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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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Patel, Jay S., Oh, Youngha, Rand, Kevin L., Wu, Wei, Cyders, Melissa A., Kroenke, Kurt, Stewart, Jesse C.·2019·Depression and Anxiety

DOI 10.1002/da.22940PMC PMC6736700

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Abstract

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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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.
ORCID: Rand, Kevin L.
Wu, Wei
Cyders, Melissa A.
Kroenke, Kurt
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
DOI: 10.1002/da.22940
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
FWCI: 13.73
Type: journal article
Language: en
Open access: green
www.ncbi.nlm.nih.gov
Licence: onlinelibrary.wiley.com/termsAndConditions#vor (vor)
doi.wiley.com/10.1002/tdm_license_1.1 (tdm)
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
Health Sciences › Medicine › Psychiatry and Mental health › 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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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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