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      Factor structure of the patient health questionnaire-4 in adults with attention-deficit/hyperactivity disorder


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          Persons with attention-deficit/hyperactivity disorder (ADHD) frequently experience symptoms of anxiety and depression. In this population, there is a need for validated brief self-report screening questionnaires to assess the severity of comorbid mental health problems. The Patient Health Questionnaire 4 (PHQ-4) is a self-report questionnaire that may contribute to this purpose as it can screen for both disorders efficiently. However, this will be the first study examining the factor structure of the PHQ-4 in samples of adults with ADHD, and also evaluating the validity of the Norwegian version of the PHQ-4.


          The aim of the current cross-sectional study was to examine the factor structure and validity of the Norwegian version of the PHQ-4 in a sample of adults who reported having been diagnosed with ADHD.


          Of 496 invited, a total of 326 participants (66%) completed the PHQ-4, The World Health Organization Five Well-Being Index, the Oslo Social Support Scale and the 4-item Perceived Stress Scale electronically in a web-portal between the 9th and 30th of June 2020.


          Confirmatory factor analysis of the PHQ-4 supported a two-factor structure [RMSEA = 0.038 (90% CI 0.000–0.159), CFI = 1.00, TLI = 0.999, SRMR = 0.004], consisting of a depression factor and an anxiety factor. Standardized factor loadings were 0.79 to 0.97. The PHQ-4 was negatively correlated with well-being and social support and positively correlated with perceived level of stress.


          This study indicates promising psychometric properties of the PHQ-4 as a measure of anxiety and depressive symptoms in adults with self-reported ADHD who are fluent in Norwegian. The questionnaire’s brevity makes it a valuable resource in research and clinical settings. However, more studies are needed to test the instrument in a clinical sample.

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          Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives

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            A brief measure for assessing generalized anxiety disorder: the GAD-7.

            Generalized anxiety disorder (GAD) is one of the most common mental disorders; however, there is no brief clinical measure for assessing GAD. The objective of this study was to develop a brief self-report scale to identify probable cases of GAD and evaluate its reliability and validity. A criterion-standard study was performed in 15 primary care clinics in the United States from November 2004 through June 2005. Of a total of 2740 adult patients completing a study questionnaire, 965 patients had a telephone interview with a mental health professional within 1 week. For criterion and construct validity, GAD self-report scale diagnoses were compared with independent diagnoses made by mental health professionals; functional status measures; disability days; and health care use. A 7-item anxiety scale (GAD-7) had good reliability, as well as criterion, construct, factorial, and procedural validity. A cut point was identified that optimized sensitivity (89%) and specificity (82%). Increasing scores on the scale were strongly associated with multiple domains of functional impairment (all 6 Medical Outcomes Study Short-Form General Health Survey scales and disability days). Although GAD and depression symptoms frequently co-occurred, factor analysis confirmed them as distinct dimensions. Moreover, GAD and depression symptoms had differing but independent effects on functional impairment and disability. There was good agreement between self-report and interviewer-administered versions of the scale. The GAD-7 is a valid and efficient tool for screening for GAD and assessing its severity in clinical practice and research.
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              The PHQ-9: validity of a brief depression severity measure.

              While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity. The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as "0" (not at all) to "3" (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients. As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score > or =10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples. In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.

                Author and article information

                Front Psychiatry
                Front Psychiatry
                Front. Psychiatry
                Frontiers in Psychiatry
                Frontiers Media S.A.
                14 July 2023
                : 14
                : 1176298
                [1] 1Department of Psychology, Norwegian University of Science and Technology , Trondheim, Norway
                [2] 2Nidaros Division of Psychiatry, Community Mental Health Centre, St. Olav’s University Hospital , Trondheim, Norway
                [3] 3Faculty of Medicine and Health Sciences, Department of Mental Health, Regional Centre for Child and Youth Mental Health and Child Welfare, Norwegian University of Science and Technology , Trondheim, Norway
                [4] 4Vårres Regional User-Led Center Central-Norway , Trondheim, Norway
                [5] 5Faculty of Medicine and Health Sciences, Department of Mental Health, Norwegian University of Science and Technology , Trondheim, Norway
                [6] 6Nidelv Division of Psychiatry, Community Mental Health Centre, St. Olav’s University Hospital , Trondheim, Norway
                Author notes

                Edited by: Dorothee Oberdhan, Otsuka Pharmaceutical Development & Commercialization, Inc., United States

                Reviewed by: Matej Stuhec, University of Maribor, Slovenia; Lietta Marie Scott, Arizona Department of Education, United States

                *Correspondence: Audun Havnen, audun.havnen@ 123456ntnu.no
                Copyright © 2023 Havnen, Lydersen, Mandahl and Lara-Cabrera.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                : 28 February 2023
                : 27 June 2023
                Page count
                Figures: 2, Tables: 4, Equations: 0, References: 72, Pages: 9, Words: 7474
                Original Research
                Custom metadata

                Clinical Psychology & Psychiatry
                anxiety,adhd,depression,factor structure,mental illness,patient health questionnaire-4,psychometric properties


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