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Validation and Utility of the Patient Health Questionnaire in Diagnosing Mental Disorders in 1003 General Hospital Spanish Inpatients

From the Department of Psychiatry, Autonomous University of Barcelona; University Hospital "Germans Trias i Pujol" (C.D.-Q. and L.S.-P.) and Biomedical Research Foundation "Germans Trias i Pujol," (T.R.) Badalona, Spain; Regenstrief Institute for Health Care, Department of Medicine (K.K), Indiana University, Indianapolis, Indiana (K.K.); and Department of Psychiatry (R.L.S), Columbia University, New York.

Address reprint requests to: Crisanto Diez-Quevedo, MD, Departament de Psiquiatria, Hospital Universitari Germans Trias i Pujol, Ctra del Canyet, s/n, E-08916 Badalona, Spain. Email: psq{at}ns.hugtip.scs.es

	ABSTRACT

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION NOTES ACKNOWLEDGMENTS REFERENCES

 
OBJECTIVE: To determine whether the Spanish version of the patient health questionnaire (PHQ) has validity and utility for diagnosing mental disorders in general hospital inpatients.

METHODS: Participants in the study were 1003 general hospital inpatients, randomly selected from all admissions over an 18-month period. All of them completed the PHQ, the Beck Depression Inventory (BDI), and measures of functional status, disability days, and health care use, including length of hospital stay. They also had a structured interview with a mental health professional.

RESULTS: A total of 416 (42%) of the 1003 general hospital inpatients had a PHQ diagnosis. There was good agreement between PHQ diagnoses and those of an independent mental health professional (for the diagnosis of any PHQ disorder, = 0.74; overall accuracy, 88%; sensitivity, 87%; specificity, 88%), similar to the original English version of the PHQ in primary care patients. Patients with PHQ diagnoses had more functional impairment, disability days, and health care use than did patients without PHQ diagnoses (group main effects for functional status measures and disability days, p < .001; group main effects for health care use, p < .01). The group main effect for hospital length of stay was not significant. An index of depression symptom severity calculated from the PHQ correlated significantly both with the number of depressive symptoms detected at interview and the total BDI score. PHQ administration was well accepted by patients.

CONCLUSIONS: The Spanish version of the PHQ has diagnostic validity in general hospital inpatients comparable to the original English version in primary care.

Key Words: mental disorders/diagnosis • general hospital inpatients • mental status schedule • psychiatric status rating scales • sensitivity and specificity • cost of illness

Abbreviations: PHQ = patient health questionnaire; BDI = Beck Depression Inventory; SF-20 = Medical Outcomes Study Short-Form General Health Survey; PRIME-MD = primary care evaluation of mental disorders; DSM-III-R = Diagnostic and Statistical Manual of Mental Disorders, 3rd edition revised; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th edition; SD = standard deviation; MHP = mental health professional; ICD-9 = International Classification of Diseases, 9th edition.

	INTRODUCTION

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Mental disorders are common and disabling in medical patients, and their influence on health care use and costs has been well established (1–11). Although less studied than primary care patients, the situation is rather similar in general hospital inpatients (12–20), who also show a relationship between mental disorders and variables related to hospitalization, such as length of stay (16, 18, 21–23). However, mental disorders are frequently unrecognized and are therefore not treated in this population (13, 22, 24) or in primary care settings (1, 3, 5–8, 10, 11, 25–28).

Several instruments have been designed for the screening of psychopathology in medical patients (29–32). However, the PRIME-MD (6) and the PHQ (11) are the first brief instruments to cover a wide range of psychopathology and to diagnose specific disorders by use of diagnostic criteria from the DSM-III-R (33) and DSM-IV (34). PRIME-MD has been translated and validated in Spanish primary care populations (8–10). This instrument is a 2-stage system in which the patient first completes a self-administered questionnaire that screens for 5 of the most common groups of disorders in primary care: depressive, anxiety, alcohol, somatoform, and eating disorders. For patients who screen positive, the physician then asks specific questions from the clinician evaluation guide. Designed for use in primary care, PRIME-MD has not been used to our knowledge with general hospital inpatients (with the exception of Beck et al. [31], who used only the mood module). Although PRIME-MD has been widely used in clinical research (35–42), its use in clinical settings has apparently been limited because of the amount of time required to administer the clinician evaluation guide. For this reason, the authors recently developed and validated a fully self-administered version of the original PRIME-MD, called the PRIME-MD PHQ (11). The 2 components of the original PRIME-MD (the patient questionnaire and the clinician evaluation guide) were combined into a single, 3-page questionnaire that can be entirely self-administered by the patient. The clinician scans the completed questionnaire, verifies positive responses, and applies diagnostic algorithms. The PHQ assesses for threshold disorders (major depressive disorder, panic disorder, other anxiety disorder, and bulimia nervosa) and subthreshold disorders (other depressive disorder, probable alcohol abuse or dependence, and binge eating disorder).

The purpose of the present study was to validate a Spanish version of the PHQ and to demonstrate its utility to enhance the recognition of mental disorders, replicating original data on primary care patients with a sample of medical and surgical inpatients in a tertiary university hospital.¹

	METHODS

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Site and Selection of Subjects
The study was conducted with medical and surgical inpatients between the ages of 18 and 74 years who were admitted to a tertiary university hospital in Spain. The hospital review board approved the study protocol. From April 1997 to September 1998, a total of 35,042 patients were admitted to the hospital. Excluded from this study were 9448 patients who were admitted to intensive care units or for ambulatory major surgery and 10,363 who were either outside the age limits or were admitted to the wards of psychiatry, obstetrics, and substance dependence disorders. Thus, 15,231 patients were potentially eligible for this study, of whom 9590 were randomly selected to participate. Of these, 4088 were not available (eg, because of surgery, other treatments, or tests); 2611 were excluded because of having already been approached in previous admissions (388), illiteracy (399), cognitive impairment (777), physical impairment precluding completion of the questionnaire (978), or non–Spanish-speaking (69); and 1069 either refused to participate or to complete the protocol. Patients who refused to participate in the study were slightly more likely to be men (62% vs. 56%) but were equally represented in medical and surgical wards.

Therefore, 1822 patients were ultimately enrolled and allocated into two groups: 1003 patients who constitute the sample for this report and 819 who were used as a control group for other purposes and are not used at all in this paper. These two groups did not differ in terms of sex, marital status, educational level, specific unit of admittance (medical, surgical, and medical-surgical wards), or length of stay and only slightly differed by age (43.0 vs. 45.3 years). All enrolled subjects provided written informed consent.

Data Collection
Within several days of admission (mean 2.0, SD 4.7), all study patients completed the PHQ. The Spanish version of the PHQ was developed similar to the Spanish version of the original PRIME-MD (9). It should be emphasized that if this Spanish language version is going to be used in a Spanish-speaking population in the United States, some changes may be required because of differences in dialects. Additionally, patients completed other items regarding visits to a physician and disability days during the 3 months prior to hospital admission, their comfort with answering the PHQ questions, and how valuable they believed the PHQ would be to their physicians in understanding and treating the problems they were having (11). Patients also completed SF-20 (43–45), which measures functional status in 6 domains, and the BDI (46).

To determine the agreement of PHQ diagnoses with those of a MHP, one of us (T.R.), an experienced clinical psychologist, interviewed all patients face-to-face within 48 hours after they completed the PHQ. The MHP was blind to the results of PHQ. The rationale and additional details of the interview, which used the overview from the Structured Clinical Interview for DSM-III-R (47) and diagnostic questions from the original PRIME-MD, are described elsewhere (6, 9). Statistical analysis was made by use of SYSTAT 9 statistical package (SPSS Inc.).

	RESULTS

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Description of Patients
The mean (SD) patient age was 43.0 (14.2) years, with a range from 18 to 74 years; 54.4% were men; all were white; 69.5% were married, 5.3% divorced, and 21.6% never married; 34.3% completed high school. The most common types of physical disorders, following ICD-9 (48) groups, were cardiocirculatory diseases (25.9%), gastrointestinal diseases (22.3%), endocrine-nutritional-metabolic-immune diseases (20.8%), cancer (15.7%), genitourinary diseases (15.7%), locomotor and connective tissue diseases (13.2%), hypertension and related disorders (13.0%), respiratory diseases (12.5%), and infectious diseases (10.3%). The two most frequent main diagnoses at discharge were cancer (11.8%) and ischemic heart disease (4.7%). The total length of stay at the hospital was 12.3 days (SD 11.1).

Accuracy (Agreement With MHPs) and Diagnostic Results of PHQ Evaluations
The operating characteristics of the Spanish version of the PHQ are generally satisfactory (Table 1) and are comparable to those of the original English version (11). Sensitivity was >76% for all individual psychiatric diagnoses (except 69% for "any anxiety disorder") and 87% for any PHQ psychiatric diagnosis. Specificity and overall accuracy were higher than 86% for all measures. Furthermore, the PHQ depression symptom severity score (the sum of scores on the 9 PHQ depressive symptoms, with a possible range of 0–27) correlated strongly with both the number of depressive symptoms recorded during MHP interview (0.71) and the total BDI score (0.76).

View larger version (48K): [in this window] [in a new window]   Fig. 1. Relationship of PHQ results to functional status (SF-20 scales). Because of missing data for some patients, the range of numbers of patients across scales was as follows: symptom-screen–negative, 409 to 422; symptom-screen–positive but no psychiatric diagnosis, 152 to 157; subthreshold psychiatric diagnosis, 197 to 208; and threshold psychiatric diagnosis, 190 to 201.

Reaction of Patients to PHQ
The majority of patients (93.3%) said they were "very" or "somewhat" comfortable answering the questions on the PHQ. Likewise, 90.7% believed that the questions were "very" or "somewhat" helpful in getting their physicians to better understand or treat the problems they were having.

	DISCUSSION

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Certainly, the patients included in this study are not fully representative of the general hospital inpatient population. The first step in the decision tree was to exclude from the target population all patients admitted to intensive care, ambulatory major surgery, psychiatry, obstetrics, and substance dependence disorders units, either for the relative unavailability of these patients or because they represented special populations. Patients under age 18 or over age 74 years were also excluded. A second step in the decision tree was to not approach in a second wave patients who were initially unavailable because of surgery, other treatments, or medical tests. Our primary aim was to evaluate psychopathology present on hospital admission, and we wished to decrease the likelihood that major treatments or the results of diagnostic tests would affect types and frequency of mental disorders in a hospitalized population. Patients not available (43%) were somewhat overrepresented in surgical (48%) and medical-surgical (58%) wards. Although this decision tree has a modest impact on the generalizability of our findings to hospital patients not studied, our results regarding the validation and utility of the PHQ in diagnosing mental disorders remain strong.

The self-administered Spanish version of PHQ has diagnostic validity in general hospital inpatients comparable to that of the original English version of PHQ (11) and the original clinician-administered PRIME-MD (6, 9) in primary care. This was demonstrated both by agreement with an independent MHP interview (criterion validity) as well as by the strong association of PHQ diagnoses with indices of functional impairment and health care use (construct validity). PHQ administration was well accepted by patients, and most believed that the questions were helpful in getting their physicians to better understand or treat the problems they were having, even though they were patients admitted to a general hospital for specific medical-surgical problems.

Even though our patients differed from patients in the original PHQ validation study in terms of several demographic (more men and married and fewer divorced) and clinical variables (inpatients vs. primary care patients and more severe medical diagnoses), the operating characteristics of the Spanish version of PHQ are generally satisfactory and comparable to those obtained by the original English version. Agreement between the PHQ and the mental health professional interview ranged between good and strong for all diagnoses. Furthermore, the PHQ index of depression symptom severity correlated strongly with both the number of depressive symptoms recorded during the MHP interview as well as the total Beck Depression Inventory score. Only a minority (12.6%) of the patients with any MHP psychiatric diagnosis was not recognized by the PHQ, and they were overrepresented in the groups of other anxiety disorders and probable alcohol abuse/dependence.

The relationship between PHQ diagnostic status and other patient outcomes in our inpatient sample was similar to that found in previous outpatient studies. As diagnostic status ascended from symptoms but no psychiatric disorder to subthreshold disorder to threshold disorder, there was a progressive increase in functional impairment, health care use, and disability days. The functional status of mentally healthy subjects (the screen-negative group) is lower in our sample, and the number of visits to a physician and the days kept from usual activities during the previous 3 months are higher, which is in accordance with the inpatient status and the more severe physical disorders in our sample. Paired comparisons show fewer differences than Spitzer et al.’s paper (11) between the screen-negative group and the screen-positive but no psychiatric diagnosis group and between the latter and the subthreshold diagnosis group, probably because of the smaller size of our sample and the higher prevalence of probable alcohol abuse/dependence, included in the subthreshold diagnosis group, which has a smaller relationship to functional status (49). Nevertheless, differences were rather similar to those obtained in the original PRIME-MD study (6).

Compared with the original PHQ primary care study, our hospitalized sample had a greater prevalence of any psychiatric diagnosis (42% vs. 28%), both threshold and subthreshold, especially because of a larger proportion of inpatients with mood disorders (26% vs. 16%), other anxiety disorders (12% vs. 7%), and probable alcohol abuse/dependence (13% vs. 7%). Part of these differences may be due to dissimilarities in demographic variables, type of patients (inpatients vs. primary care patients), and greater numbers and severity of physical disorders. Cultural differences may also play a role. For example, in the work of Baca et al. (8) in primary care in Spain, the prevalence of any psychiatric disorder was 54%, mood disorders was 38%, and anxiety disorders was 22%. Our data are generally similar to other studies of mental disorders in medical inpatients (12, 13, 16–19).

In contrast to some previous studies (16, 18, 21–23), psychiatric diagnoses were only marginally associated with length of stay in our study. This weaker relationship may be due to several factors. First, the PHQ examines a wide spectrum of psychiatric symptom severity ranging from symptoms only to threshold disorders. Some previous inpatient studies focused more on threshold disorders, and it was in this group that our study also found a modest effect on length of stay. Second, the average length of stay in our hospital was relatively long, compared with a number of other hospitals. It may be that psychiatric comorbidity has a greater effect when there are economic and other system pressures to shorten hospital stay.

The number of patients with a PHQ psychiatric diagnosis unrecognized by their physicians was higher in our study than in the original primary care sample (68% vs. 46% for any psychiatric diagnosis). One major reason may be that, in the original study, physicians were explicitly asked whether they believed the patient had a psychiatric diagnosis. Physicians in our study were unprompted and, instead, we compared the PHQ results to the presence of a diagnosis of any ICD-9 mental disorder at discharge (48). It is also possible that the detection of psychiatric diagnoses is lower in inpatient settings, where the overriding concern is the acute medical or surgical illnesses triggering hospital admission and acute care. However, substantial differences existed even within our inpatient sample, with the recognition on surgical wards being considerably lower than on the medical wards. In fact, the recognition rates on the medical wards were comparable to that demonstrated in primary care outpatient studies.

Because of its easy and well-accepted administration and its power to detect psychiatric diagnoses, the PHQ could be a useful screening procedure not only in primary care but also in general hospital care. Enhanced recognition of mental disorders, if coupled with appropriate treatment, would have the potential to improve the functional status of such patients and reduce their health care use. The busy hospital setting, however, may not always be the ideal setting to adequately address mental disorders, particularly with competing acute medical and surgical illnesses and economic pressures to shorten hospital stays (50). Also, a proportion of psychiatric symptoms present on admission may decrease by hospital discharge (17, 51). For these reasons, hospitalized patients in whom a psychiatric diagnosis is detected may warrant closer outpatient follow-up, where treatment could be instituted. As suggested in the original PHQ study and confirmed by many others, additional support may also be necessary for the primary care physicians to adequately manage those disorders that are detected (11, 52).

	ACKNOWLEDGMENTS

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This study received financial support by a full grant from the Spanish Ministry of Health–Health Research Fund (Fondo de Investigaciones Sanitarias, project 97/1184). T. Rangil was a FIS Research Fellow (97/1184). The development of the original PHQ was underwritten by an educational grant from Pfizer US Pharmaceuticals Inc, New York, NY. PRIME-MD is a trademark of Pfizer Inc. Copyright held by Pfizer Inc.

The authors wish to thank Maria Vilchez, DI, and Rosa Fernandez-Valdes, MBM, for their support in data collection and Montserrat Prats, MD, for her clinical support, as well as the health and administration staff of the University Hospital "Germans Trias i Pujol" for their help in conducting the study.

	NOTES

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¹ Copies of the Spanish version of PHQ are available upon request.

Received for publication April 14, 2000.

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