2. 948 Clinical Pediatrics 49(10)
persists, recurs, and often leads to continued depressive Health Questionnaire PHQ-9,27 or by referring the patient
illnesses in adulthood. Investigations into the differ- to a mental health professional for further evaluation.
ences of early onset and late onset depression generally The PHQ-9 has been used with adults in a variety of
suggest that early onset depression is a more severe vari- studies for the assessment and management of depres-
ant associated with increased chronicity and disability. sion.28-30 The PHQ-2 has not been tested with children or
It contributes to school failure, impaired peer and family adolescents, and there is no equivalent 2- or 3-question
relationships, teenage pregnancy, suicidal behavior, screening tool available to help diagnose depression in
and poor psychosocial and functional outcomes.9 Of adolescents.
equal concern are the large numbers of adolescents With this in mind, the goal of this study was to deter-
who report depressive symptoms but do not meet the mine whether the 2 questions posed on the PHQ-2 used
diagnostic criteria for major depressive disorder. Even to screen for depression in adults are also valid in screen-
subsyndromal depressive symptomatology in teens is ing for depression in adolescents. More specifically, we
associated with significant morbidity, including sub- sought to determine the extent to which a “yes” or “no”
stance abuse,10 poor social functioning,11 suicidal ide- answer to one or both questions on the PHQ-2 would
ation,12 and major depression in adulthood.13,14 A higher correlate with the results of 2 well-established and vali-
prevalence of depressive disorders and subsyndromal dated depression questionnaires, the Children’s Depres-
depressive disorders is found in low socioeconomic com- sion Inventory (CDI) and the Beck Depression Inventory
munities and ethnic minority groups.15-18 (BDI), and to evaluate the sensitivity, specificity, and
The negative outcomes associated with early onset overall classification accuracy of predictions made using
depression, make it crucial to identify and treat depres- this screener. Both depression questionnaires, the CDI
sion in its early stages. A study conducted by the World and the BDI, have been used with adolescents from a
Health Organization (WHO)19 reported that in North wide range of ethnically and culturally diverse back-
America, primary care and family physicians are likely grounds, including low-income African American sam-
to provide the first line of treatment for depressive disor- ples in outpatient clinics.31
ders. Others consistently report a 10% prevalence rate of Because depression in adolescents is diagnosed using
depression in primary care patients.20,21 But studies have the same DSM-IV TR criteria as depression in adults,
shown that primary care physicians fail to recognize up assuming a comparable symptom profile, it was hypoth-
to 50% of depressed patients,22,23 purportedly because of esized that the PHQ-2 would be useful in detecting
time constraints and a lack of brief, sensitive, easy-to- depression in adolescents as well. Given the high preva-
administer psychiatric screening instruments. Coyle lence of depressive disorders and subsyndromal depres-
et al24 suggested that the picture is even more grim for sive disorders in communities with lower socioeconomic
adolescents, and that more than 70% of children and status and ethnic minority groups16,17 we targeted this
adolescents suffering from serious mood disorders go population in selecting our sample for the study.
unrecognized or inadequately treated.
Despite the ongoing controversy regarding the use
of screening instruments in the detection and treatment Method
of depression in adults,25 the City of New York recom- Participants
mended that the Patient Health Questionnaire (PHQ-2),
a 2-item depression screener derived from previous Participants were recruited over a 6-month period from
research, be used in the primary care setting.26 The PHQ-2 various pediatric outpatient clinics associated with
asks patients the following 2 questions: New York’s Brookdale University Hospital and Medical
Center, in addition to the Center’s child psychiatric out-
1. During the past month, have you been bothered patient mental health clinic.
by little interest or pleasure in doing things? Adolescents were eligible to participate if they were
2. During the past month, have you been bothered between the ages of 13 and 17 years (inclusive); able to
by feeling down, depressed, or hopeless? read and to respond to the questions in the questionnaires;
not actively psychotic; able to give assent; and accompa-
If the patient responds “no” to both questions, then nied by a parent who could give consent.
the screen is negative. If the patient responds “yes” to Adolescents were excluded from the study if they had
one of the two questions, the primary care physician an acute medical illness requiring hospitalization.
is expected to follow up with additional assessment of Adolescents attending regularly scheduled clinic vis-
possible depression. This is typically accomplished by its were referred by their treating physician or therapist.
administering a longer instrument such as the Patient They were screened for their eligibility to participate in
3. Borner et al. 949
the study either by the main research clinician or by one (A positive statement = 0, a moderately negative
of the research assistants (a pediatric resident and a answer = 1, a severely negative answer = 2)
psychology intern). Reason for the clinic visit, presence
of a legal care taker, date of birth, and the patient’s grade The questionnaire covers questions pertaining to
level in school were ascertained through information negative mood, interpersonal problems, ineffectiveness,
from the treating physician or therapist and confirmed in anhedonia, and negative self-esteem. The CDI has been
the chart. Subsequently, children and parents were met shown to discriminate between clinically depressed and
by the researcher and the purpose of the study, the nondepressed psychiatric patients.33 Even though the
requirements to complete the questionnaires, and the questionnaire provides scores for the different subscales,
approximate time involvement was explained to them. we only used the total depression score for our inves-
If they both expressed interest in the study the adolescent tigation. We used a T-score of greater than 60 as a
was asked to read and answer an example of the ques- positive indicator for depression based on the manual’s
tions in order to assess his or her ability to read, under- recommendation.34
stand, and respond to the questions asked. Once the Beck Depression Inventory. The Beck Depression
adolescent’s eligibility was established both parent and Inventory (BDI)35 is a 21-item measure designed to
adolescent were asked to sign the consent or assent form detect depression in individuals 13 years through adult-
to participate in the study. hood. The respondent is asked to circle one out of four
The study protocol was approved by the Institutional responses “. . . that best describes the way you have been
Review Board of Brookdale University Hospital and feeling in the past week.” A BDI sample question reads
Medical Center. as follows:
• I don’t cry any more than usual.
Procedure • I cry more now than I used to.
The PHQ-2 was administered first. Each question was • I cry all the time now.
read aloud and the participant was asked to mark their • I used to be able to cry, but now I can’t cry even
answer “yes” or “no.” Next, the researchers explained though I want to.
the BDI and handed the questionnaire to the adolescent
instructing them to mark the most applicable answer. On (The value of a neutral answer = 0, the value of
completion of the BDI, the CDI was explained to and the mildly negative answer = 1, the moderately
then administered to each participant in similar fashion. negative answer = 2, and the severely negative
Total time for the explanation and completion of the ques- answer = 3)
tionnaires was about 20 minutes. We obtained a medical
and psychiatric history from the parent and reviewed The BDI results in one total score, with higher scores
the physical examination conducted by the pediatrician indicative of more severe depression. We used a score of
to gain a perspective on how our sample compared with greater than 10 as a positive indicator for depression, with
the general population. scores in the range 10 to 16 indicative of mild depres-
sion, scores in the range 17 to 29 indicative of moderate
depression, and scores ranging from 30 to 63 indicative
Measures of severe depression.36
Two-Item Patient Health Questionnaire (PHQ-2). This
2-item depression screener derived from previous
research26 was administered to all study participants. Results
Children’s Depression Inventory. The Children’s Depres- Sample Characteristics
sion Inventory (CDI)32 is a self-administered 27-item
questionnaire used to detect depression in children aged A total of 85 adolescents participated in this study. The
7 to 17 years. It is written in simple language (grade 1 sample consisted of 22 (25.9%) males and 63 (74.1%)
reading level) and asks the child to select one of three females between the ages of 13 and 17 years, with a
choices “that describes you best over the past two weeks.” mean age of 15.09 years (SD = 1.51). Ethnic breakdown
A CDI sample question reads as follows: of the sample was as follows; 57 (69.5%) African
American, 19 (23.2%) Hispanic, 4 (4.9%) white, 1 (1.2%)
• Nobody really loves me Asian, and 1 (1.2%) identified as “other.” Educational
• I am not sure if anybody loves me status ranged from grade 4 to grade 11, with a mean
• I am sure that somebody loves me grade level of 8.40 (SD = 1.52); approximately 13% of
4. 950 Clinical Pediatrics 49(10)
Table 1. Sample Demographic Information (N = 85) Table 2. Bivaritate Correlations Among Measures of
Depression
Variable n (%)
PHQ-2 Q1 PHQ-2 Q2
Age, M (SD) 15.09 (1.51)
Gender CDI .14 .64a
Male 22 (25.9) BDI .05 .49a
Female 63 (74.1)
Abbreviations: PHQ-2 Q1, Two-Item Depression Screener Ques-
Ethnicity
tion 1; PHQ-2 Q2, Two-Item Depression Screener Question 2;
African American 57 (69.5) CDI, Children’s Depression Inventory; BDI, Beck Depression
Hispanic 19 (23.2) Inventory.
Caucasian 4 (4.9) a
P < .01.
Asian 1 (1.2)
Other 1 (1.2)
Grade level, M (SD) 8.40 (1.52)
Discriminant Function Analyses
Family income
Parental employment 49 (58.3)
The cut scores for the CDI (T-score > 60,) and BDI (total
Public assistance 17 (20.2)
Social security income 16 (19.0)
score > 10) were used as a criterion, whereby a positive
Psychiatric history indicator of depression on either measure was considered
Emotional/behavioral problems 47 (56.0) indicative of depression. Three separate discriminant
Therapy 40 (47.6) function analyses were then conducted, using responses
Medication treatment 12 (14.6) of “yes” (ie, indicative of depression) to either question
Hospitalization 14 (16.7) of the PHQ-2, to the first question of the PHQ-2, and to
Family history 47 (56.6) the second question of the PHQ-2.
Answering “yes” to either question on the PHQ-2
resulted in an overall classification accuracy of 67.1%
the sample reported a special education curriculum. (predictive value positive = .61; predictive value neg-
Family income was predominantly sustained via paren- ative = .79); sensitivity was 85% and specificity was
tal employment (58.3%), with public assistance (20.2%) 51.1%. Answering “yes” to the first question on the
and Social Security income (19.0%) comprising a sig- PHQ-2 resulted in an overall classification accuracy of
nificant minority. A total of 71.8% received government- 54.1% (predictive value positive = .51; predictive value
supported health insurance. More than half (56.0%) of negative = .56); sensitivity was 47.5 % and specificity
all participants had a history of emotional or behavioral was 60%. Finally, answering “yes” to the second ques-
problems, with nearly half (47.6%) reporting a history tion on the PHQ-2 resulted in an overall classification
of therapy. A smaller proportion reported a history of accuracy of 72.9% (predictive value positive = .73; pre-
psychiatric treatment with medication (14.6%) or a his- dictive value negative = .73); sensitivity was 67.5% and
tory of psychiatric hospitalizations (16.7%). More than specificity was 77.8%. See Table 3 for a summary of the
half (56.6%) also reported a family history of psychiatric discriminant function analyses.
illness and possible treatment. See Table 1 for a summary
of sample demographic information.
Discussion
Summary of Results
Bivariate Correlations
Bivariate correlations between the individual questions This study sought to determine whether the use of a 2-item
on the PHQ-2 and the 2 established measures of depression screening tool (the PHQ-2) was applicable
depression revealed a significant relationship only for and valid in screening for depression in adolescents
the second question on the PHQ-2 (see Table 2). This attending various primary care clinics. A total of 85 ado-
question—which asked patients if they had felt “down, lescents between the ages of 13 and 17 years, recruited
depressed, or helpless” in the past month—was signifi- from various metropolitan pediatric outpatient clinics,
cantly correlated with both the CDI, r(85) = .64, P < .01, were administered this 2-item screening tool along with
and the BDI, r(85) = .49, P < .01. The first question— 2 other well-established measures of depression (the CDI
which asked clients if they had experienced “little plea- and the BDI). Results revealed a significant bivariate
sure or interest in doing things” in the past month—was relationship between the second question of the PHQ-2—
unrelated to both the CDI, r(85) = .14, P = .10, and the pertaining to depressed and hopeless mood—and
BDI, r(85) = .05, P = .34. the 2 established measures of depression. The first
5. Borner et al. 951
Table 3. Summary of Discriminant Function Analyses
Actual Group Statusb
Predicted Group Statusa Depressed Not Depressed
PHQ-2Q1
Depressed 19 18
Not Depressed 21 27
Sensitivity: .48 Specificity: .60
Predictive value positive: .51 Predictive value negative: .56
PHQ-2Q2
Depressed 27 10
Not Depressed 13 35
Sensitivity: .68 Specificity: .79
Predictive value positive: .73 Predictive value negative: .73
“Yes” on either PHQ-2 Q1 or PHQ-2 Q2
Depressed 34 22
Not Depressed 6 23
Sensitivity: .85 Specificity: .51
Predictive value positive: .61 Predictive value negative: .79
Abbreviations: PHQ-2 Q1, Two-Item Depression Screener Question 1; PHQ-2 Q2, Two-Item Depression Screener Question 2.
a
Based on “yes/no” responses on the PHQ-2.
b
Based on the Children’s Depression Inventory T score >60 or Beck Depression Inventory total score >10.
question—pertaining to anhedonia—was unrelated to adults. A quick screening for depression during regular
the existing measures of depression. Discriminant func- visits in the office of a family physician, pediatrician, or
tion analysis further revealed that answering “yes” to the obstetrician can be an important first step toward detect-
second question of the PHQ-2 resulted in correct clas- ing symptoms of depression in adolescents.
sification of 73% of adolescents as depressed or not A number of factors limit the generalizability and
depressed (positive predictive value = .73; negative pre- immediate applicability of the current findings. First, our
dictive value = .73; sensitivity = .68; specificity = .78). sample size was small compared with other similar studies,
The first question on the PHQ-2 appeared to have lim- and the sample included mostly minority children from
ited value in ascertaining whether adolescents are lower socioeconomic backgrounds. Thus, this is a rather
depressed or not, correctly classifying only 54% of ado- select sample and not necessarily representative of the
lescents (positive predictive value = .51; negative pre- general population of adolescents. Although one aim
dictive value = .56; sensitivity = .48; specificity = .60). of the study was to assess the validity of a screener for
Compared with using the second question only, the use depression in such an underrepresented population,
of both questions resulted in correct classification of follow-up with a larger, more representative sample
67% of adolescents (positive predictive value = .61; should still be done.
negative predictive value = .79; sensitivity = .85; speci- Even though using both questions resulted in a rela-
ficity = .51). Thus, higher sensitivity (and therefore, tively large number of false positives (because specific-
fewer false negatives) came at the hands of lower speci- ity was lower than when only Q2 was used), the high
ficity (and thus, more false positives). sensitivity achieved with both questions taken together
Based on these results it is evident that the question meant that in this population only 15% of depressed ado-
regarding feelings of depression and hopelessness is more lescents were not identified by the screen. Because this
meaningful for adolescents in this study than the question screen must be followed up by further evaluation, either
for symptoms pertaining to lack of interest or pleasure. by administering the BDI or referral to a child psychia-
Whether this is a phenomenon of adolescents in general trist, the false positive individuals will be weeded out in
or for this limited-means minority population in particu- this second process.
lar would require further studies with different popula- Considering the extraordinary time constraints pri-
tions. The results of the study show that the PHQ-2 can be mary care physicians are facing in the evaluation of their
used as a quick and relatively effective screening instru- patients, a 1- or 2-question screening tool can be extremely
ment for adolescents in a medical care setting. Adoles- valuable as the first step in the detection of depression in
cents are usually not a group that easily turns for help from adolescents.
6. 952 Clinical Pediatrics 49(10)
Author’s Note 10. Kandel DB, Davies M. High school students who
use crack and other drugs. Arch Gen Psychiatry.
At the time the research was conducted in 2006-2007, all 1996;53:71-80.
authors were with Brookdale University Hospital Medi- 11. Gotlib IH, Lewinsohn PM, Seeley JR. Symptoms versus a
cal Center. Dr St. Victor was and continues to be with the diagnosis of depression: difference in psychosocial func-
Department of Pediatrics, and Drs Braunstein, Pollack, tioning. J Consult Clin Psychol. 1995;63:90-100.
and Borner were with the Department of Psychiatry. 12. Kandel DE, Raveis VH, Davies M. Suicidal ideation in
Dr Borner is presently at the Zucker Hillside Hospital in adolescence: depression, substance use and other risk fac-
the Department of Psychiatric Research, Dr Braunstein tors. J Youth Adolesc. 1991;20:289-309.
is deceased, and Dr Pollack is retired. 13. Kubik MY, Lytle LA, Birnbaum AS, Murray DM, Perry CL.
Prevalence and correlates of depressive symptoms in
Declaration of Conflicting Interests young adolescents. Am J Health Behav. 2003;27:546-553.
The author(s) declared no conflicts of interest with respect 14. Pine DS, Cohen E, Cohen P, Brook J. Adolescent depressive
to the authorship and/or publication of this article. symptoms as predictors of adult depression: moodiness or
mood disorder? Am J Psychiatry. 1999;156:133-135.
Funding 15. Fergusson DM, Horwood LJ, Ridder EM, Beuatrais AL.
The author(s) received no financial support for the research Subthreshold depression in adolescence and mental health
and/or authorship of this article. outcome in adulthood. Arch Gen Psychiatry. 2005;62:
66-72.
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