Patient Health Questionnaire Anxiety and Depression Scale: Initial Validation in Three Clinical Trials

Kroenke, Kurt; Wu, Jingwei; Yu, Zhangsheng; Bair, Matthew J.; Kean, Jacob; Stump, Timothy; Monahan, Patrick O.

doi:10.1097/psy.0000000000000322

Cited by 504Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesPsychometric Methodologies and TestingMental Health Treatment and Access

Patient Health Questionnaire Anxiety and Depression Scale: Initial Validation in Three Clinical Trials

Open access

Kroenke, Kurt, Wu, Jingwei, Yu, Zhangsheng, Bair, Matthew J., Kean, Jacob, Stump, Timothy, Monahan, Patrick O.·2016·Psychosomatic Medicine

DOI 10.1097/psy.0000000000000322PMC PMC4927366

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Abstract

Objective: We examine the reliability and validity of the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS)—which combines the nine-item Patient Health Questionnaire depression scale and seven-item Generalized Anxiety Disorder scale—as a composite measure of depression and anxiety. Methods: Baseline data from 896 patients enrolled in two primary-care based trials of chronic pain and one oncology-practice–based trial of depression and pain were analyzed. The internal reliability, standard error of measurement, and convergent, construct, and factor structure validity, as well as sensitivity to change of the PHQ-ADS were examined. Results: The PHQ-ADS demonstrated high internal reliability (Cronbach α values of .8 to .9) in all three trials. PHQ-ADS scores can range from 0 to 48 (with higher scores indicating more severe depression/anxiety), and the estimated standard error of measurement was approximately 3 to 4 points. The PHQ-ADS showed strong convergent (most correlations, 0.7–0.8 range) and construct (most correlations, 0.4–0.6 range) validity when examining its association with other mental health, quality of life, and disability measures. PHQ-ADS cutpoints of 10, 20, and 30 indicated mild, moderate, and severe levels of depression/anxiety, respectively. Bifactor analysis showed sufficient unidimensionality of the PHQ-ADS score. PHQ-ADS change scores at 3 months differentiated ( p < .0001) between individuals classified as worse, stable, or improved by a reference measure, providing preliminary evidence for sensitivity to change. Conclusions: The PHQ-ADS may be a reliable and valid composite measure of depression and anxiety which, if validated in other populations, could be useful as a single measure for jointly assessing two of the most common psychological conditions in clinical practice and research. Trial Registration : Clinicaltrials.gov Identifier: NCT00926588 (SCOPE); NCT00386243 (ESCAPE); NCT00313573 (INCPAD).

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Claims the paper makes

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Findingown data
The PHQ-ADS showed high internal reliability, with Cronbach's alpha between 0.8 and 0.9, in all three trials.
“The PHQ-ADS demonstrated high internal reliability (Cronbach's alpha of 0.8 to 0.9) in all 3 trials.”
- Also stated in: § Psychometric Characteristics of PHQ-9, GAD-7 and PHQ-ADS in the 3 Trials · plain
  “All 3 scale scores demonstrated good internal reliability, with Cronbach's alphas in the 0.8 to 0.9 range.”
Quote in the paperSubstantial claim
Findingown data
The PHQ-ADS had construct validity with quality-of-life and disability measures, with most correlations in the 0.4 to 0.6 range.
“The PHQ-ADS showed strong convergent (most correlations 0.7-0.8 range) and construct (most correlations 0.4-0.6 range) validity when examining its association with other mental health, quality of life and disability measures.”
Quote in the paperSubstantial claim
Findingown data
The PHQ-ADS had strong convergent validity with other mental health measures, with most correlations in the 0.7 to 0.8 range.
“The PHQ-ADS showed strong convergent (most correlations 0.7-0.8 range) and construct (most correlations 0.4-0.6 range) validity when examining its association with other mental health, quality of life and disability measures.”
Quote in the paperSubstantial claim
Findingown data
The estimated standard error of measurement for the PHQ-ADS was about 3 to 4 points.
“the estimated SEM was approximately 3 to 4 points”
Quote in the paperNot a substantial claim
Findingown data
Bi-factor analysis showed that the PHQ-ADS score had sufficient unidimensionality.
“Bi-factor analysis showed sufficient unidimensionality of the PHQ-ADS score.”
- Also stated in: § Structural Validity of the PHQ-ADS · hedged
  “further suggesting sufficient unidimensionality and supporting the structural validity of a single PHQ-ADS composite score”
Quote in the paperSubstantial claim

Findingown data
In INCPAD, MHI-5 change scores classified 73 patients as worse, 115 as unchanged, and 147 as improved.
“In the INCPAD trial, there were 73 patients classified as worse, 115 as unchanged, and 147 as improved.”
Quote in the paperNot a substantial claim
Findingown data
A similar incremental dose-response pattern appeared across all quality-of-life and disability domains.
“A similar incremental “dose-response” effect is seen on all quality of life and disability domains.”
Quote in the paperSubstantial claim
Findingown data
Scree plots of eigenvalues indicated one dominant factor.
“Finally, the scree plots (Figure S1, Supplemental Digital Content 1) of the eigenvalues indicated that there was one dominant factor, because the eigenvalues dropped greatly from the first to the second factor, after which eigenvalues leveled off with much smaller drops between the second and remaining factors.”
Quote in the paperSubstantial claim
Findingown data
PHQ-ADS item-total correlations were good, ranging from 0.42 to 0.69.
“all item-total correlations were good (0.42 to 0.69)”
Quote in the paperSubstantial claim
Findingown data
Results in the INCPAD oncology trial were generally comparable to the two primary care trials but weaker on a few psychometric analyses.
“Fourth, the results in the INCPAD trial of oncology patients were, though generally comparable to the two primary care trials, weaker on a few of the psychometric analyses.”
Quote in the paperNot a substantial claim
Findingown data
The chi-square test was significant in all three trials.
“Although the chi-square test was significant in all 3 trials (suggesting some deviation from good fit), this fit index yields high power in larger samples to detect minor deviations.”
Quote in the paperNot a substantial claim
Findingown data
In SCOPE, MHI-5 change scores at 3 months classified 56 patients as worse, 113 as unchanged, and 75 as improved.
“According to the MHI-5 change scores at 3 months, there were 56 patients in the SCOPE trial who were classified as worse, 113 as unchanged, and 75 as improved.”
Quote in the paperSubstantial claim
Findingown data
Depression, anxiety, and composite psychological scores increased substantially across the four PHQ-ADS ordinal categories from minimal to severe.
“There is a large incremental increase in depression (PHQ-9), anxiety (GAD-7), and psychological composite (PROMIS-ADS, MHI-5, and MCS) scores as one goes from minimal to mild to moderate to severe levels of depression/anxiety as classified by the four PHQ-ADS ordinal categories.”
Quote in the paperSubstantial claim
Findingown data
All three scale scores had good internal reliability, with Cronbach's alpha in the 0.8 to 0.9 range.
“All 3 scale scores demonstrated good internal reliability, with Cronbach's alphas in the 0.8 to 0.9 range.”
Quote in the paperSubstantial claim
Findingown data
Construct validity was supported by moderate correlations of each of the three scales with quality-of-life and disability measures.
“Construct validity was supported by moderate correlations of each of the 3 scales with quality of life and disability measures.”
Quote in the paperSubstantial claim
Premisecitation
Depression and anxiety often occur together.
“First, depression and anxiety frequently co-occur.3-5;10-16”
- Also stated in: § Discussion · plain
  “The high comorbidity of depression and anxiety is one reason a composite measure may be useful.”
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Interpretationown data
The statistically determined SEM suggests that a 3 to 4 point change on the PHQ-ADS may represent a clinically important difference.
“The statistically-determined SEM suggests that a 3 to 4 point change on the PHQ-ADS may represent a clinically important difference.”
Quote in the paperSubstantial claim
Interpretationown data
Using the PHQ-9 and GAD-7 together increases detection of comorbid anxiety.
“This supports joint use of the PHQ-9 and GAD-7 to increase the detection of comorbid anxiety”
Quote in the paperSubstantial claim
Premisecitation
Theoretical and empirical evidence supports an overarching psychological construct that includes distinct but related depression and anxiety dimensions.
“Third, theoretical and empiric evidence supports an overarching psychological construct that encompasses distinct but related dimensions of depression and anxiety.18;19”
Quote in the paperSubstantial claim0 of 2 sources checked
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Premisecitation
The GAD-7 performs nearly as well for panic disorder, social anxiety disorder, and posttraumatic stress disorder as it does for generalized anxiety disorder.
“Although originally developed as a measure to detect generalized anxiety disorder32, the operating characteristics of the GAD-7 are nearly as good for the other common anxiety disorders in clinical practice – panic disorder, social anxiety disorder, and posttraumatic stress disorder.23”
Quote in the paperNot a substantial claim0 of 1 sources checked
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Study design and conductnone given
The assessment of construct validity relied on relatively brief PROMIS and SF mental health measures.
“Sixth, our assessment of construct validity relied on relatively brief PROMIS and SF mental health measures; future studies should compare the PHQ-ADS to more detailed depressive and anxiety scales, both in terms of construct validity as well as responsiveness to treatment.”
Quote in the paperNot a substantial claim
Interpretationreasoning
Using a composite depression-anxiety score as the primary outcome in trials that target both conditions would permit a smaller sample than using separate co-primary depression and anxiety outcomes.
“Consequently, selecting a composite score as the primary outcome for interventional studies targeting both depression and anxiety would allow for a smaller sample size than using depression and anxiety as separate co-primary outcomes.”
Quote in the paperNot a substantial claim
Interpretationown data
Comparison of PHQ-ADS change scores among MHI-5-defined worse, stable, and improved groups suggests the PHQ-ADS is sensitive to change over time.
“Also, the comparison of PHQ-ADS change scores among worse, stable, and improved groups as defined by the MHI-5 suggest the PHQ-ADS is sensitive to change over time.”
Quote in the paperSubstantial claim
- Rests on an assumption: The MHI-5 change classification of worse, unchanged, or improved is a valid reference standard for clinically meaningful change in depression and anxiety symptoms.
Interpretationown data
If only the PHQ-9 had been used, 307 patients (34.3%) with chronic pain who had anxiety only or combined anxiety and depression would not have been detected.
“Thus, if only the PHQ-9 had been used in these trials, 307 (34.3%) of patients with chronic pain who had anxiety only or, more commonly, combined anxiety and depression, would not have been detected.”
Quote in the paperSubstantial claim

May combine two claims. 28
Classified as probably not a substantial claim. 5

May combine two claims.
Findingown data
PHQ-ADS change scores at 3 months differentiated between groups classified as worse, stable, or improved by a reference measure, giving preliminary evidence of sensitivity to change.
“PHQ-ADS change scores at 3 months differentiated (P < .0001) between individuals classified as worse, stable, or improved by a reference measure, providing preliminary evidence for sensitivity to change.”
- Also stated in: § Sensitivity to Change of the PHQ-ADS · plain
  “the PHQ-ADS change scores significantly differentiated between the worse, unchanged, and improved groups in both trials”
Quote in the paperSubstantial claim
- Rests on an assumption: The MHI-5 change classification of worse, unchanged, or improved is a valid reference standard for clinically meaningful change in depression and anxiety symptoms.
May combine two claims.
Findingown data
The WRMR threshold of at most 1.0 was met for the bi-factor model in all three trials, the two-factor model in one trial, and the one-factor model in none.
“Finally, the WRMR threshold of ≤ 1.0 was achieved for the bi-factor model in all 3 trials, the 2-factor model in only 1 trial, and the 1-factor model in none of the trials.”
Quote in the paperSubstantial claim
May combine two claims.
Findingown data
The PHQ-ADS correlated most strongly with its component PHQ-9 and GAD-7 scales, and the PHQ-9 and GAD-7 correlated moderately strongly with each other.
“As shown in Table 3, the PHQ-ADS had the strongest correlations with the PHQ-9 and GAD-7 (its two component scales), and the PHQ-9 and GAD-7 had moderately strong correlations with one another.”
Quote in the paperSubstantial claim
May combine two claims.
Findingreasoning
The INCPAD trial had the highest mean depression scores, while the SCOPE trial had the lowest depression and anxiety scores.
“The INCPAD trial enrolled patients with depression as well as pain and therefore, not surprisingly, had the highest mean depression scores, whereas the SCOPE trial had the lowest depression and anxiety scores.”
Quote in the paperNot a substantial claim
May combine two claims.
Findingnone given
All three trials focused on patients with pain rather than on individuals with depression or anxiety, except that INCPAD enrolled patients with depression.
“First, all 3 trials focused on patients with pain, rather than individuals with depression (except INCPAD) or anxiety.”
Quote in the paperSubstantial claim
May combine two claims.
Findingown data
PHQ-ADS change scores differed significantly among the worse, unchanged, and improved categories by analysis of variance, and pairwise comparisons also differed in both trials.
“The PHQ-ADS change scores among categories were significantly different (P < .0001) by analysis of variance, and pairwise comparisons between the worse, unchanged, and improved categories also differed (p < .001) in both trials.”
Quote in the paperSubstantial claim
May combine two claims.
Findingown data
The three trials included a substantial number of patients meeting clinical cutpoints for depression and combined depression/anxiety, but only a small proportion with anxiety only.
“Also, there was a substantial number of patients who met clinical cutpoints for depression and combined depression/anxiety in the 3 trials, but only a small proportion with anxiety only.”
Quote in the paperSubstantial claim
May combine two claims.
Findingown data
In SCOPE, mean PHQ-ADS scores increased by 3.63 points in the worse group, decreased by 3.12 points in the stable group, and decreased by 7.96 points in the improved group, with standardized response means of -0.45, -0.51, and -0.98.
“The mean PHQ-ADS score increased 3.63 points in the worse group, declined 3.12 points in the stable group, and declined 7.96 points in the improved group, resulting in SRMs of -0.45, --0.51, and --0.98, respectively.”
Quote in the paperSubstantial claim
May combine two claims.
Findingown data
Using a 1-SEM change, the estimated minimal clinically important difference was about 2 to 3 points for the PHQ-9 and GAD-7 and about 3 to 4 points for the PHQ-ADS.
“Using a 1-SEM change to estimate a minimal clinically important difference (MCID), the MCID estimated from these 3 trials would be approximately 2 to 3 points for the PHQ-9 and GAD-7 and 3 to 4 points for the PHQ-ADS.”
Quote in the paperNot a substantial claim
May combine two claims.
Findingown data
Among the trial patients, 286 (31.9%) scored at or above 10 on both the PHQ-9 and GAD-7, 266 (29.7%) on the PHQ-9 only, 21 (2.3%) on the GAD-7 only, and 323 (36.1%) on neither.
“The number of patients in the 3 trials that achieved this cutpoint on both the PHQ-9 and GAD-7 was 286 (31.9%); on the PHQ-9 only, 266 (29.7%); on the GAD-7 only, 21 (2.3%); and on neither measure, 323 (36.1%).”
Quote in the paperSubstantial claim
May combine two claims.
Findingown data
Patient samples in two of the trials were exclusively Veterans and predominantly men.
“Second, patient samples in two of the trials were exclusively Veterans and predominantly men; thus, data on the PHQ-ADS in non-Veteran samples including more women is warranted.”
Quote in the paperSubstantial claim
May combine two claims.
Findingown data
Most factor loadings were substantially above 0.40 and were only slightly higher in the two-factor model than in the one-factor model.
“most of the factor loadings were substantially higher than the acceptable threshold of 0.40, and were only slightly higher for the 2-factor compared to the 1-factor model”
Quote in the paperNot a substantial claim
May combine two claims.
Findingown data
The three scales showed moderately strong convergent validity with composite psychological measures, with the PHQ-ADS having slightly higher correlations than the PHQ-9 and GAD-7.
“The 3 scales also showed moderately strong convergent validity with the 3 composite psychological measures (PROMIS-ADS, MHI-5, and MCS) with the PHQ-ADS having slightly higher correlations than the PHQ-9 and GAD-7.”
Quote in the paperSubstantial claim
May combine two claims.
Findingown data
Fit generally improved slightly when comparing the two-factor model with the one-factor model, and improved more when comparing the bi-factor model with either.
“There was generally a small improvement in fit when comparing the 2-factor to 1-factor model, and a greater improvement when comparing the bi-factor to either the 1-factor or 2-factor models.”
Quote in the paperSubstantial claim
May combine two claims.
Findingown data
In the three trials, mean PHQ-9 scores reflected moderate depression and mean GAD-7 scores reflected mild anxiety.
“As shown in Table 2, the mean PHQ-9 and GAD-7 scores in the 3 trials represent moderate levels of depression and mild levels of anxiety, respectively.”
Quote in the paperNot a substantial claim
May combine two claims.
Findingown data
In INCPAD, mean PHQ-ADS scores decreased in all three groups: by 5.10 points in the worse group, 9.72 points in the unchanged group, and 16.40 points in the improved group, with standardized response means of -0.57, -1.28, and -1.89.
“The mean PHQ-ADS score decreased in all 3 groups (--5.10 points in the worse group, --9.72 points in the unchanged group, and --16.40 in the improved group, resulting in SRMs of --0.57, --1.28, and -1.89, respectively.”
Quote in the paperSubstantial claim
May combine two claims.
Findingown data
The CFI threshold of at least .95 was met for all three models in SCOPE and ESCAPE but only for the bi-factor model in INCPAD.
“The CFI threshold of ≥ .95 was achieved for all 3 models in the SCOPE and ESCAPE trials but only for the bifactor model in the INCPAD trial.”
Quote in the paperSubstantial claim
May combine two claims.
Findingown data
Using a 2-SEM change, the estimated minimal clinically important difference was about 4 to 6 points for the PHQ-9 and GAD-7 and about 6 to 8 points for the PHQ-ADS.
“Using a more conservative estimate of a 2-SEM change, the MCID would be approximately 4 to 6 points for the PHQ-9 and GAD-7 and 6 to 8 points for the PHQ-ADS.”
Quote in the paperSubstantial claim
May combine two claims.
Findingown data
The RMSEA threshold of at most .06 was met for the bi-factor model in two trials but for none of the one-factor or two-factor models.
“The RMSEA threshold of ≤ .06 was achieved for the bifactor model in two of the trials but in none of the trials for the 1-factor and 2-factor models.”
Quote in the paperSubstantial claim
May combine two claims.
Interpretationown data
The PHQ-ADS may be a reliable and valid composite measure of depression and anxiety.
“The PHQ-ADS may be a reliable and valid composite measure of depression and anxiety”
- Also stated in: § Conclusions · hedged
  “The PHQ-ADS may be a reliable and valid composite measure of depression and anxiety which, if validated in other populations, could be useful as a single measure for jointly assessing two of the most common psychological conditions in clinical practice and research.”
Quote in the paperSubstantial claim
May combine two claims.
Interpretationown data
PHQ-ADS scores of 10, 20, and 30 mark mild, moderate, and severe depression/anxiety, respectively.
“PHQ-ADS cutpoints of 10, 20, and 30 indicated mild, moderate, and severe levels of depression/anxiety, respectively.”
- Also stated in: § Discussion · hedged
  “Second, cutpoints of 10, 20, and 30 on the PHQ-ADS indicate mild, moderate, and severe levels of depression/anxiety symptoms, respectively.”
Quote in the paperSubstantial claim
May combine two claims.
Interpretationown data
Taken together, the fit indices and factor loadings support the traditional scoring of the PHQ-9 and GAD-7 as depression and anxiety scales and support sufficient unidimensionality of the PHQ-ADS composite score.
“Taken together, the fit indices and the factor loadings point to the validity of the traditional scoring of the PHQ-9 and GAD-7 as depression and anxiety scale scores as well as the sufficient unidimensionality of scoring the PHQ-ADS as a composite score.”
Quote in the paperSubstantial claim
Probably not a substantial claim: may not pass S2 (checkable).
Interpretationreasoning
The PHQ-ADS score may be useful in studies as an outcome variable or as a covariate in multivariable analyses.
“The PHQ-ADS score may be useful in studies for which a single depression/anxiety score is desirable as either an outcome variable or as a covariate to adjust for in multivariable analyses.”
Quote in the paperNot a substantial claim
May combine two claims.
Premisecitation
Both the PHQ-9 and GAD-7 have been shown to be sensitive to change when treatment response is monitored.
“Moreover, both measures have proven sensitive to change when monitoring treatment response.20;33-36”
Quote in the paperNot a substantial claim0 of 5 sources checked
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Classified as probably not a substantial claim. May combine two claims.
Premisecitation
The PHQ-9 and GAD-7 have strong internal and test-retest reliability and construct and factor-structure validity.
“The PHQ-9 and GAD-7 have strong internal and test-retest reliability as well as construct and factor-structure validity.20”
Quote in the paperSubstantial claim0 of 1 sources checked
- cites [20] source
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Interpretationreasoning
A PHQ-ADS screening cutpoint would be higher than the PHQ-9 or GAD-7 cutpoint of 10 because the PHQ-ADS has a greater score range; for example, 20 corresponded to moderate depression/anxiety on the PHQ-ADS in this sample.
“Certainly, a PHQ-ADS screening cutpoint would be higher than that of the PHQ-9 or GAD-7 (which are ≥ 10) since its score range is greater; for example, 10 represents a cutpoint for moderate depressive symptoms on the PHQ-9 and moderate anxiety symptoms on the GAD-7, whereas 20 represented a cutpoint for moderate depressive/anxiety symptoms on the PHQ-ADS in our sample.”
Quote in the paperNot a substantial claim
May combine two claims.
Study design and conductown data
The study did not use a structured criterion standard diagnostic interview, so it could not compare the sensitivity and specificity of the PHQ-ADS with the PHQ-9 and GAD-7.
“Fifth, we did not use a structured criterion standard diagnostic interview in these 3 trials to determine which patients met criteria for depressive or anxiety disorders, and thus were unable to compare the sensitivity and specificity of the PHQ-ADS with the PHQ-9 and GAD-7.”
Quote in the paperSubstantial claim
Classified as probably not a substantial claim.
Interpretationreasoning
Because depression and anxiety are moderately strongly intercorrelated, a composite score is attractive as a covariate in multivariable and adjusted analyses.
“Fourth, the moderately strong intercorrelation between depression and anxiety makes a composite score attractive as a covariate in multivariate modeling and other types of adjusted analyses.”
Quote in the paperSubstantial claim
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Premisecitation
The PHQ-9 and GAD-7 are among the best validated and most commonly used measures of depression and anxiety, respectively.
“The Patient Health Questionnaire 9-item depression scale (PHQ-9) and 7-item Generalized Anxiety Disorder scale (GAD-7) are among the best validated and most commonly used depression and anxiety measures, respectively.20-25”
Quote in the paperNot a substantial claim0 of 6 sources checked
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Interpretationreasoning
The PHQ-ADS may be useful for monitoring treatment of depression and anxiety together.
“The PHQ-ADS may also be useful in monitoring the concomitant treatment of depression and anxiety, especially since some treatments work across both conditions.”
Quote in the paperSubstantial claim
- Rests on an assumption: Some interventions, such as cognitive-behavioral therapy and certain classes of antidepressants, are effective for both depression and anxiety.
May combine two claims.
Study design and conductown data
The study did not test responsiveness of the PHQ-ADS to treatment because none of the three trials specifically treated anxiety and only one targeted depression.
“Third, we did not test responsiveness to treatment of the PHQ-ADS since none of the 3 trials were specifically treating anxiety and only one was targeting depression.”
Quote in the paperSubstantial claim

31 of 31

The paper relies on this without support.
The MHI-5 change classification of worse, unchanged, or improved is a valid reference standard for clinically meaningful change in depression and anxiety symptoms.
“three MHI-5 change groups (worse, same, improved) were computed for each patient by determining whether the MHI-5 declined or improved by more than 1.0 standard error of measurement (SEM) from baseline to follow-up at 3 months”
“the comparison of PHQ-ADS change scores among worse, stable, and improved groups as defined by the MHI-5 suggest the PHQ-ADS is sensitive to change over time”
The paper relies on this without support.
Some interventions, such as cognitive-behavioral therapy and certain classes of antidepressants, are effective for both depression and anxiety.
“some interventions (e.g., cognitive-behavioral therapy; certain classes of antidepressants) are effective for both depression and anxiety”

2 of 2

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Participants who interacted with BalanceUP experienced a clinically important improvement, reporting an average 3.9 (SD 5.59) point reduction of perceived depression and anxiety symptoms after the intervention.
“Participants who interacted with BalanceUP experienced a clinically important improvement, reporting, on average, a 3.9 (SD 5.59) point reduction [85] of perceived depression and anxiety symptoms after the intervention.”
From Development and Evaluation of a Smartphone-Based Chatbot Coach to Facilitate a Balanced Lifestyle in Individuals With Headaches (BalanceUP App): Randomized Controlled Trial (2024) · cites this paper as [85]
The Results section (Psychometric Characteristics) estimates a 3–4 point PHQ-ADS change as a minimal clinically important difference, and the Discussion says such a change may be clinically important. That supports a tentative interpretation of a 3.9-point reduction, but this validation paper does not report BalanceUP participants or their stated mean reduction and SD; it also does not establish that their change was clinically important. (LLM, conf=0.88)
Experimental — accuracy not yet measured
PHQ-ADS has good internal consistency (α = 0.88-0.92).
“PHQ-ADS is the combined sum score of the questionnaires Generalized Anxiety Disorder Screener (GAD-7) and Patient Health Questionnaire (PHQ-9) as a composite measure of depression and anxiety, with good internal consistency [α = 0.88–0.92; (51)].”
From Clinical and Cost-Effectiveness of PSYCHOnlineTHERAPY: Study Protocol of a Multicenter Blended Outpatient Psychotherapy Cluster Randomized Controlled Trial for Patients With Depressive and Anxiety Disorders (2021) · cites this paper as [51]
The Results section (“Psychometric Characteristics of PHQ-9, GAD-7 and PHQ-ADS in the 3 Trials”; page unavailable) reports good internal reliability, with Cronbach’s alphas in the 0.8–0.9 range. Our copy does not give the cited precise range of 0.88–0.92, so it supports the qualitative claim but not those endpoints. (LLM, conf=0.84)
Experimental — accuracy not yet measured
The Patient Health Questionnaire (PHQ-9) has good internal consistency (α>.80).
“The scale has demonstrated good internal consistency (α>.80) [42].”
From The Effectiveness of a Smartphone Intervention Targeting Suicidal Ideation in Young Adults: Randomized Controlled Trial Examining the Influence of Loneliness (2023) · cites this paper as [42]
The PHQ-ADS is a composite measure of depression and anxiety consisting of the combined sum score of the GAD-7 and PHQ-9, and it has good internal consistency (α = .88 to .92).
“PHQ-ADS is the combined sum score of the questionnaires GAD-7 and PHQ-9 as a composite measure of depression and anxiety, with good internal consistency (α = .88 to .92) [50].”
From Effectiveness and cost-effectiveness of guided Internet- and mobile-based CBT for adolescents and young adults with chronic somatic conditions and comorbid depression and anxiety symptoms (youthCOACHCD): study protocol for a multicentre randomized controlled trial (2020) · cites this paper as [50]
The 3-category approach may result in overestimation of MIDs.
“In addition, although a 3-category approach (i.e., Worse, Same, or Better SF-36 Vitality scores) has commonly been used to determine MIDs and converges with distribution-based methods [68, 69], it may result in overestimation of MIDs.”
From Comparative responsiveness and minimally important difference of fatigue symptom inventory (FSI) scales and the FSI-3 in trials with cancer survivors (2022) · cites this paper as [69]

The PHQ-9: Validity of a brief depression severity measure
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001) · Journal of General Internal Medicine · doi:10.1046/j.1525-1497.2001.016009606.x · Cited by 44,910 · see citing works
Self-citation
A Brief Measure for Assessing Generalized Anxiety Disorder: The GAD-7
Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006) · Archives of Internal Medicine · doi:10.1001/archinte.166.10.1092 · Cited by 31,765 · see citing works
Self-citation
Lifetime and 12-Month Prevalence of DSM-III-R Psychiatric Disorders in the United States: Results From the National Comorbidity Survey
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Validation and Utility of a Self-report Version of PRIME-MD<SUBTITLE>The PHQ Primary Care Study</SUBTITLE>
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Bifactor Models and Rotations: Exploring the Extent to Which Multidimensional Data Yield Univocal Scale Scores
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Common mental disorders and disability across cultures. Results from the WHO Collaborative Study on Psychological Problems in General Health Care
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Depression Comorbid with Anxiety: Results from the WHO Study on Psychological Disorders in Primary Health Care
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“AWorld Health Organization study involving the administration of a structured psychiatric interview to 5438 primary care patients from 15 international primary sites found that 39% of patients with current depression also had an anxiety disorder, and 44% with a current anxiety disorder also had comorbid depression (53…”
Background
Comorbid Depression, Chronic Pain, and Disability in Primary Care
Arnow, B. A., Hunkeler, E. M., Blasey, C. M., Lee, J., Constantino, M. J., FIREMAN, B. H., KRAEMER, H. C., Dea, R., Robinson, R., & Hayward, C. (2006) · Psychosomatic Medicine · doi:10.1097/01.psy.0000204851.15499.fc · Cited by 533 · see citing works
Latent structure of the Hospital Anxiety And Depression Scale: a 10-year systematic review
Cosco, T. D., Doyle, F., Ward, M., & McGee, H. (2012) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2011.06.008 · Cited by 417 · see citing works
Depression and Anxiety in the United States: Findings From the 2006 Behavioral Risk Factor Surveillance System
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Screening for mood and anxiety disorders with the five-item, the three-item, and the two-item Mental Health Inventory
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Screening and case finding for major depressive disorder using the Patient Health Questionnaire (PHQ-9): a meta-analysis
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The epidemiology of generalized anxiety disorder
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Accuracy of the Hospital Anxiety and Depression Scale as a screening tool in cancer patients: a systematic review and meta-analysis
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Effect of Telecare Management on Pain and Depression in Patients With Cancer
Kroenke, K., Theobald, D., Wu, J., Norton, K., Morrison, G. C., Carpenter, J. S., & Tu, W. (2010) · JAMA · doi:10.1001/jama.2010.944 · Cited by 325 · see citing works
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Psychometric comparison of the Generalized Anxiety Disorder Scale-7 and the Penn State Worry Questionnaire for measuring response during treatment of generalised anxiety disorder
Dear, B. F., Titov, N., Sunderland, M., McMillan, D., Anderson, T., Lorian, C., & Robinson, E. (2011) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2011.582138 · Cited by 282 · see citing works
Common and specific dimensions of self-reported anxiety and depression: Implications for the cognitive and tripartite models
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Usefulness of five-item and three-item Mental Health Inventories to screen for depressive symptoms in the general population of Japan
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Efficiency of static and computer adaptive short forms compared to full-length measures of depressive symptoms
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Depression, anxiety, and somatoform disorders: vague or distinct categories in primary care? Results from a large cross-sectional study
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Telecare Collaborative Management of Chronic Pain in Primary Care: A Randomized Clinical Trial
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Confirmatory Factor Analysis: An Introduction for Psychosomatic Medicine Researchers
Babyak, M. A., & Green, S. B. (2010) · Psychosomatic Medicine · doi:10.1097/psy.0b013e3181de3f8a · Cited by 191 · see citing works
Operating Characteristics of PROMIS Four-Item Depression and Anxiety Scales in Primary Care Patients with Chronic Pain
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Comparative Responsiveness of Pain Outcome Measures Among Primary Care Patients With Musculoskeletal Pain
Krebs, E. E., Bair, M. J., Damush, T. M., Tu, W., Wu, J., & Kroenke, K. (2010) · Medical Care · doi:10.1097/mlr.0b013e3181eaf835 · Cited by 162 · see citing works
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Fibromyalgia and neuropathic pain - differences and similarities. A comparison of 3057 patients with diabetic painful neuropathy and fibromyalgia
Koroschetz, J., Rehm, S., Gockel, U., Brosz, M., Freynhagen, R., Tölle, T. R., & Baron, R. (2011) · BMC Neurology · doi:10.1186/1471-2377-11-55 · Cited by 161 · see citing works
The accuracy of Patient Health Questionnaire-9 in detecting depression and measuring depression severity in high-risk groups in primary care
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Evaluation of Stepped Care for Chronic Pain (ESCAPE) in Veterans of the Iraq and Afghanistan Conflicts: A Randomized Clinical Trial
Bair, M. J., Ang, D., Wu, J., Outcalt, S. D., Sargent, C., Kempf, C., Froman, A., Schmid, A. A., Damush, T. M., Yu, Z., et al. (2015) · JAMA Internal Medicine · doi:10.1001/jamainternmed.2015.97 · Cited by 125 · see citing works
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Anxiety and depression: a 40‐year perspective on relationships regarding prevalence, distribution, and comorbidity
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Systematic Use of Patient-Rated Depression Severity Monitoring: Is It Helpful and Feasible in Clinical Psychiatry?
Duffy, F. F., Chung, H., Trivedi, M. H., Rae, D. S., Regier, D. A., & Katzelnick, D. J. (2008) · Psychiatric Services · doi:10.1176/ps.2008.59.10.1148 · Cited by 109 · see citing works
Overlap of Anxiety and Depression in a Managed Care Population: Prevalence and Association With Resource Utilization
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What is the best screening test for depression in chronic spinal pain patients?
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The Indiana Cancer Pain and Depression (INCPAD) trial
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Practical clinical tool to monitor dementia symptoms: the HABC-Monitor
Monahan, Boustani, Alder, Galvin, J. E., Perkins, A. J., Healey, Chehresa, Shepard, Bubp, Frame, et al. (2012) · Clinical Interventions in Aging · doi:10.2147/cia.s30663 · Cited by 78 · see citing works
Does This Patient Have Generalized Anxiety or Panic Disorder?: The Rational Clinical Examination Systematic Review
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Frequency and patterns of psychiatric comorbidity in a sample of primary care patients with anxiety disorders
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Stepped Care to Optimize Pain Care Effectiveness (SCOPE) trial: study design and sample characteristics
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Anxiety but Not Social Stressors Predict 12-Month Depression and Pain Severity
Bair, M. J., Poleshuck, E. L., Wu, J., Krebs, E. E., Damush, T. M., Tu, W., & Kroenke, K. (2012) · Clinical Journal of Pain · doi:10.1097/ajp.0b013e3182652ee9 · Cited by 62 · see citing works
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Depression Outcomes in Psychiatric Clinical Practice: Using a Self-Rated Measure of Depression Severity
Katzelnick, D. J., Duffy, F. F., Chung, H., Regier, D. A., Rae, D. S., & Trivedi, M. H. (2011) · Psychiatric Services · doi:10.1176/ps.62.8.pss6208_0929 · Cited by 56 · see citing works
Cut Point Determination in the Measurement of Pain and Its Relationship to Psychosocial and Functional Measures After Traumatic Spinal Cord Injury: A Retrospective Model Spinal Cord Injury System Analysis
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Cancer-Related Pain and Disability: A Longitudinal Study
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Correlates of pain interference in multiple sclerosis.
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Sensitivity to change and minimal clinically important difference of the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7)
Toussaint, A., Hüsing, P., Gumz, A., Wingenfeld, K., Härter, M., Schramm, E., & Löwe, B. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.01.032 · Cited by 641 · see citing works
Modelling the contribution of the Big Five personality traits, health anxiety, and COVID-19 psychological distress to generalised anxiety and depressive symptoms during the COVID-19 pandemic
Nikčević, A. V., Marino, C., Kolubinski, D. C., Leach, D., & Spada, M. M. (2021) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.10.053 · Cited by 344 · see citing works
“Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS; Kroenke et al., 2016).”
Effect of the COVID‐19 pandemic on the mental health of carers of people with intellectual disabilities
Willner, P., Rose, J., Kroese, B. S., Murphy, G. H., Langdon, P. E., Clifford, C., Hutchings, H. A., Watkins, A. J., Hiles, S., & Cooper, V. (2020) · Journal of Applied Research in Intellectual Disabilities · doi:10.1111/jar.12811 · Cited by 240 · see citing works
“These 7- and 9-item screening instruments are widely used, inter alia within the NHS, and sometimes combined as a 16-item Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS: Kroenke et al., 2016).”
Testing the Effects of COVID-19 Confinement in Spanish Children: The Role of Parents’ Distress, Emotional Problems and Specific Parenting
Romero, E., López‐Romero, L., Domínguez-Álvarez, B., Villar, P., & Fraguela, J. A. G. (2020) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph17196975 · Cited by 244 · see citing works
“Parents’ emotional problems were assessed with the four-item version of the Patient Health Questionnaire for Depression and Anxiety (PHQ-4) [45], an ultra-brief screening tool to assess anxiety (e.g., “Feeling nervous, anxious, or on edge”; α = 0.73; MIC = 0.58) and depressive symptoms (e.g., “Feeling down, depressed,…”
Influential
Mental Health, Physical Activity, and Quality of Life of US Adolescent Athletes During COVID-19–Related School Closures and Sport Cancellations: A Study of 13 000 Athletes
McGuine, T. A., Biese, K. M., Petrovska, L., Hetzel, S., Reardon, C. L., Kliethermes‌, S., Bell, D. R., Brooks, A., & Watson, A. M. (2020) · Journal of Athletic Training · doi:10.4085/1062-6050-0478.20 · Cited by 229 · see citing works
“In addition to the total score, GAD-7 categorical scores of 0 to 4, 5 to 9, 10 to 14, and 15 to 21 correspond to no, mild, moderate, and severe anxiety symptoms, respectively.(29,30) The PHQ-9 is a 9-item screening questionnaire for depression symptoms with scores ranging from 0 to 27; a higher score indicates a great…”
Background
Critical Care Nurse Burnout, Moral Distress, and Mental Health During the COVID-19 Pandemic: A United States Survey
Guttormson, J., Calkins, K., McAndrew, N. S., Fitzgerald, J. M., Losurdo, H., & Loonsfoot, D. (2022) · Heart & Lung · doi:10.1016/j.hrtlng.2022.04.015 · Cited by 237 · see citing works
“Subscale scores range from 0 to 27 (depression subscale) and 0 to 21 (anxiety subscale).(29) Depression Subscale Scores of 5, 10, 15, and 20 represent mild, moderate, moderately severe, and severe depression, respectively.”
BackgroundInfluential
Mental health among healthcare providers during coronavirus disease (COVID-19) outbreak in Saudi Arabia
AlAteeq, D. A., Aljhani, S., Althiyabi, I., & Majzoub, S. (2020) · Journal of Infection and Public Health · doi:10.1016/j.jiph.2020.08.013 · Cited by 225 · see citing works
Validity and reliability of the Generalized Anxiety Disorder-7 (GAD-7) among university students of Bangladesh
Dhira, T. A., Rahman, M. A., Sarker, A. R., & Mehareen, J. (2021) · PLoS ONE · doi:10.1371/journal.pone.0261590 · Cited by 233 · see citing works
Organisational behaviour
Oksynoyd, K. (2009) · KnoRus eBooks · doi:10.15216/9785390001943 · Cited by 180 · see citing works
Refuting the myth of a ‘tsunami’ of mental ill-health in populations affected by COVID-19: evidence that response to the pandemic is heterogeneous, not homogeneous
Shevlin, M. E., Butter, S., McBride, O., Murphy, J., Miller, J. G., Hartman, T. K., Levita, L., Mason, L., Martínez, A. P., McKay, R., et al. (2021) · Psychological Medicine · doi:10.1017/s0033291721001665 · Cited by 181 · see citing works
“Moderate severity (20–48) was used to identify caseness, and scores from the PHQ-ADS have been found to demonstrate high internal reliability, as well as good convergent and construct validity in clinical samples (Kroenke, Baye, & Lourens, 2019; Kroenke et al., 2016).”
The Psychological Impact of COVID-19 Pandemic on Women’s Mental Health during Pregnancy: A Rapid Evidence Review
Ahmad, M., & Vismara, L. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18137112 · Cited by 167 · see citing works
“Some studies used a combined measure for depression and anxiety: two applied the Hospital Anxiety and Depression Scale (HADS) [47], and one the Patient Health Questionnaire Anxiety–Depression Scale (PHQ-ADS) [48].”
Influential
Association between pretreatment emotional distress and immune checkpoint inhibitor response in non-small-cell lung cancer
Zeng, Y.-Y., Hu, C.-H., Li, Y.-Z., Zhou, J.-S., Wang, S.-X., Liu, M.-D., Qiu, Z.-H., Deng, C., Ma, F., Xia, C., et al. (2024) · Nature Medicine · doi:10.1038/s41591-024-02929-4 · Cited by 159 · see citing works
Fragile heroes. The psychological impact of the COVID-19 pandemic on health-care workers in Italy
Conti, C. M., Fontanesi, L., Lanzara, R., Rosa, I., & Porcelli, P. (2020) · PLoS ONE · doi:10.1371/journal.pone.0242538 · Cited by 130 · see citing works
Minimally important differences and severity thresholds are estimated for the PROMIS depression scales from three randomized clinical trials
Kroenke, K., Stump, T. E., Chen, C. X., Kean, J., Bair, M. J., Damush, T. M., Krebs, E. E., & Monahan, P. O. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.01.101 · Cited by 131 · see citing works
“A 3-point difference on the PHQ-9 represents a reasonable MID with a 5-point difference being an upper bound.(Kroenke et al., 2016; Lowe et al., 2004) Using linear regression, we regressed the PROMIS depression scores on the PHQ-9 scores.”
MethodSelf-citation
Anxiety and Depression in Heart Failure: An Updated Review
Rashid, S., Qureshi, A. G., Noor, T. A., Yaseen, K., Sheikh, M. A. A., Malik, M. A., & Malik, J. (2023) · Current Problems in Cardiology · doi:10.1016/j.cpcardiol.2023.101987 · Cited by 123 · see citing works
Comparative validity and responsiveness of PHQ-ADS and other composite anxiety-depression measures
Kroenke, K., Baye, F. M., & Lourens, S. G. (2018) · Journal of Affective Disorders · doi:10.1016/j.jad.2018.12.098 · Cited by 99 · see citing works
Self-citation
Comparative Responsiveness and Minimally Important Difference of Common Anxiety Measures
Kroenke, K., Baye, F. M., & Lourens, S. G. (2019) · Medical Care · doi:10.1097/mlr.0000000000001185 · Cited by 97 · see citing works
Self-citation
Sensitivity and specificity of the Patient Health Questionnaire (PHQ-9, PHQ-8, PHQ-2) and General Anxiety Disorder scale (GAD-7, GAD-2) for depression and anxiety diagnosis: a cross-sectional study in a Peruvian hospital population
Villarreal-Zegarra, D., Barrera-Begazo, J., Otazú-Alfaro, S., Mayo-Puchoc, N., Bazo-Alvarez, J. C., & Huarcaya-Victoria, J. (2023) · BMJ Open · doi:10.1136/bmjopen-2023-076193 · Cited by 93 · see citing works
“The inclusion criteria were that they had complete PHQ-9 and GAD-7 data and were of legal age (>18 years).”
Background
Validity and reliability of the Patient Health Questionnaire scale (PHQ-9) among university students of Bangladesh
Rahman, M. A., Dhira, T. A., Sarker, A. R., & Mehareen, J. (2022) · PLoS ONE · doi:10.1371/journal.pone.0269634 · Cited by 106 · see citing works
Validation of the patient health questionnaire-9 and the generalized anxiety disorder-7 in Lithuanian student sample
Pranckevičienė, A., Saudargienė, A., Gečaitė-Stončienė, J., Liaugaudaitė, V., Griškova-Bulanova, I., Šimkutė, D., Naginienė, R., Dainauskas, L. L., Čeidaitė, G., & Burkauskas, J. (2022) · PLoS ONE · doi:10.1371/journal.pone.0263027 · Cited by 78 · see citing works
A Web-Based Group Cognitive Behavioral Therapy Intervention for Symptoms of Anxiety and Depression Among University Students: Open-Label, Pragmatic Trial
Bantjes, J. R., Kazdin, A. E., Cuijpers, P. J., Breet, E., Dunn‐Coetzee, M., Davids, C., Stein, D. J., & Kessler, R. C. (2021) · JMIR Mental Health · doi:10.2196/27400 · Cited by 76 · see citing works
“The primary outcomes were symptoms of anxiety (ie, GAD-7 scores), symptoms of depression (ie, PHQ-9 scores), and symptoms of comorbid anxiety and depression (using combined GAD-7 and PHQ-9 scores as proposed by the developers of the instruments to yield a composite anxiety and depression score) [63].”
Method
Screening for psychological distress using the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS): Initial validation of structural validity in dialysis patients
Chilcot, J., Hudson, J. L., Moss-Morris, R., Carroll, A., Game, D., Simpson, A., & Hotopf, M. (2018) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2017.09.007 · Cited by 77 · see citing works
“As argued by Kroenke et al (20), the PHQ-ADS does not undermine the utility or value of using either the PHQ-9 or GAD-7.”
BackgroundMethodResultInfluential
Non-disclosing youth: a cross sectional study to understand why young people do not disclose suicidal thoughts to their mental health professional
McGillivray, L., Rheinberger, D., Wang, J. J., Burnett, A., & Torok, M. H. (2022) · BMC Psychiatry · doi:10.1186/s12888-021-03636-x · Cited by 78 · see citing works
“80, [28]) and in the present sample (α=.”
BackgroundMethod
User Engagement and Clinical Impact of the Manage My Pain App in Patients With Chronic Pain: A Real-World, Multi-site Trial
Bhatia, A., Kara, J., Janmohamed, T., Prabhu, A., Lebovic, G., Katz, J., & Clarke, H. (2021) · JMIR mHealth and uHealth · doi:10.2196/26528 · Cited by 73 · see citing works
Testing the effects of COVID-19 confinement in Spanish children: The role of parents’ distress, emotional problems and specific parentingPreprint
Romero, E., López‐Romero, L., Domínguez-Álvarez, B., et al. (2020) · doi:10.31234/osf.io/spxtw · Cited by 69 · see citing works
The COVID‐19 anxiety syndrome and selective attentional bias towards COVID‐19‐related stimuli in UK residents during the 2020–2021 pandemic
Albery, I. P., Spada, M. M., & Nikčević, A. V. (2021) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2639 · Cited by 60 · see citing works
“2.3.7 | Patient Health Questionnaire Anxiety and Depression Scale (Kroenke et al., 2016) This self-report measure assesses the severity of generalized anxiety and depression symptoms.”
BackgroundMethodInfluential
Sleep disturbances, academic performance, depressive symptoms and substance use among medical students in Bogota, Colombia
Correa, J. E. B., Aristizabal-Mayor, J. D., Lasalvia, P., Ruiz, Á. J., & Martínez, P. H. (2018) · Sleep Science · doi:10.5935/1984-0063.20180041 · Cited by 69 · see citing works
“Thus, instruments that consider this feature may be more adequate for future research, such as the Patient Health Questionnaire Anxiety and Depression Scale 65 .”
Method
Long-Term Outcomes of a Therapist-Supported, Smartphone-Based Intervention for Elevated Symptoms of Depression and Anxiety: Quasiexperimental, Pre-Postintervention Study
Economides, M., Ranta, K., Nazander, A., Hilgert, O., Goldin, P. R., Raevuori, A., & Forman‐Hoffman, V. L. (2019) · JMIR mhealth and uhealth · doi:10.2196/14284 · Cited by 51 · see citing works
“A clinically significant improvement in anxiety symptoms has previously been defined as a GAD-7 score reduction of ≥ 3 [46].”
Linguistic measures of psychological distance track symptom levels and treatment outcomes in a large set of psychotherapy transcripts
Nook, E. C., Hull, T. D., Nock, M. K., & Somerville, L. H. (2022) · Proceedings of the National Academy of Sciences · doi:10.1073/pnas.2114737119 · Cited by 61 · see citing works
“We consequently collapsed these two measures into a single assessment of internalizing symptoms by summing the two scales together, as has been done in prior work (63).”
Method
Factorial Structure and Validity of Depression (PHQ-9) and Anxiety (GAD-7) Scales after Traumatic Brain Injury
Teymoori, A., Gorbunova, A., Haghish, E. F., Real, R. G. L., Zeldovich, M., Wu, Y.-J., Polinder, S., Asendorf, T., Menon, D. K., & von Steinbüchel, N. (2020) · Journal of Clinical Medicine · doi:10.3390/jcm9030873 · Cited by 56 · see citing works
Increasing Data and Understanding of Adolescent Mental Health Worldwide: UNICEF’s Measurement of Mental Health Among Adolescents at the Population Level Initiative
Carvajal-Vélez, L., Requejo, J. H., Åhs, J. W., Idele, P., Adewuya, A. O., Cappa, C., Guthold, R., Kapungu, C., Kieling, C., Patel, V., et al. (2021) · Journal of Adolescent Health · doi:10.1016/j.jadohealth.2021.03.019 · Cited by 60 · see citing works
“The MMAP validation process has encompassed assessing scales such as the Revised Children’s Anxiety and Depression Scale [9] and tools from the Patient Health Questionnaire set [10].”
Method
Burnout Status of Italian Healthcare Workers during the First COVID-19 Pandemic Peak Period
Conti, C. M., Fontanesi, L., Lanzara, R., Rosa, I., Doyle, R., & Porcelli, P. (2021) · Healthcare · doi:10.3390/healthcare9050510 · Cited by 56 · see citing works
“The GAD-7 has good reliability, construct, factorial, and procedural validity [46,47].”
Background
Measurement validity of the Patient‐Health Questionnaire‐9 in US nursing home residents
Bélanger, E., Thomas, K. S., Jones, R. N., Epstein-Lubow, G. P., & Mor, V. (2019) · International Journal of Geriatric Psychiatry · doi:10.1002/gps.5074 · Cited by 52 · see citing works
Effects of Spiritual Care on Well-Being of Intensive Care Family Surrogates: A Clinical Trial
Torke, A. M., Varner-Perez, S. E., Burke, E. S., Taylor, T. A., Slaven, J. E., Kozinski, K., Maiko, S. M., Pfeffer, B. J., & Banks, S. K. (2022) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2022.12.007 · Cited by 57 · see citing works
Changes in the Health of Adolescent Athletes: A Comparison of Health Measures Collected Before and During the COVID-19 Pandemic
McGuine, T. A., Biese, K. M., Hetzel, S., Petrovska, L., Kliethermes‌, S., Reardon, C. L., Bell, D. R., Brooks, A., & Watson, A. M. (2021) · Journal of Athletic Training · doi:10.4085/1062-6050-0739.20 · Cited by 52 · see citing works
Vestibular deficits and psychological factors correlating to dizziness handicap and symptom severity
Herdman, D., Norton, S., Pavlou, M., Murdin, L. J., & Moss-Morris, R. E. (2020) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2020.109969 · Cited by 53 · see citing works
Seeking and Sharing Mental Health Information on Social Media During COVID-19: Role of Depression and Anxiety, Peer Support, and Health Benefits
Akhther, N., & Sopory, P. (2022) · Journal of Technology in Behavioral Science · doi:10.1007/s41347-021-00239-x · Cited by 51 · see citing works
Development of an international standard set of clinical and patient-reported outcomes for children and adults with congenital heart disease: a report from the International Consortium for Health Outcomes Measurement Congenital Heart Disease Working Group
Hummel, K., Whittaker, S., Sillett, N., Basken, A., Berghammer, M. C., Chalela, T., Chauhan, J., Garcia, L. A., Hasan, B. S., Jenkins, K. J., et al. (2021) · European Heart Journal - Quality of Care and Clinical Outcomes · doi:10.1093/ehjqcco/qcab009 · Cited by 50 · see citing works
“40,41 As with cognition, these outcomes were not elected in paediatrics, with agreement that longitudinal measurement would be adequately completed with adult measurement.”
Background
Neurocognitive dysfunctioning and the impact of comorbid depression and anxiety in patients with somatic symptom and related disorders: a cross-sectional clinical study
de Vroege, L., Timmermans, A., Kop, W. J., & van der Feltz-Cornelis, C. M. (2018) · Psychological Medicine · doi:10.1017/s0033291717003300 · Cited by 50 · see citing works
“A recent report has demonstrated the validity of combining the PHQ-9 and GAD-7 as a single measure for jointly assessing two of the most common psychological conditions in patients with somatic symptoms (Kroenke et al. 2016).”
Background
Pandemic trajectories of depressive and anxiety symptoms and their predictors: Five-wave study during the COVID-19 pandemic in PolandPreprint
Gambin, M. (2021) · OSF Preprints (OSF Preprints) · Cited by 50 · see citing works
High School Sports During the COVID-19 Pandemic: The Effect of Sport Participation on the Health of Adolescents
McGuine, T. A., Biese, K. M., Hetzel, S., Schwarz, A., Kliethermes‌, S., Reardon, C. L., Bell, D. R., Brooks, M. A., & Watson, A. M. (2021) · Journal of Athletic Training · doi:10.4085/1062-6050-0121.21 · Cited by 52 · see citing works
Organisational Behaviour
Alblas, G., Wijsman, E., van Noort, M., & du Pon, C. (2019) · Routledge eBooks · doi:10.4324/9781003022121 · Cited by 50 · see citing works
Interrelationship between depression, anxiety, pain, and treatment adherence in hemophilia: results from a US cross-sectional survey
Witkop, M., Lambing, A. Y., Nichols, C. D., Munn, J. E., Anderson, T. L., & Tortella, B. J. (2019) · Patient Preference and Adherence · doi:10.2147/ppa.s212723 · Cited by 49 · see citing works
The development and validation of Huaxi emotional-distress index (HEI): A Chinese questionnaire for screening depression and anxiety in non-psychiatric clinical settings
Wang, J., Guo, W., Zhang, L., Deng, W., Wang, H.-Y., Yu, J., Luo, S., Huang, M., Dong, Z., Li, D., et al. (2017) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2017.04.001 · Cited by 43 · see citing works
“[24] Kroenke K, Wu J, Yu Z, Bair MJ, Kean J, Stump T, et al.”
Background
Effectiveness of a mental health stepped-care programme for healthcare workers with psychological distress in crisis settings: a multicentre randomised controlled trial
Mediavilla, R., Felez-Nobrega, M., McGreevy, K. R., Monistrol-Mula, A., Bravo-Ortiz, M.-F., Bayón, C., Giné-Vázquez, I., Villaescusa, R., Muñoz-Sanjosé, A., Aguilar-Ortiz, S., et al. (2023) · BMJ Mental Health · doi:10.1136/bmjment-2023-300697 · Cited by 47 · see citing works
Association between osteoarthritis and mental health in a Korean population: a nationwide study
Jung, J. H., Seok, H., Kim, J., Song, G. G., & Choi, S. J. (2017) · International Journal of Rheumatic Diseases · doi:10.1111/1756-185x.13098 · Cited by 45 · see citing works
Positive experiences in the parent–child relationship during the COVID ‐19 lockdown in Poland: The role of emotion regulation, empathy, parenting self‐efficacy, and social support
Woźniak‐Prus, M., Gambin, M., Sekowski, M. M., Cudo, A., Pisula, E., Kiepura, E., Boruszak‐Kiziukiewicz, J., & Kmita, G. (2023) · Family Process · doi:10.1111/famp.12856 · Cited by 92 · see citing works
Transactional Associations Between Parent and Late Adolescent Internalizing Symptoms During the COVID-19 Pandemic: The Moderating Role of Avoidant Coping
Lorenzo, N. E., Zeytinoglu, S., Morales, S., Listokin, J. R., Almas, A. N., Degnan, K. A., Henderson, H. A., Chronis-Tuscano, A. M., & Fox, N. A. (2021) · Journal of Youth and Adolescence · doi:10.1007/s10964-020-01374-z · Cited by 47 · see citing works
Minority stressors, rumination, and psychological distress in monozygotic twins discordant for sexual minority status
Timmins, L., Rimes, K. A., & Rahman, Q. (2017) · Psychological Medicine · doi:10.1017/s003329171700321x · Cited by 45 · see citing works
“PHQ-ADS = Patient Health Questionnaire Anxiety and Depression Scale, ONSWellbeing = U.K. Office for National Statistics Well-Being Scale. a Excludes two participants who reported “Little or no romantic infatuations.” b Excludes three participants who reported no sexual partners. c Excludes one participant who reported…”
BackgroundMethodInfluential
Changes in mental health symptoms from pre-COVID-19 to COVID-19 among participants with systemic sclerosis from four countries: A Scleroderma Patient-centered Intervention Network (SPIN) Cohort study
Thombs, B. D., Kwakkenbos, L., Henry, R. S., Carrier, M., Patten, S. B., Harb, S. I., Bourgeault, A., Tao, L., Bartlett, S. J., Mouthon, L., et al. (2020) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2020.110262 · Cited by 42 · see citing works
Religious/spiritual struggles and psychological distress: A test of three models in a longitudinal study of adults with chronic health conditions
Cowden, R. G., Pargäment, K. I., Chen, Z. J., Davis, E. B., Lemke, A. W., Glowiak, K. J., Rueger, S. Y., & Worthington, E. L. (2021) · Journal of Clinical Psychology · doi:10.1002/jclp.23232 · Cited by 43 · see citing works
The efficacy of self-guided internet and mobile-based interventions for preventing anxiety and depression–A systematic review and meta-analysis
Edge, D., Watkins, E. R., Limond, J., & Mugadza, J. (2023) · Behaviour Research and Therapy · doi:10.1016/j.brat.2023.104292 · Cited by 42 · see citing works
Mental Health Promotion and Intervention in Occupational Settings: Protocol for a Pilot Study of the MENTUPP Intervention
Arensman, E., O’Connor, C., Leduc, C., Griffin, E., Cully, G., Dhálaigh, D. N., Holland, C., Audenhove, C. V., Coppens, E., Tsantila, F., et al. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph19020947 · Cited by 37 · see citing works
“Five Wellbeing Index (WHO-5) [85] # Depression and anxiety: Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS) [86] # Depression stigma: Depression Stigma Scale (DSS) [87] # Presenteeism in the workplace: Stanford Presenteeism Scale (SPS-6) [88] # Productivity: Work Productivity and Activity Impairmen…”
Background
Maintenance of treatment gains up to 12-months following a three-week cognitive processing therapy-based intensive PTSD treatment programme for veterans
Held, P., Zalta, A. K., Smith, D. L., Bagley, J. M., Steigerwald, V. L., Boley, R. A., Miller, M. L., Brennan, M. B., Horn, R. V., & Pollack, M. H. (2020) · European Journal of Psychotraumatology · doi:10.1080/20008198.2020.1789324 · Cited by 42 · see citing works
Feasibility and potential efficacy of a guided internet- and mobile-based CBT for adolescents and young adults with chronic medical conditions and comorbid depression or anxiety symptoms (youthCOACHCD): a randomized controlled pilot trial
Geirhos, A., Domhardt, M., Lunkenheimer, F., Temming, S., Holl, R. W., Minden, K., Warschburger, P., Meissner, T., Mueller-Stierlin, A. S., & Baumeister, H. (2022) · BMC Pediatrics · doi:10.1186/s12887-022-03134-3 · Cited by 37 · see citing works
“Depressive and anxiety symptom severity Patient Health Questionnaire Anxiety and Depression Scale (PHQ‐ ADS) [40] X X X”
BackgroundInfluential
Pandemic trajectories of depressive and anxiety symptoms and their predictors: five-wave study during the COVID-19 pandemic in Poland
Gambin, M., Oleksy, T., Sekowski, M. M., Wnuk, A., Woźniak-Prus, M., Kmita, G., Holas, P., Pisula, E., Łojek, E., Hansen, K., et al. (2021) · Psychological Medicine · doi:10.1017/s0033291721005420 · Cited by 53 · see citing works
“…results can be found at: https://osf.io/mpfwq/ We used the following questionnaires: Patient Health Questionnaire Anxiety-Depression Scale (PHQ-ADS; Kroenke et al., 2016); Difficulties in Emotion Regulation Scale Short Form (DERS-SF; Kaufman et al., 2016); Brief Empathic Sensitivity Questionnaire…”
Psychological impact of the COVID-19 pandemic within institutional quarantine and isolation centres and its sociodemographic correlates in Qatar: a cross-sectional study
Reagu, S. M., Wadoo, O., Latoo, J., Nelson, D., Ouanes, S., Masoodi, N. A., Karim, M. A., Iqbal, Y., Abdulla, S. A. A., Al-Nuaimi, S. K., et al. (2021) · BMJ Open · doi:10.1136/bmjopen-2020-045794 · Cited by 40 · see citing works
Maladaptive schemas as a potential mechanism through which irrational beliefs relate to psychological distress in athletes
Turner, M. J., Aspin, G., & Gillman, J. C. (2019) · Psychology of sport and exercise · doi:10.1016/j.psychsport.2019.04.015 · Cited by 46 · see citing works
Association between depression or anxiety symptoms and immune-inflammatory characteristics in in-patients with tuberculosis: A cross-sectional study
Liu, X., Bai, X., Ren, R., Tan, L., Zhang, Y., Lan, H., Yang, Q., He, J., & Tang, X. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.985823 · Cited by 39 · see citing works
Mental Health and Substance Use of Farmers in Canada during COVID-19
Thompson, R., Hagen, B. N. M., Lumley, M. N., Winder, C. B., Gohar, B., & Jones‐Bitton, A. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph192013566 · Cited by 37 · see citing works
Psychological stress and health-related quality of life among tuberculosis patients: a prospective cohort study
Febi, A. R., Manu, M. K., Mohapatra, A. K., Praharaj, S. K., & Guddattu, V. (2021) · ERJ Open Research · doi:10.1183/23120541.00251-2021 · Cited by 50 · see citing works
Psychological responses to the COVID-19 pandemic are heterogeneous but have stabilised over time: 1 year longitudinal follow-up of the COVID-19 Psychological Research Consortium (C19PRC) study
Shevlin, M. E., Butter, S., McBride, O., Murphy, J., Miller, J. G., Hartman, T. K., Levita, L., Mason, L., Martínez, A. P., McKay, R., et al. (2021) · Psychological Medicine · doi:10.1017/s0033291721004025 · Cited by 36 · see citing works
“Anxiety-depression was measured using the Patient Health Questionnaire Anxiety-Depression Scale (PHQ-ADS), a 16-item scale used as a composite measure of depression and anxiety (Kroenke et al., 2016), with scores ranging from 0 to 48.”
Method
Effects of a multi-faceted education and support programme on anxiety symptoms among people with systemic sclerosis and anxiety during COVID-19 (SPIN-CHAT): a two-arm parallel, partially nested, randomised, controlled trial
Thombs, B. D., Kwakkenbos, L., Levis, B., Bourgeault, A., Henry, R. S., Levis, A. W., Harb, S. I., Tao, L., Carrier, M., Bustamante, L., et al. (2021) · The Lancet Rheumatology · doi:10.1016/s2665-9913(21)00060-6 · Cited by 38 · see citing works
Can Yoga or Physical Therapy for Chronic Low Back Pain Improve Depression and Anxiety Among Adults From a Racially Diverse, Low-Income Community? A Secondary Analysis of a Randomized Controlled Trial
Joyce, C. T., Roseen, E. J., Keysor, J. J., Gross, K. D., Culpepper, L., & Saper, R. B. (2021) · Archives of Physical Medicine and Rehabilitation · doi:10.1016/j.apmr.2021.01.072 · Cited by 38 · see citing works
Neurocognitive functioning in patients with conversion disorder/functional neurological disorder
de Vroege, L., Koppenol, I., Kop, W. J., Riem, M. M. E., & Feltz-Cornelis, C. M. V. D. (2020) · Journal of Neuropsychology · doi:10.1111/jnp.12206 · Cited by 36 · see citing works
“A cut-off score of 10 on theGAD-7 was used to detect anxiety (Kroenke et al., 2016).”
Method
An Evidence-Based Theory of Psychological Adjustment to Long-Term Physical Health Conditions: Applications in Clinical Practice
Carroll, S., Moon, Z., Hudson, J. L., Hulme, K., & Moss-Morris, R. E. (2022) · Psychosomatic Medicine · doi:10.1097/psy.0000000000001076 · Cited by 34 · see citing works
“PHQ-ADS is a combined measure of anxiety and low mood (40).”
Background
Do morally injurious experiences and index events negatively impact intensive PTSD treatment outcomes among combat veterans?
Held, P., Klassen, B. J., Steigerwald, V. L., Smith, D. L., Bravo, K., Rozek, D. C., Horn, R. V., & Zalta, A. K. (2021) · European Journal of Psychotraumatology · doi:10.1080/20008198.2021.1877026 · Cited by 40 · see citing works
“A 5-point change on the PHQ-9 has previously been suggested to represent clinically meaningful change (Kroenke et al., 2016).”
Method
What are the optimal measures to identify anxiety and depression in people diagnosed with head and neck cancer (HNC): a systematic review
Shunmugasundaram, C., Rutherford, C., Butow, P. N., Sundaresan, P., & Dhillon, H. M. (2020) · Journal of Patient-Reported Outcomes · doi:10.1186/s41687-020-00189-7 · Cited by 35 · see citing works
Effectiveness and cost-effectiveness of guided Internet- and mobile-based CBT for adolescents and young adults with chronic somatic conditions and comorbid depression and anxiety symptoms (youthCOACHCD): study protocol for a multicentre randomized controlled trial
COACH consortium, Lunkenheimer, F., Domhardt, M., Geirhos, A., Kilian, R., Mueller-Stierlin, A. S., Holl, R. W., Meissner, T., Minden, K., Moshagen, M., et al. (2020) · Trials · doi:10.1186/s13063-019-4041-9 · Cited by 37 · see citing works
Development and Evaluation of a Smartphone-Based Chatbot Coach to Facilitate a Balanced Lifestyle in Individuals With Headaches (BalanceUP App): Randomized Controlled Trial
Ulrich, S., Gantenbein, A. R., Zuber, V., Von Wyl, A., Kowatsch, T., & Künzli, H. (2024) · Journal of Medical Internet Research · doi:10.2196/50132 · Cited by 36 · see citing works
“To measure effectiveness, we defined mental well-being as the primary outcome, measured by the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS) [85].”
Influential
Antibody prevalence after three or more COVID-19 vaccine doses in individuals who are immunosuppressed in the UK: a cross-sectional study from MELODY
Pearce, F., Lim, S. H., Bythell, M., Lanyon, P., Hogg, R., Taylor, A., Powter, G., Cooke, G., Ward, H., Chilcot, J., et al. (2023) · The Lancet Rheumatology · doi:10.1016/s2665-9913(23)00160-1 · Cited by 36 · see citing works
“To assess the ability of the model to distinguish patients who had a positive antibody status, concordance statistics (C statistic; equal to the area under the receiver operating curve) and 95% CIs were calculated (appendix p 19).”
Illness perceptions predict distress in patients with chronic kidney disease
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“The minimal clinically important difference (MCID) has been estimated as 2–3 points [80] and we considered 3 points to indicate an MCID in the present study.”
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“The sensitivity and specificity of the PHQ-9 and GAD-7 with respect to independent criterion standards have been reported in several studies (22,25,27), and excellent psychometric properties have been reported for all three PHQ scales (22,28,29).”
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Authors: Kroenke, K., Wu, J., Yu, Z., Bair, M. J., Kean, J., Stump, T., & Monahan, P. O.
Affiliations: Regenstrief Institute (US)
Corresponding author: Kroenke, Kurt
ORCID: Kroenke, Kurt
Wu, Jingwei
Yu, Zhangsheng
Bair, Matthew J.
Kean, Jacob
Stump, Timothy
Monahan, Patrick O.
Venue: Psychosomatic Medicine
Publisher: Ovid Technologies (Wolters Kluwer Health)
Published: 2016-07
Volume: 78
Issue: 6
Pages: 716-727
ISSN: 0033-3174 (ISSN-L)
1534-7796
DOI: 10.1097/psy.0000000000000322
PMC: PMC4927366
OpenAlex: W2397812290
Semantic Scholar: a700e31d97d255b2287483ce1a3755190c55cdd1
Cited by: 504
References: 76
Citations by year: 2026: 70 · 2025: 80 · 2024: 76 · 2023: 50 · 2022: 69 · 2021: 77 · 2020: 43 · 2019: 18 · 2018: 9 · 2017: 9 · 2013: 1
FWCI: 17.08
Type: journal article
Language: en
Open access: green
www.ncbi.nlm.nih.gov
Locations: Psychosomatic Medicine (publishedVersion)
PubMed (publishedVersion)
PubMed Central (acceptedVersion)
IUScholarWorks (Indiana University) (submittedVersion)
PMC
Funders: U.S. Department of Veterans Affairs (IIR 07-119, IK2 RX000879)
National Institutes of Health (UL1TR001108)
National Cancer Institute (R01CA115369)
National Institute of Arthritis and Musculoskeletal and Skin Diseases (R01AR064081)
National Center for Advancing Translational Sciences
Topics: Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Social Sciences › Decision Sciences › Management Science and Operations Research › Psychometric Methodologies and Testing
Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
Keywords: depression, anxiety, psychometric validation, reliability statistics, sensitivity to change, chronic pain, cancer pain, primary care, bifactor analysis, unidimensionality, quality of life, disability
MeSH terms: Adult, Aged, Aged, 80 and over, Anxiety Disorders, Depressive Disorder, Female, Humans, Male, Middle Aged, Psychiatric Status Rating Scales, Psychometrics, Veterans, Reproducibility of Results, Young Adult

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Patient Health Questionnaire Anxiety and Depression Scale: Initial Validation in Three Clinical Trials

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