The factor structure of the Patient Health Questionnaire-9 in stroke: A comparison with a non-stroke population

It is unclear if certain post-stroke somatic symptoms load onto items of the Patient Health Questionnaire-9 (PHQ-9), a self-report depression questionnaire. We investigated these concerns in a stroke sample using factor analysis, benchmarked against a non-stroke comparison group. The secondary datas...

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Published in:Journal of psychosomatic research 2025-01, Vol.188, p.111983, Article 111983
Main Authors: Blake, J.J., Munyombwe, T., Fischer, F., Quinn, T.J., Van der Feltz-Cornelis, C.M., De Man-van Ginkel, J.M., Santos, I.S., Jeon, Hong Jin, Köhler, S., Schram, M.T., Wang, J.L., Levin-Aspenson, H.F., Whooley, M.A., Hobfoll, S.E., Patten, S.B., Simning, A., Gracey, F., Broomfield, N.M.
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Language:English
Subjects:
Adult
Aged
Confirmatory factor analysis
Depression
Depression - diagnosis
Depression - psychology
Dimensionality
Factor Analysis, Statistical
Female
Humans
Male
Middle Aged
Patient Health Questionnaire
PHQ-9
Psychometrics
Self Report
Stroke
Stroke - complications
Stroke - psychology
Surveys and Questionnaires
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container_end_page
container_issue
container_start_page 111983
container_title Journal of psychosomatic research
container_volume 188
creator Blake, J.J.
Munyombwe, T.
Fischer, F.
Quinn, T.J.
Van der Feltz-Cornelis, C.M.
De Man-van Ginkel, J.M.
Santos, I.S.
Jeon, Hong Jin
Köhler, S.
Schram, M.T.
Wang, J.L.
Levin-Aspenson, H.F.
Whooley, M.A.
Hobfoll, S.E.
Patten, S.B.
Simning, A.
Gracey, F.
Broomfield, N.M.
description It is unclear if certain post-stroke somatic symptoms load onto items of the Patient Health Questionnaire-9 (PHQ-9), a self-report depression questionnaire. We investigated these concerns in a stroke sample using factor analysis, benchmarked against a non-stroke comparison group. The secondary dataset constituted 787 stroke and 12,016 non-stroke participants. A subsample of 1574 comparison participants was selected via propensity score matching. Dimensionality was assessed by comparing fit statistics of one-factor, two-factor, and bi-factor models. Between-group differences in factor structure were explored using measurement invariance. A two-factor model, consisting of somatic and cognitive-affective factors, showed better fit than the unidimensional model (CFI = 0.984 versus CFI = 0.974, p 
doi_str_mv 10.1016/j.jpsychores.2024.111983
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We investigated these concerns in a stroke sample using factor analysis, benchmarked against a non-stroke comparison group. The secondary dataset constituted 787 stroke and 12,016 non-stroke participants. A subsample of 1574 comparison participants was selected via propensity score matching. Dimensionality was assessed by comparing fit statistics of one-factor, two-factor, and bi-factor models. Between-group differences in factor structure were explored using measurement invariance. A two-factor model, consisting of somatic and cognitive-affective factors, showed better fit than the unidimensional model (CFI = 0.984 versus CFI = 0.974, p &lt; .001), but the high correlation between the factors indicated unidimensionality (r = 0.866). Configural invariance between stroke and non-stroke was supported (CFI = 0.983, RMSEA = 0.080), as were invariant thresholds (p = .092) and loadings (p = .103). Strong invariance was violated (p &lt; .001, ΔCFI = −0.003), stemming from differences in the tiredness and appetite intercepts. These differences resulted in a moderate overestimation of depression in stroke when using a summed score approach, relative to the comparison sample (Cohen's d = 0.434). The findings suggest that the PHQ-9 measures a single factor in stroke. Because stroke patients may report higher tiredness on item 4, caution is advisable when classifying patients as depressed if they are near the cut-off and have significant post-stroke fatigue. Caution is also advised when comparing total scores between stroke and other populations. •The PHQ-9 is unidimensional in stroke.•PHQ-9 scores are modestly inflated in stroke compared to the general population.•Interpret scores near the cut-off cautiously in those with severe fatigue.•Comparability of total scores between stroke and non-stroke should not be assumed.</description><identifier>ISSN: 0022-3999</identifier><identifier>ISSN: 1879-1360</identifier><identifier>EISSN: 1879-1360</identifier><identifier>DOI: 10.1016/j.jpsychores.2024.111983</identifier><identifier>PMID: 39602869</identifier><language>eng</language><publisher>England: Elsevier Inc</publisher><subject>Adult ; Aged ; Confirmatory factor analysis ; Depression ; Depression - diagnosis ; Depression - psychology ; Dimensionality ; Factor Analysis, Statistical ; Female ; Humans ; Male ; Middle Aged ; Patient Health Questionnaire ; PHQ-9 ; Psychometrics ; Self Report ; Stroke ; Stroke - complications ; Stroke - psychology ; Surveys and Questionnaires</subject><ispartof>Journal of psychosomatic research, 2025-01, Vol.188, p.111983, Article 111983</ispartof><rights>2024 The Authors</rights><rights>Copyright © 2024 The Authors. 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All rights reserved.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><cites>FETCH-LOGICAL-c299t-ea42a869f755a9ca4c7a00173e768759ab7c827ff5fc61b234f2fc31b659f95d3</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>314,780,784,27924,27925</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/39602869$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Blake, J.J.</creatorcontrib><creatorcontrib>Munyombwe, T.</creatorcontrib><creatorcontrib>Fischer, F.</creatorcontrib><creatorcontrib>Quinn, T.J.</creatorcontrib><creatorcontrib>Van der Feltz-Cornelis, C.M.</creatorcontrib><creatorcontrib>De Man-van Ginkel, J.M.</creatorcontrib><creatorcontrib>Santos, I.S.</creatorcontrib><creatorcontrib>Jeon, Hong Jin</creatorcontrib><creatorcontrib>Köhler, S.</creatorcontrib><creatorcontrib>Schram, M.T.</creatorcontrib><creatorcontrib>Wang, J.L.</creatorcontrib><creatorcontrib>Levin-Aspenson, H.F.</creatorcontrib><creatorcontrib>Whooley, M.A.</creatorcontrib><creatorcontrib>Hobfoll, S.E.</creatorcontrib><creatorcontrib>Patten, S.B.</creatorcontrib><creatorcontrib>Simning, A.</creatorcontrib><creatorcontrib>Gracey, F.</creatorcontrib><creatorcontrib>Broomfield, N.M.</creatorcontrib><title>The factor structure of the Patient Health Questionnaire-9 in stroke: A comparison with a non-stroke population</title><title>Journal of psychosomatic research</title><addtitle>J Psychosom Res</addtitle><description>It is unclear if certain post-stroke somatic symptoms load onto items of the Patient Health Questionnaire-9 (PHQ-9), a self-report depression questionnaire. We investigated these concerns in a stroke sample using factor analysis, benchmarked against a non-stroke comparison group. The secondary dataset constituted 787 stroke and 12,016 non-stroke participants. A subsample of 1574 comparison participants was selected via propensity score matching. Dimensionality was assessed by comparing fit statistics of one-factor, two-factor, and bi-factor models. Between-group differences in factor structure were explored using measurement invariance. A two-factor model, consisting of somatic and cognitive-affective factors, showed better fit than the unidimensional model (CFI = 0.984 versus CFI = 0.974, p &lt; .001), but the high correlation between the factors indicated unidimensionality (r = 0.866). Configural invariance between stroke and non-stroke was supported (CFI = 0.983, RMSEA = 0.080), as were invariant thresholds (p = .092) and loadings (p = .103). Strong invariance was violated (p &lt; .001, ΔCFI = −0.003), stemming from differences in the tiredness and appetite intercepts. These differences resulted in a moderate overestimation of depression in stroke when using a summed score approach, relative to the comparison sample (Cohen's d = 0.434). The findings suggest that the PHQ-9 measures a single factor in stroke. Because stroke patients may report higher tiredness on item 4, caution is advisable when classifying patients as depressed if they are near the cut-off and have significant post-stroke fatigue. 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We investigated these concerns in a stroke sample using factor analysis, benchmarked against a non-stroke comparison group. The secondary dataset constituted 787 stroke and 12,016 non-stroke participants. A subsample of 1574 comparison participants was selected via propensity score matching. Dimensionality was assessed by comparing fit statistics of one-factor, two-factor, and bi-factor models. Between-group differences in factor structure were explored using measurement invariance. A two-factor model, consisting of somatic and cognitive-affective factors, showed better fit than the unidimensional model (CFI = 0.984 versus CFI = 0.974, p &lt; .001), but the high correlation between the factors indicated unidimensionality (r = 0.866). Configural invariance between stroke and non-stroke was supported (CFI = 0.983, RMSEA = 0.080), as were invariant thresholds (p = .092) and loadings (p = .103). Strong invariance was violated (p &lt; .001, ΔCFI = −0.003), stemming from differences in the tiredness and appetite intercepts. These differences resulted in a moderate overestimation of depression in stroke when using a summed score approach, relative to the comparison sample (Cohen's d = 0.434). The findings suggest that the PHQ-9 measures a single factor in stroke. Because stroke patients may report higher tiredness on item 4, caution is advisable when classifying patients as depressed if they are near the cut-off and have significant post-stroke fatigue. Caution is also advised when comparing total scores between stroke and other populations. •The PHQ-9 is unidimensional in stroke.•PHQ-9 scores are modestly inflated in stroke compared to the general population.•Interpret scores near the cut-off cautiously in those with severe fatigue.•Comparability of total scores between stroke and non-stroke should not be assumed.</abstract><cop>England</cop><pub>Elsevier Inc</pub><pmid>39602869</pmid><doi>10.1016/j.jpsychores.2024.111983</doi><oa>free_for_read</oa></addata></record>
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ispartof Journal of psychosomatic research, 2025-01, Vol.188, p.111983, Article 111983
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1879-1360
1879-1360
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source ScienceDirect Freedom Collection
subjects Adult
Aged
Confirmatory factor analysis
Depression
Depression - diagnosis
Depression - psychology
Dimensionality
Factor Analysis, Statistical
Female
Humans
Male
Middle Aged
Patient Health Questionnaire
PHQ-9
Psychometrics
Self Report
Stroke
Stroke - complications
Stroke - psychology
Surveys and Questionnaires
title The factor structure of the Patient Health Questionnaire-9 in stroke: A comparison with a non-stroke population
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