2. 948 Clinical Pediatrics 49(10)persists, recurs, and often leads to continued depressive Health Questionnaire PHQ-9,27 or by referring the patientillnesses in adulthood. Investigations into the differ- to a mental health professional for further evaluation.ences of early onset and late onset depression generally The PHQ-9 has been used with adults in a variety ofsuggest that early onset depression is a more severe vari- studies for the assessment and management of depres-ant associated with increased chronicity and disability. sion.28-30 The PHQ-2 has not been tested with children orIt contributes to school failure, impaired peer and family adolescents, and there is no equivalent 2- or 3-questionrelationships, teenage pregnancy, suicidal behavior, screening tool available to help diagnose depression inand poor psychosocial and functional outcomes.9 Of adolescents.equal concern are the large numbers of adolescents With this in mind, the goal of this study was to deter-who report depressive symptoms but do not meet the mine whether the 2 questions posed on the PHQ-2 useddiagnostic criteria for major depressive disorder. Even to screen for depression in adults are also valid in screen-subsyndromal depressive symptomatology in teens is ing for depression in adolescents. More specifically, weassociated with significant morbidity, including sub- sought to determine the extent to which a “yes” or “no”stance abuse,10 poor social functioning,11 suicidal ide- answer to one or both questions on the PHQ-2 wouldation,12 and major depression in adulthood.13,14 A higher correlate with the results of 2 well-established and vali-prevalence of depressive disorders and subsyndromal dated depression questionnaires, the Children’s Depres-depressive disorders is found in low socioeconomic com- sion Inventory (CDI) and the Beck Depression Inventorymunities and ethnic minority groups.15-18 (BDI), and to evaluate the sensitivity, specificity, and The negative outcomes associated with early onset overall classification accuracy of predictions made usingdepression, make it crucial to identify and treat depres- this screener. Both depression questionnaires, the CDIsion in its early stages. A study conducted by the World and the BDI, have been used with adolescents from aHealth Organization (WHO)19 reported that in North wide range of ethnically and culturally diverse back-America, primary care and family physicians are likely grounds, including low-income African American sam-to provide the first line of treatment for depressive disor- ples in outpatient clinics.31ders. Others consistently report a 10% prevalence rate of Because depression in adolescents is diagnosed usingdepression in primary care patients.20,21 But studies have the same DSM-IV TR criteria as depression in adults,shown that primary care physicians fail to recognize up assuming a comparable symptom profile, it was hypoth-to 50% of depressed patients,22,23 purportedly because of esized that the PHQ-2 would be useful in detectingtime constraints and a lack of brief, sensitive, easy-to- depression in adolescents as well. Given the high preva-administer psychiatric screening instruments. Coyle lence of depressive disorders and subsyndromal depres-et al24 suggested that the picture is even more grim for sive disorders in communities with lower socioeconomicadolescents, and that more than 70% of children and status and ethnic minority groups16,17 we targeted thisadolescents suffering from serious mood disorders go population in selecting our sample for the study.unrecognized or inadequately treated. Despite the ongoing controversy regarding the useof screening instruments in the detection and treatment Methodof depression in adults,25 the City of New York recom- Participantsmended that the Patient Health Questionnaire (PHQ-2),a 2-item depression screener derived from previous Participants were recruited over a 6-month period fromresearch, be used in the primary care setting.26 The PHQ-2 various pediatric outpatient clinics associated withasks patients the following 2 questions: New York’s Brookdale University Hospital and Medical Center, in addition to the Center’s child psychiatric out- 1. During the past month, have you been bothered patient mental health clinic. by little interest or pleasure in doing things? Adolescents were eligible to participate if they were 2. During the past month, have you been bothered between the ages of 13 and 17 years (inclusive); able to by feeling down, depressed, or hopeless? read and to respond to the questions in the questionnaires; not actively psychotic; able to give assent; and accompa- If the patient responds “no” to both questions, then nied by a parent who could give consent.the screen is negative. If the patient responds “yes” to Adolescents were excluded from the study if they hadone of the two questions, the primary care physician an acute medical illness requiring hospitalization.is expected to follow up with additional assessment of Adolescents attending regularly scheduled clinic vis-possible depression. This is typically accomplished by its were referred by their treating physician or therapist.administering a longer instrument such as the Patient They were screened for their eligibility to participate in
3. Borner et al. 949the study either by the main research clinician or by one (A positive statement = 0, a moderately negativeof the research assistants (a pediatric resident and a answer = 1, a severely negative answer = 2)psychology intern). Reason for the clinic visit, presenceof a legal care taker, date of birth, and the patient’s grade The questionnaire covers questions pertaining tolevel in school were ascertained through information negative mood, interpersonal problems, ineffectiveness,from the treating physician or therapist and confirmed in anhedonia, and negative self-esteem. The CDI has beenthe chart. Subsequently, children and parents were met shown to discriminate between clinically depressed andby the researcher and the purpose of the study, the nondepressed psychiatric patients.33 Even though therequirements to complete the questionnaires, and the questionnaire provides scores for the different subscales,approximate time involvement was explained to them. we only used the total depression score for our inves-If they both expressed interest in the study the adolescent tigation. We used a T-score of greater than 60 as awas asked to read and answer an example of the ques- positive indicator for depression based on the manual’stions in order to assess his or her ability to read, under- recommendation.34stand, and respond to the questions asked. Once the Beck Depression Inventory. The Beck Depressionadolescent’s eligibility was established both parent and Inventory (BDI)35 is a 21-item measure designed toadolescent were asked to sign the consent or assent form detect depression in individuals 13 years through adult-to participate in the study. hood. The respondent is asked to circle one out of four The study protocol was approved by the Institutional responses “. . . that best describes the way you have beenReview Board of Brookdale University Hospital and feeling in the past week.” A BDI sample question readsMedical Center. as follows: • I don’t cry any more than usual.Procedure • I cry more now than I used to.The PHQ-2 was administered first. Each question was • I cry all the time now.read aloud and the participant was asked to mark their • I used to be able to cry, but now I can’t cry evenanswer “yes” or “no.” Next, the researchers explained though I want to.the BDI and handed the questionnaire to the adolescentinstructing them to mark the most applicable answer. On (The value of a neutral answer = 0, the value ofcompletion of the BDI, the CDI was explained to and the mildly negative answer = 1, the moderatelythen administered to each participant in similar fashion. negative answer = 2, and the severely negativeTotal time for the explanation and completion of the ques- answer = 3)tionnaires was about 20 minutes. We obtained a medicaland psychiatric history from the parent and reviewed The BDI results in one total score, with higher scoresthe physical examination conducted by the pediatrician indicative of more severe depression. We used a score ofto gain a perspective on how our sample compared with greater than 10 as a positive indicator for depression, withthe general population. scores in the range 10 to 16 indicative of mild depres- sion, scores in the range 17 to 29 indicative of moderate depression, and scores ranging from 30 to 63 indicativeMeasures of severe depression.36 Two-Item Patient Health Questionnaire (PHQ-2). This2-item depression screener derived from previousresearch26 was administered to all study participants. Results Children’s Depression Inventory. The Children’s Depres- Sample Characteristicssion Inventory (CDI)32 is a self-administered 27-itemquestionnaire used to detect depression in children aged A total of 85 adolescents participated in this study. The7 to 17 years. It is written in simple language (grade 1 sample consisted of 22 (25.9%) males and 63 (74.1%)reading level) and asks the child to select one of three females between the ages of 13 and 17 years, with achoices “that describes you best over the past two weeks.” mean age of 15.09 years (SD = 1.51). Ethnic breakdownA CDI sample question reads as follows: of the sample was as follows; 57 (69.5%) African American, 19 (23.2%) Hispanic, 4 (4.9%) white, 1 (1.2%) • Nobody really loves me Asian, and 1 (1.2%) identified as “other.” Educational • I am not sure if anybody loves me status ranged from grade 4 to grade 11, with a mean • I am sure that somebody loves me grade level of 8.40 (SD = 1.52); approximately 13% of
4. 950 Clinical Pediatrics 49(10)Table 1. Sample Demographic Information (N = 85) Table 2. Bivaritate Correlations Among Measures of DepressionVariable n (%) PHQ-2 Q1 PHQ-2 Q2Age, M (SD) 15.09 (1.51)Gender CDI .14 .64a Male 22 (25.9) BDI .05 .49a Female 63 (74.1) Abbreviations: PHQ-2 Q1, Two-Item Depression Screener Ques-Ethnicity tion 1; PHQ-2 Q2, Two-Item Depression Screener Question 2; African American 57 (69.5) CDI, Children’s Depression Inventory; BDI, Beck Depression Hispanic 19 (23.2) Inventory. Caucasian 4 (4.9) a P < .01. Asian 1 (1.2) Other 1 (1.2)Grade level, M (SD) 8.40 (1.52) Discriminant Function AnalysesFamily income Parental employment 49 (58.3) The cut scores for the CDI (T-score > 60,) and BDI (total Public assistance 17 (20.2) Social security income 16 (19.0) score > 10) were used as a criterion, whereby a positivePsychiatric history indicator of depression on either measure was considered Emotional/behavioral problems 47 (56.0) indicative of depression. Three separate discriminant Therapy 40 (47.6) function analyses were then conducted, using responses Medication treatment 12 (14.6) of “yes” (ie, indicative of depression) to either question Hospitalization 14 (16.7) of the PHQ-2, to the first question of the PHQ-2, and to Family history 47 (56.6) the second question of the PHQ-2. Answering “yes” to either question on the PHQ-2 resulted in an overall classification accuracy of 67.1%the sample reported a special education curriculum. (predictive value positive = .61; predictive value neg-Family income was predominantly sustained via paren- ative = .79); sensitivity was 85% and specificity wastal employment (58.3%), with public assistance (20.2%) 51.1%. Answering “yes” to the first question on theand Social Security income (19.0%) comprising a sig- PHQ-2 resulted in an overall classification accuracy ofnificant minority. A total of 71.8% received government- 54.1% (predictive value positive = .51; predictive valuesupported health insurance. More than half (56.0%) of negative = .56); sensitivity was 47.5 % and specificityall participants had a history of emotional or behavioral was 60%. Finally, answering “yes” to the second ques-problems, with nearly half (47.6%) reporting a history tion on the PHQ-2 resulted in an overall classificationof therapy. A smaller proportion reported a history of accuracy of 72.9% (predictive value positive = .73; pre-psychiatric treatment with medication (14.6%) or a his- dictive value negative = .73); sensitivity was 67.5% andtory of psychiatric hospitalizations (16.7%). More than specificity was 77.8%. See Table 3 for a summary of thehalf (56.6%) also reported a family history of psychiatric discriminant function analyses.illness and possible treatment. See Table 1 for a summaryof sample demographic information. Discussion Summary of ResultsBivariate CorrelationsBivariate correlations between the individual questions This study sought to determine whether the use of a 2-itemon the PHQ-2 and the 2 established measures of depression screening tool (the PHQ-2) was applicabledepression revealed a significant relationship only for and valid in screening for depression in adolescentsthe second question on the PHQ-2 (see Table 2). This attending various primary care clinics. A total of 85 ado-question—which asked patients if they had felt “down, lescents between the ages of 13 and 17 years, recruiteddepressed, or helpless” in the past month—was signifi- from various metropolitan pediatric outpatient clinics,cantly correlated with both the CDI, r(85) = .64, P < .01, were administered this 2-item screening tool along withand the BDI, r(85) = .49, P < .01. The first question— 2 other well-established measures of depression (the CDIwhich asked clients if they had experienced “little plea- and the BDI). Results revealed a significant bivariatesure or interest in doing things” in the past month—was relationship between the second question of the PHQ-2—unrelated to both the CDI, r(85) = .14, P = .10, and the pertaining to depressed and hopeless mood—andBDI, r(85) = .05, P = .34. the 2 established measures of depression. The first
5. Borner et al. 951Table 3. Summary of Discriminant Function Analyses Actual Group StatusbPredicted Group Statusa Depressed Not DepressedPHQ-2Q1Depressed 19 18Not Depressed 21 27Sensitivity: .48 Specificity: .60Predictive value positive: .51 Predictive value negative: .56PHQ-2Q2Depressed 27 10Not Depressed 13 35Sensitivity: .68 Specificity: .79Predictive value positive: .73 Predictive value negative: .73“Yes” on either PHQ-2 Q1 or PHQ-2 Q2Depressed 34 22Not Depressed 6 23Sensitivity: .85 Specificity: .51Predictive value positive: .61 Predictive value negative: .79Abbreviations: PHQ-2 Q1, Two-Item Depression Screener Question 1; PHQ-2 Q2, Two-Item Depression Screener Question 2.a Based on “yes/no” responses on the PHQ-2.b Based on the Children’s Depression Inventory T score >60 or Beck Depression Inventory total score >10.question—pertaining to anhedonia—was unrelated to adults. A quick screening for depression during regularthe existing measures of depression. Discriminant func- visits in the office of a family physician, pediatrician, ortion analysis further revealed that answering “yes” to the obstetrician can be an important first step toward detect-second question of the PHQ-2 resulted in correct clas- ing symptoms of depression in adolescents.sification of 73% of adolescents as depressed or not A number of factors limit the generalizability anddepressed (positive predictive value = .73; negative pre- immediate applicability of the current findings. First, ourdictive value = .73; sensitivity = .68; specificity = .78). sample size was small compared with other similar studies,The first question on the PHQ-2 appeared to have lim- and the sample included mostly minority children fromited value in ascertaining whether adolescents are lower socioeconomic backgrounds. Thus, this is a ratherdepressed or not, correctly classifying only 54% of ado- select sample and not necessarily representative of thelescents (positive predictive value = .51; negative pre- general population of adolescents. Although one aimdictive value = .56; sensitivity = .48; specificity = .60). of the study was to assess the validity of a screener forCompared with using the second question only, the use depression in such an underrepresented population,of both questions resulted in correct classification of follow-up with a larger, more representative sample67% of adolescents (positive predictive value = .61; should still be done.negative predictive value = .79; sensitivity = .85; speci- Even though using both questions resulted in a rela-ficity = .51). Thus, higher sensitivity (and therefore, tively large number of false positives (because specific-fewer false negatives) came at the hands of lower speci- ity was lower than when only Q2 was used), the highficity (and thus, more false positives). sensitivity achieved with both questions taken together Based on these results it is evident that the question meant that in this population only 15% of depressed ado-regarding feelings of depression and hopelessness is more lescents were not identified by the screen. Because thismeaningful for adolescents in this study than the question screen must be followed up by further evaluation, eitherfor symptoms pertaining to lack of interest or pleasure. by administering the BDI or referral to a child psychia-Whether this is a phenomenon of adolescents in general trist, the false positive individuals will be weeded out inor for this limited-means minority population in particu- this second process.lar would require further studies with different popula- Considering the extraordinary time constraints pri-tions. The results of the study show that the PHQ-2 can be mary care physicians are facing in the evaluation of theirused as a quick and relatively effective screening instru- patients, a 1- or 2-question screening tool can be extremelyment for adolescents in a medical care setting. Adoles- valuable as the first step in the detection of depression incents are usually not a group that easily turns for help from adolescents.
6. 952 Clinical Pediatrics 49(10)Author’s Note 10. Kandel DB, Davies M. High school students who use crack and other drugs. Arch Gen Psychiatry.At the time the research was conducted in 2006-2007, all 1996;53:71-80.authors were with Brookdale University Hospital Medi- 11. Gotlib IH, Lewinsohn PM, Seeley JR. Symptoms versus acal Center. Dr St. Victor was and continues to be with the diagnosis of depression: difference in psychosocial func-Department of Pediatrics, and Drs Braunstein, Pollack, tioning. J Consult Clin Psychol. 1995;63:90-100.and Borner were with the Department of Psychiatry. 12. Kandel DE, Raveis VH, Davies M. Suicidal ideation inDr Borner is presently at the Zucker Hillside Hospital in adolescence: depression, substance use and other risk fac-the Department of Psychiatric Research, Dr Braunstein tors. J Youth Adolesc. 1991;20:289-309.is deceased, and Dr Pollack is retired. 13. Kubik MY, Lytle LA, Birnbaum AS, Murray DM, Perry CL. Prevalence and correlates of depressive symptoms inDeclaration of Conflicting Interests young adolescents. Am J Health Behav. 2003;27:546-553.The author(s) declared no conflicts of interest with respect 14. Pine DS, Cohen E, Cohen P, Brook J. Adolescent depressiveto the authorship and/or publication of this article. symptoms as predictors of adult depression: moodiness or mood disorder? Am J Psychiatry. 1999;156:133-135.Funding 15. Fergusson DM, Horwood LJ, Ridder EM, Beuatrais AL.The author(s) received no financial support for the research Subthreshold depression in adolescence and mental healthand/or authorship of this article. outcome in adulthood. Arch Gen Psychiatry. 2005;62: 66-72.References 16. Roberts RE, Roberts CR, Chen YR. Ethnocultural differences 1. Committee on Psychosocial Aspects of Child and Family in prevalence of adolescent depression. Am J Community Psy- Health and Task Force on Mental Health. Policy statement— chol. 1997;25:95-110. the future of pediatrics: mental health competencies for 17. Shaikh IA, Shaikh MA. Correlates of depression in the pediatric primary care. Pediatrics. 2009;124:410-421. United States. Ann Epidemiol. 2004;14:603-603. 2. Birmaher B, Ryan ND, Williamson DE, et al. Childhood and 18. Goodman E, Slap GB, Huang B. The public health impact adolescent depression: a review of the past 10 years. Part I. of socioeconomic status on adolescent depression and obe- J Am Acad Child Adolesc Psychiatry. 1996;35;1427-1439. sity. Am J Public Health. 2003;93:1844-1850. 3. Birmaher B, Ryan ND, Williamson DE, et al. Child- 19. Weiller E, Bisserbe JC, Maier W, Lecrubier Y. Prevalence hood and adolescent depression: a review of the past and recognition of anxiety syndromes in five European 10 years. Part II. J Am Acad Child Adolesc Psychiatry. primary care settings: A report from the WHO Study on 1996;35:1575-1583. Psychological Problems in General Health Care. Br J Psy- 4. Lewinsohn PM, Hops H, Roberts RE, Seeley JR, Andrews chiatry. 1998;173(Suppl 34):18-23. JA. (1993) Adolescent psychopathology 1: prevalence 20. Brown C, Schulberg HC. Diagnosis and treatment of and incidence of depression and other DSM-III-R disor- depression in primary medical care practice: the applica- ders in high school students. Journal of Abnorm Psychol. tion of research findings to clinical practice. J Clin Psychol. 1993;102:133-144. 1998;54:303-314. 5. Kessler RC, Walters EE. Epidemiology of DSM-III-R 21. Katon W, Schulberg H. Epidemiology of depression in major depression and minor depression among adoles- primary care. Gen Hosp Psychiatry. 1992;14:237-247. cents and young adults in the national comorbidity survey. 22. Kessler D, Bennewith O, Lewis G, Sharp D. Detection of Depress Anxiety. 1998;7:3-14. depression and anxiety in primary care: follow-up study. 6. Zalsman G, Brent DA, Weersing VR. Depressive disor- BMJ. 2002;325:1016-1017. ders in childhood and adolescence: an overview: epide- 23. Pignone MP, Gaynes BN, Rushton JL, et al. Screening miology, clinical manifestation and risk factors. Child for depression in adults: a summary of the evidence for Adolesc Psychiatr Clin N Am. 2006;15:827-841. the U.S. Preventive Services Task Force. Ann Intern Med. 7. American Psychiatric Association. Diagnostic and Statistical 2002;136:765-776. Manual of Mental Disorders, Fourth Edition, Text Revision. 24. Coyle JT, Pine DS, Charney DS, et al; Depression and Washington, DC: American Psychiatric Association; 2000. Bipolar Support Alliance Consensus Development Panel. 8. Weissman MM, Wolk S, Goldstein RB, et al. Depressed Depression and bipolar support alliance consensus state- adolescents grown up. JAMA. 1999;281:1707-1713. ment on the unmet needs in diagnosis and treatment of 9. Birmaher B, Bridge JA, Williamson DE, et al. Psycho- mood disorders in children and adolescents. J Am Acad social functioning in youth at high risk to develop major Child Adolesc Psychiatry. 2003;42:1494-1503. depressive disorder. J Am Acad Child Adolesc Psychiatry. 25. Gilbody S, Sheldon T, Wessely S. Should we screen for 2004;43:839-846. Depression? BMJ. 2006;332:1027-1030.
7. Borner et al. 95326. Arroll B, Khin N, Kerse N. Screening for depression in Inventory-II in a low-income African American sample of primary care with two verbally asked questions: cross- medical outpatients. Psychol Assess. 2005;17:110-114. sectional study. BMJ. 2003;327:1144-1146. 32. Kovacs M. Children’s Depression Inventory (CDI)27. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity Manual. North Tonawanda, NY: Multi-Health Systems; of a brief depression severity measure. J Gen Intern Med. 1992. 2001;16:606-613. 33. Lobovits DA, Hendal PJ. Childhood depression:28. Sielk M, Altiner A, Janssen B, et al. Prevalence and diag- prevalence using DSM-III criteria and validity of par- nosis of depression in primary care. A critical comparison ent and child depression scales. J Pediatr Psychol. between PHQ-9 and GPs’ judgement [in German]. Psychi- 1985;10:45-54. atr Praxis. 2009;36:169-174. 34. Kovacs M. Children’s Depression Inventory (CDI). In29. DeJesus RS, Vickers KS, Melin GJ, Williams MD. A Rush AJ Jr, First MB, Blacker D, eds. Handbook of Psy- system-based approach to depression management in pri- chiatric Measures. Washington, DC: American Psychiat- mary care using the Patient Health Questionnaire. Mayo ric Association; 2005. Clin Proc. 2007;82:1395-1402. 35. Beck AT. The Beck Depression Inventory Manual. San30. Cannon DS, Tiffany ST, Coon H, et al. The PHQ-9 as a brief Antonio, TX: Harcourt Brace Jovanovich; 1987. assessment of lifetime major depression. Psychol Assess. 36. Beck AT, Steer RA. Beck Depression Inventory (BDI). In 2007;19:247-251. Rush AJ Jr, First MB, Blacker D, eds. Handbook of Psy-31. Grothe KB, Dutton GR, Jones GN, Bodenlos J, Ancona chiatric Measures. Washington, DC: American Psychiat- M, Brantley PJ. Validation of the Beck Depression ric Association; 2005.
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