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
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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/over-detection 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). On the basis of 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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The PHQ-8 has good reliability (α=.86-.89) and has shown validity across different racial and ethnic groups.
“The PHQ-8 has good reliability (α=.86-.89) and has shown validity across different racial and ethnic groups [69].”
From App-Based Mindfulness Meditation for People of Color Who Experience Race-Related Stress: Protocol for a Randomized Controlled Trial (2022) · cites this paper as [69]
The Results (page unavailable) find measurement invariance across racial and ethnic groups, and Methods > Measures describes high internal consistency—but both findings concern the PHQ-9. The cited paper does not establish these properties for the PHQ-8 or report the claimed α=.86–.89 range. (LLM, conf=0.84)
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- Authors
- Patel, J. S., Oh, Y., Rand, K. L., Wu, W., Cyders, M. A., Kroenke, K., & Stewart, J. C.
- Affiliations
- Indiana University – Purdue University Indianapolis (US)
- Texas Tech University (US)
- Regenstrief Institute (US)
- Corresponding author
- Stewart, Jesse C.
- Venue
- Depression and Anxiety
- Publisher
- Wiley
- Published
- 2019-07-29
- Volume
- 36
- Issue
- 9
- Pages
- 813-823
- ISSN
- 1091-4269 (ISSN-L)
- 1520-6394
- PMC
- PMC6736700
- OpenAlex
- W2786060782
- Cited by
- 306
- References
- 71
- Citations by year
- 2026: 47 · 2025: 49 · 2024: 83 · 2023: 49 · 2022: 36 · 2021: 25 · 2020: 11 · 2019: 5 · 2017: 1
- FWCI
- 13.73
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Licence
- Locations
- Depression and Anxiety (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- IUScholarWorks (Indiana University) (submittedVersion)
- PMC
- Funders
- National Heart, Lung, and Blood Institute (R01HL122245)
- Topics
- Social Sciences › Decision Sciences › Management Science and Operations Research › Psychometric Methodologies and Testing
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Keywords
- PHQ-9, measurement invariance, depression screening, factor structure, somatic depressive symptoms, sociodemographic disparities, sex differences, race and ethnicity, educational attainment, NHANES
- MeSH terms
- Patient Health Questionnaire, Depression, Depressive Disorder, Educational Status, Ethnicity, Factor Analysis, Statistical, Female, Humans, Male, Mass Screening, Middle Aged, Nutrition Surveys, Psychometrics, Racial Groups
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