The patient health questionnaire for adolescents: Validation of an instrument for the assessment of mental disorders among adolescent primary care patients

doi:10.1016/S1054-139X(01)00333-0

Journal of Adolescent Health

Volume 30, Issue 3, March 2002, Pages 196-204

https://doi.org/10.1016/S1054-139X(01)00333-0 Get rights and content

Abstract

Purpose: To investigate the validity of the Patient Health Questionnaire for Adolescents (PHQ-A), a self-administered instrument that assesses anxiety, eating, mood, and substance use disorders among adolescent primary care patients.

Methods: A total of 403 adolescents from California, New Jersey, New York, and Ohio completed the PHQ-A and the Medical Outcomes Study Short-Form General Health Survey (SF-20) during or shortly after a visit to a primary care clinic or a school nurse’s office. A few days later, clinical psychologists who were blind to the results of the PHQ-A administered a semi-structured clinical interview to assess the same psychiatric disorders and to conduct a global assessment of functioning (GAF) among 403 patients. Diagnostic agreement coefficients were computed and analyses of covariance were conducted.

Results: Findings support the diagnostic validity of the PHQ-A. The PHQ-A and the clinical interview produced similar estimates of the prevalence rates of anxiety, eating, mood, and substance use disorders. The PHQ-A demonstrated satisfactory sensitivity, specificity, diagnostic agreement, and overall diagnostic accuracy, compared with the clinical interview. Adolescents with PHQ-A diagnoses experienced significantly poorer mental and overall functioning, more physical pain, and poorer overall health compared with those without psychiatric disorders. These differences remained significant after patients’ age, gender, ethnicity, and site were controlled statistically.

Conclusion: The PHQ-A may be used to assist primary care practitioners in identifying psychiatric disorders among their adolescent patients. The PHQ-A is the first such tool to be tested for use in adolescents and offers an acceptable and efficient tool for early detection and recognition of mental disorders in this high-risk group.

Section snippets

Development of the PHQ-A

The two components of the original PRIME-MD (the patient questionnaire and the clinical evaluation guide) were combined into a 6-page, 67-item questionnaire that can be entirely self-administered by the patient in 5 minutes or less. The clinician scans the completed questionnaire and applies diagnostic algorithms that are printed in abbreviated form at the bottom of each page. In this study, the data from the PHQ-A were entered into a computer program that applied the diagnostic algorithms

Research questions

The present study investigated the validity of the PHQ-A in a multisite sample of adolescent patients in a range of primary care settings, by focusing on the following questions: (a) “Are diagnoses made with the PHQ-A as accurate as diagnoses made with the original PRIME-MD interview, using independent diagnoses made by mental health professionals (MHPs) as the criterion standard?”; (b) “Is the prevalence of mental disorders identified using the PHQ-A comparable to that obtained from MHP

Sample

The sample consisted of 403 English-speaking adolescent primary care patients (36.7% male, 63.3% female) between the ages of 13 and 18 years (mean age = 15.90 years, SD =1.24) who showed no evidence of mental retardation or organic mental disorder and had at least 9 years of education. The composition of the sample was 77.2% white, 4.2% African-American, 12.4% Hispanic, 2.2% Asian or Pacific Islander, 1.5% Native American and 2.2% Other. A total of 254 participants were recruited from the

Diagnostic results of PHQ-A evaluations

As Table 1 indicates, 20.8% of the participants were diagnosed with psychiatric disorders using the PHQ-A, while 19.6% of the participants were diagnosed with psychiatric disorders by the mental health professionals. Thirty-three patients (8.2%) were diagnosed with one psychiatric disorder, while 51 (12.7%) were diagnosed with two or more disorders. There were 16 co-occurring anxiety and depressive disorders, 12 co-occurring depressive and substance use disorders, 3 cases with depressive

Discussion

The present findings indicate that the diagnostic validity of the PHQ-A is comparable to that of the original PRIME-MD interview and the adult PHQ. The diagnostic validity of the PHQ-A was demonstrated by agreement with an independent interview by a mental health professional (criterion validity) and by the association of PHQ-A diagnoses with indices of impaired functioning, distress, and poor health (construct validity). Compared with the findings of the MHP interview, the PHQ-A demonstrated

Acknowledgements

This research was supported by a grant from the Aaron Diamond Foundation to Jeffrey G. Johnson, Ph.D. and grants from the Hibbard E. Williams Research Fund, University of California, Davis School of Medicine to Emily S. Harris, M.D. The development of the 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.

References (41)

P.M Lewinsohn et al.
Natural course of adolescent major depressive disorderI Continuity into young adulthood
J Am Acad Child Adolesc Psychiatry
(1999)
E.J Costello et al.
Adolescent outcomes of childhood disordersThe consequences of severity and impairment
J Am Acad Child Adolesc Psychiatry
(1999)
U Rao et al.
Unipolar depression in adolescentsClinical outcome in adulthood
J Am Acad Child Adolesc Psychiatry
(1995)
A Angold et al.
Impaired but undiagnosed
J Am Acad Child Adolesc Psychiatry
(1999)
S.L Kaplan et al.
Adverse health behaviors and depressive symptomatology in adolescents
J Am Acad Child Adolesc Psychiatry
(1984)
H.C Schulberg et al.
Mental disorders in primary careEpidemiologic, diagnostic, and treatment research directions
Gen Hosp Psychiat
(1988)
J.F Borus et al.
Primary health care providers’ recognition and diagnosis of mental disorders in their patients
Gen Hosp Psychiatry
(1988)
E.J Costello
Child psychiatric disorders and their correlatesA primary care pediatric sample
J Am Acad Child Adolesc Psychiatry
(1989)
L.A Richardson et al.
Identification and treatment of children’s mental health problems by primary care providersA critical review of research
Arch Psychiatr Nurs
(1996)
D Shaffer et al.
The NIMH Diagnostic Interview Schedule for Children Version 2. (DICS-2.3)Description, acceptability, prevalence rates, and performance in the MECA study
J Am Acad Child Adolesc Psychiatry
(1996)

K.B Wells et al.

Agreement between face-to-face and telephone-administered versions of the depression section of the NIMH Diagnostic Interview Schedule

J Psychiatr Res

(1988)

D Offord et al.

Lowering the burden of suffering from child psychiatric disorderTrade-offs among clinical, targeted, and universal interventions

J Am Acad Child Adolesc Psychiatry

(1998)

M Cappelli et al.

Identifying depressed and suicidal adolescents in a teen clinic

J Adolesc Health

(1995)

R.C Kessler et al.

Lifetime and 12-month prevalence of DSM-III-R-psychiatric disorders in the United StatesResults from the National Comorbidity Survey

Arch Gen Psychiatry

(1994)

P.M Lewinsohn

Natural course of adolescent major depressive disorder in a community samplePredictors of recurrence in young adults

Am J Psychiatry

(2000)

A Angold et al.

Comorbidity

J Child Psychol Psychiatry

(1999)

D.L Newman et al.

Psychiatric disorder in a birth cohort of young adultsPrevalence, comorbidity, clinical significance, and new case incidence from ages 11 to 21

J Consult Clin Psych

(1996)

A Martin et al.

Adolescent depressionWindow of (missed?) opportunity

Am J Psychiatry

(2000)

E.J Costello

Primary care pediatric and child psychopathologyA review of diagnostic, treatment, and referral practices

Pediatrics

(1986)

J.E Barrett et al.

The prevalence of psychiatric disorders in a primary care practice

Arch Gen Psychiatry

(1988)

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Original articleThe patient health questionnaire for adolescents: Validation of an instrument for the assessment of mental disorders among adolescent primary care patients

Abstract

Section snippets

Development of the PHQ-A

Research questions

Sample

Diagnostic results of PHQ-A evaluations

Discussion

Acknowledgements

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Gen Hosp Psychiat

Gen Hosp Psychiatry

J Am Acad Child Adolesc Psychiatry

Arch Psychiatr Nurs

J Am Acad Child Adolesc Psychiatry

J Psychiatr Res

J Am Acad Child Adolesc Psychiatry

J Adolesc Health

Lifetime and 12-month prevalence of DSM-III-R-psychiatric disorders in the United StatesResults from the National Comorbidity Survey

Arch Gen Psychiatry

Natural course of adolescent major depressive disorder in a community samplePredictors of recurrence in young adults

Am J Psychiatry

Comorbidity

J Child Psychol Psychiatry

Psychiatric disorder in a birth cohort of young adultsPrevalence, comorbidity, clinical significance, and new case incidence from ages 11 to 21

J Consult Clin Psych

Adolescent depressionWindow of (missed?) opportunity

Am J Psychiatry

Primary care pediatric and child psychopathologyA review of diagnostic, treatment, and referral practices

Pediatrics

The prevalence of psychiatric disorders in a primary care practice

Arch Gen Psychiatry

Original article
The patient health questionnaire for adolescents: Validation of an instrument for the assessment of mental disorders among adolescent primary care patients