Measurement invariance of the patient health questionnaire-9 (PHQ-9) depression screener in U.S. adults across sex, race/ethnicity, and education level: NHANES 2005–2016
Date
2019-07-29
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American English
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Wiley
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Patel, J. S., Oh, Y., Rand, K. L., Wu, W., Cyders, M. A., Kroenke, K., & Stewart, J. C. (2019). Measurement invariance of the patient health questionnaire-9 (PHQ-9) depression screener in U.S. adults across sex, race/ethnicity, and education level: NHANES 2005–2016. Depression and Anxiety, 36(9), 813–823. https://doi.org/10.1002/da.22940
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1520-6394
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Background:
Despite its popularity, little is known about the measurement invariance of the Patient Health Questionnaire-9 (PHQ-9) across U.S. sociodemographic groups. Use of a screener shown not to possess measurement invariance could result in under-detection/treatment of depression, potentially exacerbating sociodemographic disparities in depression. Therefore, we assessed the factor structure and measurement invariance of the PHQ-9 across major U.S. sociodemographic groups.
Methods:
U.S. population representative data came from the 2005–2016 National Health and Nutrition Examination Survey (NHANES) cohorts We conducted a measurement invariance analysis of 31,366 respondents across sociodemographic factors of sex, race/ethnicity, and education level.
Results:
Considering results of single-group confirmatory factor analyses (CFAs), depression theory, and research utility, we justify a two-factor structure for the PHQ-9 consisting of a cognitive/affective factor and a somatic factor (RMSEA=0.034, TLI=0.985, CFI=0.989). Based on multiple-group CFAs testing configural, scalar, and strict factorial invariance, we determined that invariance held for sex, race/ethnicity, and education level groups, as all models demonstrated close model fit (RMSEA=0.025–0.025, TLI=0.985–0.992, CFI=0.986–0.991). Finally, for all steps ΔCFI was < −0.004, and ΔRMSEA was < 0.01.
Conclusions:
We demonstrate that the PHQ-9 is acceptable to use in major U.S. sociodemographic groups and allows for meaningful comparisons in total, cognitive/affective, and somatic depressive symptoms across these groups, extending its use to the community. This knowledge is timely as medicine moves towards alternative payment models emphasizing high-quality and cost-efficient care, which will likely incentivize behavioral and population health efforts. We also provide a consistent, evidence-based approach for calculating PHQ-9 subscale scores.
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Depression and Anxiety
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PMC
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