A 4-item measure of depression and anxiety: Validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population

Löwe, Bernd; Wahl, Inka; Rose, Matthias; Spitzer, Carsten; Glaesmer, Heide; Wingenfeld, Katja; Schneider, Antonius; Brähler, Elmar

doi:10.1016/j.jad.2009.06.019

« Previous Next »Journal of Affective Disorders
Volume 122, Issue 1 , Pages 86-95, April 2010

A 4-item measure of depression and anxiety: Validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population

Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Hamburg-Eilbek (Schön Clinics), Germany
- Corresponding author. Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany. Tel.: +49 40 7410 59733; fax: +49 40 7410 54975.
Inka Wahl
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Hamburg-Eilbek (Schön Clinics), Germany
Matthias Rose
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Hamburg-Eilbek (Schön Clinics), Germany
Carsten Spitzer
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Hamburg-Eilbek (Schön Clinics), Germany
Heide Glaesmer
- Department of Medical Psychology and Medical Sociology, University of Leipzig, Germany
Katja Wingenfeld
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Hamburg-Eilbek (Schön Clinics), Germany
Antonius Schneider
- Department of Primary Care and Health Care Research, University Medical Center, Heidelberg, Germany
Elmar Brähler
- Department of Medical Psychology and Medical Sociology, University of Leipzig, Germany

Received 28 February 2009; received in revised form 15 June 2009; accepted 16 June 2009.

Abstract

Background

The 4-item Patient Health Questionnaire-4 (PHQ-4) is an ultra-brief self-report questionnaire that consists of a 2-item depression scale (PHQ-2) and a 2-item anxiety scale (GAD-2). Given that PHQ-4, PHQ-2, and GAD-2 have not been validated in the general population, this study aimed to investigate their reliability and validity in a large general population sample and to generate normative data.

Methods

A nationally representative face-to-face household survey was conducted in Germany in 2006. The survey questionnaire consisted of the PHQ-4, other self-report instruments, and demographic characteristics.

Results

Of the 5030 participants (response rate=72.9%), 53.6% were female and mean (SD) age was 48.4 (18.0) years. The sociodemographic characteristics of the study sample closely match those of the total populations in Germany as well as those in the United States. Confirmatory factor analyses showed very good fit indices for a two-factor solution (RMSEA .027; 90% CI .023–.032). All models tested were structurally invariant between different age and gender groups. Construct validity of the PHQ-4, PHQ-2, and GAD-2 was supported by intercorrelations with other self-report scales and with demographic risk factors for depression and anxiety. PHQ-2 and GAD-2 scores of 3 corresponded to percentile ranks of 93.4% and 95.2%, respectively, whereas PHQ-2 and GAD-2 scores of 5 corresponded to percentile ranks of 99.0% and 99.2%, respectively.

Limitation

A criterion standard diagnostic interview for depression and anxiety was not included.

Conclusions

Results from this study support the reliability and validity of the PHQ-4, PHQ-2, and GAD-2 as ultra-brief measures of depression and anxiety in the general population. The normative data provided in this study can be used to compare a subject's scale score with those determined from a general population reference group.

Keywords: Depression, Anxiety, Screening, Psychometrics, Validation studies, Patient Health Questionnaire (PHQ)