reported comprehensive data on these measures from population or community samples.

The aim of this study was to describe gender- and age-specific PHQ-9 and GAD-7 item and summary data contributed by those who completed this survey.

Methods

The PHQ-9 and GAD-7 were used as indicators of symptoms of depression and anxiety in a national online anonymous survey to assess the mental health of adults in Australia during the COVID-19 restrictions.

Data were analysed descriptively.

Results

Complete survey responses were contributed by 13,829 people.

For both measures, item-by-item results, summary statistics (mean, standard deviation, minimum, maximum, median and interquartile range) and prevalence of severity categories are reported for the whole sample, and disaggregated by gender and age groups.

Conclusions

These comprehensive data provide a useful point of comparison for future COVID-19-related or other research among population or community samples.

Other researchers are encouraged to report detailed PHQ-9 and GAD-7 data in the future, to enable and promote relevant between-group comparisons.

Reference

Stocker, R., Tran, T., Hammarberg, K., Nguyen, H., Rowe, H. & Fisher, J. (2021) Patient Health Questionnaire 9 (PHQ-9) and General Anxiety Disorder 7 (GAD-7) data contributed by 13,829 respondents to a national survey about COVID-19 restrictions in Australia. Psychiatry Research. doi: 10.1016/j.psychres.2021.113792. Online ahead of print.

What are Rating Scales for Depression?

Introduction

A depression rating scale is a psychiatric measuring instrument having descriptive words and phrases that indicate the severity of depression for a time period.

When used, an observer may make judgements and rate a person at a specified scale level with respect to identified characteristics. Rather than being used to diagnose depression, a depression rating scale may be used to assign a score to a person’s behaviour where that score may be used to determine whether that person should be evaluated more thoroughly for a depressive disorder diagnosis. Several rating scales are used for this purpose.

Between 1918 and 2009, more than 280 measures of depressive severity were developed and published (Santor, Gregus & Welch, 2009).

What is the Purpose of a Rating Scale?

To determine degree of depression.

Who Can Complete Rating Scales?

Scales Completed by Researchers

Some depression rating scales are completed by researchers. For example, the Hamilton Depression Rating Scale includes 21 questions with between 3 and 5 possible responses which increase in severity. The clinician must choose the possible responses to each question by interviewing the patient and by observing the patient’s symptoms. Designed by psychiatrist Max Hamilton in 1960, the Hamilton Depression Rating Scale is one of the two most commonly used among those completed by researchers assessing the effects of drug therapy. Alternatively, the Montgomery-Åsberg Depression Rating Scale has ten items to be completed by researchers assessing the effects of drug therapy and is the other of the two most commonly used among such researchers. Another scale is the Raskin Depression Rating Scale; which rates the severity of the patients symptoms in three areas: verbal reports, behaviour, and secondary symptoms of depression.

Scales Completed by Patients

Some depression rating scales are completed by patients. The Beck Depression Inventory, for example, is a 21-question self-report inventory that covers symptoms such as irritability, fatigue, weight loss, lack of interest in sex, and feelings of guilt, hopelessness or fear of being punished. The scale is completed by patients to identify the presence and severity of symptoms consistent with the DSM-IV diagnostic criteria. The Beck Depression Inventory was originally designed by psychiatrist Aaron T. Beck in 1961.

The Geriatric Depression Scale (GDS) is another self-administered scale, but in this case it is used for older patients, and for patients with mild to moderate dementia. Instead of presenting a five-category response set, the GDS questions are answered with a simple “yes” or “no”. The Zung Self-Rating Depression Scale is similar to the Geriatric Depression Scale in that the answers are preformatted. In the Zung Self-Rating Depression Scale, there are 20 items: ten positively worded and ten negatively worded. Each question is rated on a scale of 1 through 4 based on four possible answers: “a little of the time”, “some of the time”, “good part of the time”, and “most of the time”.

The Patient Health Questionnaire (PHQ) sets are self-reported depression rating scales. For example, the Patient Health Questionnaire-9 (PHQ-9) is a self-reported, 9-question version of the Primary Care Evaluation of Mental Disorders. The Patient Health Questionnaire-2 (PHQ-2) is a shorter version of the PHQ-9 with two screening questions to assess the presence of a depressed mood and a loss of interest or pleasure in routine activities; a positive response to either question indicates further testing is required.

The two questions on the Patient Health Questionnaire-2 (PHQ-2):

During the past month, have you often been bothered by feeling down, depressed, or hopeless?

During the past month, have you often been bothered by little interest or pleasure in doing things?

Scales Completed by Patients and Researchers

The Primary Care Evaluation of Mental Disorders (PRIME-MD) is completed by the patient and a researcher. This depression rating scale includes a 27-item screening questionnaire and follow-up clinician interview designed to facilitate the diagnosis of common mental disorders in primary care. Its lengthy administration time has limited its clinical usefulness; it has been replaced by the Patient Health Questionnaire.

What is the Validity and Usefulness of Rating Scales?

How Useful are Rating Scales?

Screening programmes using rating scales to search for candidates for a more in-depth evaluation have been advocated to improve detection of depression, but there is evidence that they do not improve detection rates, treatment, or outcome. There is also evidence that a consensus on the interpretation of rating scales, in particular the Hamilton Rating Scale for Depression, is largely missing, leading to misdiagnosis of the severity of a patient’s depression. However, there is evidence that portions of rating scales, such as the somatic section of the PHQ-9, can be useful in predicting outcomes for subgroups of patients like coronary heart disease patients.

How Valid are Rating Scales?

Several research articles have come out in the past several years that question the validity of sum-score rating scales for depression.

Fried, E.I. (2017) The 52 Symptoms of Major Depression: Lack of Content Overlap Among Seven Common Depression Scales. Journal of Affective Disorders. 208, pp.191-197. https://doi.org/10.1016/j.jad.2016.10.019.

Santor, D.A., Gregus, M. & Welch, A. (2009) Eight Decades of Measurement in Depression. Measurement: Interdisciplinary Research and Perspectives. 4(3), pp.135-155. https://doi.org/10.1207/s15366359mea0403_1.

Copyrighted vs. Public Domain Rating Scales

The Beck Depression Inventory is copyrighted, a fee must be paid for each copy used, and photocopying it is a violation of copyright. There is no evidence that the BDI-II is more valid or reliable than other depression scales, and public domain scales such as the Centre for Epidemiological Studies Depression Scale (CES-D), the Zung Depression scale and Patient Health Questionnaire – Nine Item (PHQ-9) has been studied as a useful tool.

Other copyrighted scales allow individual clinicians and researchers to make copies for their own use, but require licenses for electronic versions or large-scale redistribution, including:

  • The Clinically Useful Depression Outcome Scale (CUDOS).
  • The Inventory of Depressive Symptomatology (IDS).
  • The Mood and Feelings Questionnaire (MFQ).
  • The Quick Inventory of Depressive Symptoms (QIDS).
  • The Patient Health Questionnaire (PHQ).
    • Research in process – Banner University Medical Centre.
  • Hamilton Rating Scale (HRSDD, HDRS, Ham-D).
  • Columbia Suicide Severity Rating Scale (C-SSRS).
  • Depression and Anxiety Stress Scales (DASS).
  • Depression Self-Rating Scale for Children.
  • Brief Psychiatric Rating Scale (BPRS).
  • Geriatric Depression Scale (GDS).
  • Beck’s Depression Inventory (BDI).
  • HEADS-ED, used in hospital emergency departments.
  • Children’s Depression Rating Scale (CDRS).
  • Behavioural Activation for Depression Scale (BADS-SF).
  • Edinburgh Postnatal Depression Scale.
  • Quick Inventory of Depressive Symptomatology Clinician (QIDS-C).
  • Quick Inventory of Depressive Symptomatology Self Report (QIDS-SR).
  • Kutcher Adolescent Depression Scale (KADS-11).
  • Montgomery-Asberg Depression Scale (MADRS).
  • Clinically Useful Depression Outcome Scale (CUDOS).
  • Hospital Anxiety and Depression Scale.
  • Primary Care Evaluation of Mental Disorders (PRIME-MD).
  • Children’s Depression Inventory (CDI).

Should Service Users be Involved in Co-Designing Surveys they will Use?

Research Paper Title

Validation of a Comprehensive Patient Experience Survey for Addiction and Mental Health that was Co-designed with Service Users.

Background

A rigorous survey development process was undertaken to design and test a novel, comprehensive patient experience measure that can be used across the full continuum of addiction and mental health programs.

Service users were involved in all aspects of the measure’s development, including the selection of items, pre-testing, naming of the scales, and interpretation of the results.

Methods

Survey data was collected from 1222 patients in treatment in a variety of service settings across Alberta, Canada (89% outpatients; 60% female).

Results

An exploratory factor analysis identified five subscales-patient-centred care, treatment effectiveness, staff behaviour, availability and coordination of care, and communication.

The subscales had high internal reliability (Cronbach’s alpha = 0.77 to 0.85) and test-retest reliability ranged from 0.53 to 0.82 across the five scales.

Conclusions

Scores on the new instrument were correlated with treatment outcomes.

The assessment of patient experience should be integrated into a continuous, sustainable quality improvement process to be truly effective.

Reference

Currie, S.R., Liu, P., Adamyk-Simpson, J. & Stanich, J. (2020) Validation of a Comprehensive Patient Experience Survey for Addiction and Mental Health that was Co-designed with Service Users. Community Mental Health Journal. 56(4), pp.735-743. doi: 10.1007/s10597-019-00534-1. Epub 2020 Jan 1.

Can Questionnaires Guide Decisions to Refer Adults in Mental Health Services to Autism Diagnostic Services?

Research Paper Title

Testing adults by questionnaire for social and communication disorders, including autism spectrum disorders, in an adult mental health service population.

Background

Autism is difficult to identify in adults due to lack of validated self-report questionnaires.

The researchers compared the effectiveness of the autism-spectrum quotient (AQ) and the Ritvo autism-Asperger’s diagnostic scale-revised (RAADS-R) questionnaires in adult mental health services in two English counties.

Methods

A subsample of adults who completed the AQ and RAADS-R were invited to take part in an autism diagnostic observation schedule (ADOS Module 4) assessment with probability of selection weighted by scores on the questionnaires.

Results

There were 364 men and 374 women who consented to take part.

Recorded diagnoses were most commonly mood disorders (44%) and mental and behavioural disorders due to alcohol/substance misuse (19%), and 4.8% (95% CI [2.9, 7.5]) were identified with autism (ADOS Module 4 10+).

One had a pre-existing diagnosis of autism; five (26%) had borderline personality disorders (all female) and three (17%) had mood disorders.

The AQ and RAADS-R had fair test accuracy (area under receiver operating characteristic [ROC] curve 0.77 and 0.79, respectively).

AQ sensitivity was 0.79 (95% CI [0.54, 0.94]) and specificity was 0.77 (95% CI [0.65, 0.86]); RAADS-R sensitivity was 0.75 (95% CI [0.48, 0.93]) and specificity was 0.71 (95% CI [0.60, 0.81]).

Conclusions

The AQ and RAADS-R can guide decisions to refer adults in mental health services to autism diagnostic services.

Reference

Brugha, T., Tyrer, F., Leaver, A., Lewis, S., Seaton, S., Morgan, Z., Tromans, S. & van Rensburg, K. (2020) Testing adults by questionnaire for social and communication disorders, including autism spectrum disorders, in an adult mental health service population. International Journal of Methods in Psychiatric Research. 29(1):e1814. doi: 10.1002/mpr.1814. Epub 2020 Jan 10.

Can Testing by Questionnaire Guide Decisions to Refer Adults in Mental Health Services to Autism Diagnostic Services?

Research Paper Title

Testing adults by questionnaire for social and communication disorders, including autism spectrum disorders, in an adult mental health service population.

Background

Autism is difficult to identify in adults due to lack of validated self-report questionnaires.

The researchers compared the effectiveness of the autism-spectrum quotient (AQ) and the Ritvo autism-Asperger’s diagnostic scale-revised (RAADS-R) questionnaires in adult mental health services in two English counties.

Methods

A sub-sample of adults who completed the AQ and RAADS-R were invited to take part in an autism diagnostic observation schedule (ADOS Module 4) assessment with probability of selection weighted by scores on the questionnaires.

Results

There were 364 men and 374 women who consented to take part. Recorded diagnoses were most commonly mood disorders (44%) and mental and behavioural disorders due to alcohol/substance misuse (19%), and 4.8% (95% CI [2.9, 7.5]) were identified with autism (ADOS Module 4 10+).

One had a pre-existing diagnosis of autism; five (26%) had borderline personality disorders (all female) and three (17%) had mood disorders.

The AQ and RAADS-R had fair test accuracy (area under receiver operating characteristic [ROC] curve 0.77 and 0.79, respectively).

AQ sensitivity was 0.79 (95% CI [0.54, 0.94]) and specificity was 0.77 (95% CI [0.65, 0.86]); RAADS-R sensitivity was 0.75 (95% CI [0.48, 0.93]) and specificity was 0.71 (95% CI [0.60, 0.81]).

Conclusions

The AQ and RAADS-R can guide decisions to refer adults in mental health services to autism diagnostic services.

Reference

Brugha, T., Tyrer, F., Leaver, A., Lewis, S., Seaton, S., Morgan, Z., Tromans, S. & van Rensburg, K. (2020) Testing adults by questionnaire for social and communication disorders, including autism spectrum disorders, in an adult mental health service population. International Journal of Methods in Psychiatric Research. 29(1):e1814. doi: 10.1002/mpr.1814. Epub 2020 Jan 10.

Comparing the Effectiveness of Prompt Mental Health Care to Treatment as Usual

Research Paper Title

Effectiveness of Prompt Mental Health Care, the Norwegian Version of Improving Access to Psychological Therapies: A Randomized Controlled Trial.

Background

The innovative treatment model Improving Access to Psychological Therapies (IAPT) and its Norwegian adaptation, Prompt Mental Health Care (PMHC), have been evaluated by cohort studies only. Albeit yielding promising results, the extent to which these are attributable to the treatment thus remains unsettled.

Therefore the objective of this research was to investigate the effectiveness of the PMHC treatment compared to treatment as usual (TAU) at 6-month follow-up.

Methods

A randomised controlled trial with parallel assignment was performed in two PMHC sites (Sandnes and Kristiansand) and enrolled clients between November 9, 2015 and August 31, 2017. Participants were 681 adults (aged ≥18 years) considered for admission to PMHC due to anxiety and/or mild to moderate depression (Patient Health Questionnaire [PHQ-9]/Generalised Anxiety Disorder scale [GAD-7] scores above cutoff). These were randomly assigned (70:30 ratio; n = 463 to PMHC, n = 218 to TAU) with simple randomisation within each site with no further constraints. The main outcomes were recovery rates and changes in symptoms of depression (PHQ-9) and anxiety (GAD-7) between baseline and follow-up. Primary outcome data were available for 73/67% in PMHC/TAU. Sensitivity analyses based on observed patterns of missingness were also conducted. Secondary outcomes were work participation, functional status, health-related quality of life, and mental well-being.

Results

A reliable recovery rate of 58.5% was observed in the PMHC group and of 31.9% in the TAU group, equalling a between-group effect size of 0.61 (95% CI 0.37 to 0.85, p < 0.001). The differences in degree of improvement between PMHC and TAU yielded an effect size of -0.88 (95% CI -1.23 to -0.43, p < 0.001) for PHQ-9 and -0.60 (95% CI -0.90 to -0.30, p < 0.001) for GAD-7 in favour of PMHC. All sensitivity analyses pointed in the same direction, with small variations in point estimates. Findings were slightly more robust for depressive than anxiety symptoms. PMHC was also more effective than TAU in improving all secondary outcomes, except for work participation (z = 0.415, p = 0.69).

Conclusions

The PMHC treatment was substantially more effective than TAU in alleviating the burden of anxiety and depression. This adaptation of IAPT is considered a viable supplement to existing health services to increase access to effective treatment for adults who suffer from anxiety and mild to moderate depression. A potential effect on work participation needs further examination.

Reference

Knapstad, M., Lervik, L.V., Sæther, S.M.M., Aarø, L.E. & Smith, O.R.F. (2019) Effectiveness of Prompt Mental Health Care, the Norwegian Version of Improving Access to Psychological Therapies: A Randomized Controlled Trial. Psychotherapy and Psychosomatics. 1-16. doi: 10.1159/000504453. [Epub ahead of print].