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Measuring depression severity in general practice: discriminatory performance of the PHQ-9, HADS-D, and BDI-II
Open accessAbstract
BACKGROUND: The UK Quality and Outcomes Framework (QOF) rewards practices for measuring symptom severity in patients with depression, but the endorsed scales have not been comprehensively validated for this purpose. AIM: To assess the discriminatory performance of the QOF depression severity measures. DESIGN AND SETTING: Psychometric assessment in nine Scottish general practices. METHOD: Adult primary care patients diagnosed with depression were invited to participate. The HADS-D, PHQ-9, and BDI-II were assessed against the HRSD-17 interview. Discriminatory performance was determined relative to the HRSD-17 cut-offs for symptoms of at least moderate severity, as per criteria set by the American Psychiatric Association (APA) and NICE. Receiver operating characteristic curves were plotted and area under the curve (AUC), sensitivity, specificity, and likelihood ratios (LRs) calculated. RESULTS: A total of 267 were recruited per protocol, mean age = 49.8 years (standard deviation [SD] = 14.1), 70% female, mean HRSD-17=12.6 (SD = 7.62, range = 0-34). For APA criteria, AUCs were: HADS-D = 0.84; PHQ-9 = 0.90; and BDI-II = 0.86. Optimal sensitivity and specificity were reached where HADS-D ≥9 (74%, 76%); PHQ-9 ≥12 (77%, 79%), and BDI-II ≥23 (74%, 75%). For NICE criteria: HADS-D AUC = 0.89; PHQ-9 AUC = 0.93; and BDI-II AUC = 0.90. Optimal sensitivity and specificity were reached where HADS-D ≥10 (82%, 75%), PHQ-9 ≥15 (89%, 83%), and BDI-II ≥28 (83%, 80%). LRs did not provide evidence of sufficient accuracy for clinical use. CONCLUSION: As selecting treatment according to depression severity is informed by an evidence base derived from trials using HRSD-17, and none of the measures tested aligned adequately with that tool, they are inappropriate for use.
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Measuring depression severity in global mental health: comparing the PHQ-9 and the BDI-II
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Metadata
- Authors
- Cameron, I. M., Cardy, A., Crawford, J. R., du Toit, S. W., Hay, S., Lawton, K., Mitchell, K., Sharma, S., Shivaprasad, S., Winning, S., & Reid, I. C.
- Affiliations
- University of Aberdeen (GB)
- Corresponding author
- Cameron, Isobel M
- Venue
- British Journal of General Practice
- Published
- 2011-07
- Volume
- 61
- Issue
- 588
- Pages
- e419-e426
- ISSN
- 0960-1643 (ISSN-L)
- 1478-5242
- PMC
- PMC3123505
- OpenAlex
- W2170351571
- Cited by
- 109
- References
- 36
- Citations by year
- 2026: 4 · 2025: 5 · 2024: 7 · 2023: 10 · 2022: 5 · 2021: 8 · 2020: 8 · 2019: 13 · 2018: 8 · 2017: 5 · 2016: 5 · 2015: 6 · 2014: 11 · 2013: 7 · 2012: 6
- FWCI
- 10.30
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- British Journal of General Practice (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Topics
- 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
- Social Sciences › Decision Sciences › Management Science and Operations Research › Psychometric Methodologies and Testing
- Keywords
- depression severity, PHQ-9, Beck Depression Inventory-II, primary care, Quality and Outcomes Framework, depression screening, sensitivity and specificity, likelihood ratios
- MeSH terms
- Adult, Depressive Disorder, Female, Humans, Male, Middle Aged, Psychiatric Status Rating Scales, Psychometrics, Surveys and Questionnaires, ROC Curve, Scotland, Sensitivity and Specificity, Observer Variation, General Practice
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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