The validity and reliability of the PHQ-9 in screening for post-stroke depression

Background: Depression affects about 30% of stroke survivors within 5 years. Timely diagnosis and management of post-stroke depression facilitate motor recovery and improve independence. The original version of the Patient Health Questionnaire-9 (PHQ-9) is recognized as a good screening tool for post-stroke depression. However, no validation studies have been undertaken for the use of the Thai PHQ-9 in screening for depression among Thai stroke patients.

Methods: The objectives were to determine the criterion validity and reliability of the Thai PHQ-9 in screening for post-stroke depression by comparing its results with those of a psychiatric interview as the gold standard. First-ever stroke patients aged ≥45 years with a stroke duration 2 weeks-2 years were administered the Thai PHQ-9. The gold standard was a psychiatric interview leading to a DSM-5 diagnosis of depressive disorder and adjustment disorder with a depressed mood. The summed-scored-based diagnosis of depression with the PHQ-9 was obtained. Validity and reliability analyses, and a receiver operating characteristic curve analysis, were performed.

Results: In all, 115 stroke patients with a mean age of 64 years (SD: 10 years) were enrolled. The mean PHQ-9 score was 5.2 (SD: 4.8). Using the DSM-5 criteria, 11 patients (9.6%) were diagnosed with depressive disorder, 12 patients (10.5%) were diagnosed with adjustment disorder with a depressed mood. Both disorders were combined as a group of post-stroke depression. The Thai PHQ-9 had satisfactory internal consistency (Cronbach's alpha: 0.78). The algorithm-based diagnosis of the Thai PHQ-9 had low sensitivity (0.52) but very high specificity (0.94) and positive likelihood ratio (9.6). Used as a summed-scored-based diagnosis, an optimal cut-off score of six revealed a sensitivity of 0.87, specificity of 0.75, positive predictive value of 0.46, negative predictive value of 0.95, and positive likelihood ratio of 3.5. The area under the curve was 0.87 (95% CI: 0.78-0.96).

Conclusions: The Thai PHQ-9 has acceptable psychometric properties for detecting a mixture of major depression and adjustment disorder in post-stroke patients, with a recommended cut-off score of ≥6 for a Thai population.