Psychiatry Research 328 (2023) 115486

Contents lists available at ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Youth screening depression: Validation of the Patient Health

Questionnaire-9 (PHQ-9) in a representative sample of adolescents
Eduardo Fonseca-Pedrero a, *, Adriana Díez-Gómez a, Alicia Pérez-Albéniz a, Susana Al-Halabí b,
Beatriz Lucas-Molina c, Martin Debbané d, e
a
Universidad de La Rioja, Spain
b
Universidad de Oviedo, Spain
c
Universidad de Valencia, Spain
d
Developmental Clinical Psychology Research Unit, Faculty of Psychology and Educational Sciences, University of Geneva, Switzerland
e
Research Department of Clinical, Educational and Health Psychology, University College London, United Kingdom

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Depression symptoms and mood disorders constitute one of the major public health challenges
Depression among youths. Thus, early prevention and intervention for depression should be a priority. The main goal of the
Adolescents present study was to validate the Patient Health Questionnaire-9 (PHQ-9) scores in a school-based sample of non-
Psychometric
clinical adolescents.
Validation
PHQ-9
Method: Stratified random sampling was conducted. Participants were 2235 students (M = 14.49, SD =1.76,
Mental health range= 12–18 years), 52.9 % were female, from 34 secondary schools in Spain. Several previously validated self-
reported questionnaires of mental health and psychopathology were administrated.
Results: The unidimensional factorial model of the PHQ-9 items showed adequate goodness of fit indices. Strong
measurement invariance across gender was found. Omega for the PHQ-9 total score was 0.87. The PHQ-9 total
score was positively associated with anxiety symptoms and emotional and behavioral problems, and negatively
associated with prosocial behavior and quality of life.
Conclusions: The PHQ-9 is a brief, easy, and reliable tool for assessing self-reported depressive symptoms in both
clinical and school settings. PHQ-9 may be used as a screening tool for universal early detection and monito­
rization of depression symptoms during adolescence.

1. Introduction treatment can be quite costly from both personal and public health
perspectives (Davis et al., 2022).
Emotional problems (e.g., depression, anxiety) are among the lead­ Depression, as a continuum phenotype, encompasses a range of
ing causes of associated disability and global burden of disease in young mood-related concepts and a spectrum of difficulties, placing at its most
people. The Global Burden of Diseases, Injuries, and Risk Factors Study extreme end clinical disorders that could be expressed as mood syn­
GBD (2019) (GBD 2019 Mental Disorders Collaborators, 2022) revealed dromes; while at the other end, depression can refer to a mood state in
that mental disorders remained among the top ten causes of burden of the context of normative affective experience (Hankin, 2015; Thapar
disease worldwide, with no evidence of an overall reduction in burden et al., 2022). Across this quantitative variation, intermediate (subclini­
since 1990. The World Health Organization (WHO, 2022) informs that cal or subthreshold depression) expressions can also be identified.
one billion people worldwide have a diagnosis of a mental disorder Subthreshold depression is associated with low mood and additional
(more than one in eight adults and adolescents). Depression in young depressive symptoms such as loss of interest and enjoyment, but without
people is a rising concern, so it is our duty as a society to promote, reaching the diagnostic threshold (Thapar et al., 2022). Previous works
protect and care for the mental health of the entire population, in have found that youth depression is continuously, not categorically,
particular of one of the most vulnerable groups, children and adoles­ distributed. This viewpoint of the dimensional alternative to traditional
cents. Thus, missed opportunities for depression identification and Nosologies (e.g., Diagnostic and Statistical Manual of Mental Disorders)

* Corresponding author at: University of La Rioja, C/ Luis de Ulloa, 2, Edificio VIVES; C.P: 26004, Logroño, La Rioja, Spain.
E-mail address: [email protected] (E. Fonseca-Pedrero).

https://doi.org/10.1016/j.psychres.2023.115486
Received 17 July 2023; Received in revised form 14 September 2023; Accepted 15 September 2023
Available online 16 September 2023
0165-1781/© 2023 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
E. Fonseca-Pedrero et al. Psychiatry Research 328 (2023) 115486

are related with psychopathology models as, the Hierarchical Taxonomy previous studies, yet there is little information on the psychometric
of Psychopathology (HiTOP) (Kotov et al., 2021). Conceptualizing properties of the PHQ-9 scores in large and representative samples of the
depression (internalizing spectra) as a graded dimension has implica­ general population. For instance, few studies have tested the measure­
tions for theory and practice, as well as for methods and measurement ment invariance by gender or gathered new validity evidence using
(Eaton et al., 2023; Hankin et al., 2005). modern psychometric methods as item response theory (IRT) for this
The prevalence put forward by developmental epidemiological measurement tool.
research for major depressive disorder and dysthymia is situated around In this context, the main goal of the present study was to validate the
8 % (95 % CI: 0.02–0.13) and 4 % (95 % CI: 0.01–0.07) among ado­ PHQ-9 scores in a school-based sample of adolescents. This study aimed
lescents, respectively. In addition, the global point prevalence rate of to: a) analyze the prevalence of depressive symptoms; b) examine the
elevated self-reported depressive symptoms from 2001 to 2020 was 34 internal structure of the PHQ-9 scores; c) test the measurement invari­
% (95 % CI: 0.30–.38) (Shorey et al., 2022). That is, 34 % of adolescents ance of the PHQ-9 by gender; d) estimate the reliability of the PHQ-9
worldwide, aged 10–19 years, are at risk of developing clinical depres­ scores; and e) analyze the association between PHQ-9 scores and psy­
sion, which exceeds the reported estimates of individuals aged 18 to 25 chometric indicators of mental health and quality of life. In line with
years. The age of onset, severity, persistence, and comorbidity are fac­ previous literature, it was hypothesized that the one-factor model of the
tors to consider in the study of depression symptoms during this PHQ-9 would have adequate goodness-of-fit indices. In addition, we
developmental stage. Previous studies have found that the average age further hypothesized that this hypothesized dimensional model would
of development of any mental disorders is 14.5 years (Solmi et al., be equal across gender. We also expected that the reliability estimation
2022). The proportion of individuals with onset of mood disorders of the PHQ-9 scores would be adequate. Finally, we expected that
before the age of 14, 18, 25 were, respectively, 2.5 %, 11.5 %, 34.5 %, depressive symptoms would be related with emotional and behavioural
and the peak age was 20.5 years (k = 79, median = 31, IQR = 21–46) difficulties.
(Solmi et al., 2022). Additionally, adverse outcomes associated with
clinical and subclinical depression during adolescence include the onset 2. Method
of other mental health disorders (e.g., anxiety, substance abuse, and
conduct disorders). Elevated depressive symptoms are associated with 2.1. Participants
many outcomes as risk behaviours, health problems, and adverse psy­
chosocial outcomes in interpersonal, social, educational, and occupa­ Stratified random sampling was conducted at the class level in the
tional functioning as well as suicidal behaviours (Thapar et al., 2022). total student population of La Rioja (region in Northern Spain). The
For instance, in the educational sphere, depression was associated with students belonged to different public and charter educational centers,
poorer school grades (Riglin et al., 2014) and school absenteeism compulsory secondary education and vocational training. Strata were
(Finning et al., 2019). formed depending on the public and charter nature of the educational
Depression symptoms and disorders in adolescents are frequently institutions, and the educational level. A total of 34 schools and 98
misdiagnosed and undertreated. Routine screening, from a preventive classrooms participated in the study.
approach, has the potential to improve the early and reliable identifi­ The initial sample consisted of 2640 students. Those participants
cation of depressive symptoms. According to NICE Guidelines [NG134] that: a) showed a high score on the Oviedo Infrequency Response Scale
for depression in children and young people, healthcare professionals in (more than 2 points) (n = 175) and were over 18 years of age (n = 247)
primary care, schools and other relevant community settings should be were removed. Thus, a total of 2235 students, 1045 men (46.8 %), 1183
trained to detect symptoms of depression, and to assess children and (52.9 %) women, and 7 (0.3 %) non-binary identity participated in the
young people who may be at risk of depression (NICE Guidance, 2019). study. The mean age was 14.49 years (SD=1.76), age range between 12
The detection of these individuals with subclinical depression, whether and 18 years. The age distribution was as follows: 12 years, n = 280; 13
in health, social or educational settings, requires the availability of years, n = 387; 14 years, n = 396; 15 years, n = 408; 16 years, n = 371;
adequate tools to make informed and data-driven decisions. The PHQ-9 17 years, n = 240; and 18 years, n = 153. The 90.8 % of the sample was
(Kroenke et al., 2001; Spitzer et al., 1999) has become a standard identified as Spanish.
measure of depression research and clinical practice. The PHQ-9 is a
self-report developed to assess the severity of depression according to 2.2. Instruments
DSM criteria. Its psychometric properties have been adequately exam­
ined (El-Den et al., 2018; Kroenke, 2021). Previous studies showed Socio-demographics, mental health problems, and lifestyle. An ad hoc
strong evidence that the PHQ-9 can be used as a unidimensional mea­ instrument was developed to assess age, school grade, sex, gender, and
sure of depressive symptoms (Bianchi et al., 2022). In primary care nationality. In addition, family history of mental disorder was assessed.
settings, the brief nature and ease of scoring of this instrument make it Information about lifestyle was also collected: general health, hours of
an excellent choice for providers and researchers looking to implement sleep, time to fall asleep, and frequency of free-time activities.
depression screening (Richardson et al., 2010). The evidence suggests Patient Health Questionnaire-9 (PHQ-9) (Kroenke et al., 2001; Spitzer
that assessing the factors separately will not provide any useful infor­ et al., 1999). The PHQ-9 is composed of nine questions designed to
mation for most patients (Boothroyd et al., 2019). An adolescent version assess depressive symptomatology according to DSM criteria. The items
of the PHQ-9 was also designed (Johnson et al., 2002). In addition, the are answered according to the frequency of symptoms (0 = not at all, 1=
standard PHQ-9 has been validated in previous work with adolescents some days, 2 = more than half of the days, 3 = almost every day). A higher
(Anum et al., 2019; Borghero et al., 2018; Burdzovic & Brunborg, 2017; score is indicative of greater depressive symptomatology. The PHQ-9
Fatiregun and Kumapayi, 2014; Leung et al., 2020, Rhew et al., 2016; has been validated into Spanish (González-Blanch et al., 2018).
Richardson et al., 2010; Sinclair-McBride et al., 2018). For instance, Generalized Anxiety Disorder Assessment (GAD-7) (Spitzer et al.,
Burdzovic and Brundorg (2017), in a sample of Norwegian adolescents, 2006). The GAD-7 is a seven-item instrument used to measure or assess
found a single-factor structure for the PHQ-9. the severity of generalized anxiety disorder. Each item asks the indi­
Many instruments can be used to assess depression symptoms, but vidual to rate the severity of his or her symptoms over the past two
further adaptation of tests is needed to identify these experiences at an weeks. Response options include 0 = not at all, 1 = several days, 2 = more
early age (Bernaras et al., 2019). This developmental period involves than half the days, 3 = almost every day. The GAD-7 has been validated
physical, psychological, and social changes, which may increase an in­ into Spanish (Muñoz-Navarro et al., 2017). In this study, the reliability
dividual’s sensitivity and reactivity to stress exposure (Beck et al., of the total score was adequate (McDonald’s Omega = 0.90)
2021). To date, although the standard PHQ-9 has been validated in Strengths and Difficulties Questionnaire (SDQ) (Goodman, 1997). The

2
E. Fonseca-Pedrero et al. Psychiatry Research 328 (2023) 115486

SDQ is a self-report questionnaire that is widely used for the assessment called the configural model, which is the first and least restrictive model
of different emotional and behavioural problems related to mental specified and is important because it represents the baseline model
health in adolescents. The SDQ is made up of a total of 25 statements against which all subsequent specified invariance models are compared.
distributed across five subscales: Emotional symptoms, Conduct prob­ The configural model is established by specifying and testing the CFA
lems, Hyperactivity, Peer problems, and Prosocial behavior. The first model for each group separately. Once the theoretical model has been
four subscales yield a Total difficulties score. In this study we used a validated in both groups, configural invariance is then examined,
Likert-type response format with three options (0 = not true, 1 = some­ requiring that the same pattern of fixed and freely estimated model
what true, 2 = certainly true). The validated Spanish version of the SDQ parameters is equivalent across groups; however, no equality constraints
was used in the present study (Ortuño-Sierra et al., 2022). The SDQ total are imposed on the model parameters between groups. Configural
difficulties score showed adequate reliability in this sample (McDonald’s invariance is tested by assessing the model fit. When configural invari­
Omega = 0.75). ance is met (i.e., the model fits the data), it suggests that at least the
Kidscreen-10 Index (Ravens-Sieberer et al., 2010). The Kidscreeen-10 general factor structure is similar, but not necessarily equivalent, across
Index is a measurement instrument developed and validated to assess groups. The next step is to impose equality constraints on the factor
health-related quality of life in children and adolescents aged 8 to 18 loadings across the groups to test metric or weak invariance. If the model
years. It presents a total of 10 questions in a Likert 5-choice response fit with the constrained parameters is significantly and practically worse
format, where a higher score is indicative of higher quality of life. The than the baseline or configural model, then weak invariance is not
Kidscreen-10 has been validated in Spain (Aymerich et al., 2005). The supported. When metric invariance is met, it suggests that the same unit
Kidscreeen-10 scores showed good reliability in this sample (McDo­ of measurement is being used for the item across the groups and that the
nald’s Omega = 0.91). participants interpret and respond to the measure in a similar manner
The Oviedo Infrequency Scale-revisited (INF-OV-R) (Fonseca-Pedrero (Horn and McArdle, 1992). The final step is to impose constraints on the
et al., 2009). The INF-OV-R was administered to the participants to item intercepts and factor loadings to test strong or scalar invariance
detect those who responded in a random, pseudorandom or dishonest across groups. The confirmation of the invariance of the intercepts
manner. The INF-OV-R instrument is a self-report composed of 10 items permits comparison of the latent means in both groups. The analyzed
in a dichotomic scale format (Yes/No). Students with more than two models are nested in that the imposed constraints are progressively
incorrect responses on the INF-OV-R scale were eliminated from the added. Due to the limitations of the Δ χ2 regarding its sensitivity to
sample. sample size, Cheung and Rensvold (2002) proposed a more practical
criterion, the Δ CFI, to determine if nested models are practically
2.3. Procedure equivalent. In this study, when Δ CFI is greater than 0.01 between two
nested models, the more constrained model is rejected since the addi­
The research was approved by the Ethical Committee of Clinical tional constraints have produced practically worse fit. However, if the
Research of La Rioja (CEImLAR, PI 552). The psychometric measures change in CFI is less than or equal to 0.01, it is considered that all
were administered collectively, through personal computers, in groups specified equal constraints are tenable; therefore, we can continue with
of 10 to 30 students, during school hours and in a classroom specially the next step in the analysis of measurement invariance.
prepared for this purpose. Administration took place under the super­ Fourth, reliability estimation of the PHQ-9 scores were estimated
vision of the researchers trained in a standard protocol. No incentive was using McDonald’s Omega. In addition, from the IRT framework with the
provided for their participation. Participants’ parents were asked to sign 2-PL Model, the test information function was computed. Classical test
an informed consent form so that their children could participate in the theory methods cannot give us direct guidance on the latent trait of a
study. Participants were informed of the confidentiality of their re­ measure to accurately assess depressive experiences at various points
sponses and of the voluntary nature of the study. This work is part of a along the continuum (Hambleton et al., 1991). IRT methods provide
broader project called PSICE (Evidence-based Psychology in Educational estimates of the position on the latent trait (i.e., the theta level) where
Contexts) (Fonseca-Pedrero et al., 2023b) (ClinicalTrials.gov. Ref: the tool provides the most information. Test information function
NCT05322642). graphically depict the regions of the latent trait continuum most pre­
cisely assessed. Greater information reflects greater measurement ac­
2.4. Data analyses curacy, or reliability. Test information function are estimated on the
same latent trait scale (standardized M = 0; SD=1), yielding information
First, we calculated the prevalence and descriptive statistics of the that is comparable across tests (Olino et al., 2012).
PHQ-9 items. The PHQ-9 total score was divided into the following Fifth, the associations between PHQ-9 scores and other mental
categories of increasing severity: 0–4 (minimal), 5–9 (mild), 10–14 health indicators were calculated. SPSS 22.0, FACTOR 10.5.01, and
(moderate), 15–19 (moderately severe), and 20–27 points (severe). JASP were used for data analyses.
Second, in order to analyze the internal structure of the PHQ-9,
several confirmatory factor analyses (CFA) were performed. Attending 3. Results
to previous studies, a one-dimensional model was examined. Diagonally
Weighted Least Squares estimator was used. The following goodness-of- 3.1. Descriptive statistics
fit indices were used: Chi-square (χ2), Comparative Fit Index (CFI),
Tucker-Lewis Index (TLI), Root Mean Square Error of Approximation Prevalence and descriptive statistics for the PQH-9 items are shown
(RMSEA) and 90 % Confidence interval, and Standardized Root Mean in Table 1. The prevalence rates of depressive symptoms according to
Square Residual (SRMR). Hu and Bentler (1999) suggested that RMSEA the recommended cut-off points were: 52.1 % (minimal), 20.2 % (mild),
should be 0.06 or less for a good model fit and CFI and TLI should be 15.2 % (moderate), 8.1 % (moderately severe), and 4.4 % (severe).
0.95 or more, though any value over 0.90 tends to be considered
acceptable. 3.2. Confirmatory factor analysis of the PHQ-9 items
Third, in order to test measurement invariance across gender, suc­
cessive multigroup CFAs were conducted. Basically, a hierarchical set of The standardized factor loadings for the total sample and by gender
steps are followed when testing measurement invariance, typically are shown in Table 2. Goodness-of-fit indices for the one-dimensional
starting with the determination of a well-fitting multigroup and baseline model were adequate (see Table 3).
model and continuing with the establishment of successive equivalence
constraints in the model parameters across groups. The baseline model is

3
E. Fonseca-Pedrero et al. Psychiatry Research 328 (2023) 115486

Table 1
Prevalence (%) of response and descriptive statistics for the items of the Patient Health Questionnaire-9 (PHQ-9) in the whole sample.
Item Not at Several More than half of the Almost every M SD Skewness Kurtosis
all days days day

1 Little interest or pleasure in doing things 37.3 44.4 10.5 7.8 0.89 0.88 0.90 0.21
2 Feeling down, depressed, or hopeless 36.2 42.9 11.9 9 0.94 0.91 0.83 − 0.06
3 Trouble falling or staying asleep, or sleeping too much 53.1 25.4 9.4 12.1 0.80 1.03 1.05 − 0.18
4 Feeling tired or having little energy 59.1 21.3 10.3 9.4 0.70 0.99 1.21 0.20
5 Poor appetite or overeating 27.7 44.7 14.4 13.2 1.13 0.97 0.62 − 0.53
6 Feeling bad about yourself – or that you are a failure 56.5 26.4 8.5 8.5 0.69 0.95 1.26 0.51
7 Trouble concentrating on things 37.9 34.8 15.2 12 1.01 1.01 0.68 − 0.64
8 Moving or speaking so slowly that other people could have 63.8 22.4 9.3 4.6 0.55 0.84 1.47 1.26
noticed
9 Thoughts that you would be better off dead or of hurting 82.5 11.2 3.5 2.7 0.26 0.65 2.75 7.26
yourself

3.5. Evidence based on the relations of the PHQ-9 scores to other

Table 2
variables
Standardized factor loadings of the Patient Health Questionnaire-9 (PHQ-9) for
the total sample and by gender.
We also studied the correlation between the PHQ-9 total score and
Items Total sample Male Female
mental health psychometric indicators. As shown in Table 4, the PHQ-9
1 0.843 0.802 0.832 total score was positively and statistically significant correlated with
2 0.737 0.667 0.796 anxiety symptoms, and emotional and behavioral problems, and nega­
3 0.710 0.593 0.714
tively associated with prosocial behavior and quality of life.
4 0.732 0.609 0.729
5 0.722 0.625 0.735
6 0.835 0.802 0.803 4. Discussion
7 0.607 0.590 0.627
8 0.561 0.498 0.554
Depression symptoms and disorder is a common problem among
9 0.799 0.778 0.773
adolescents (Shorey et al., 2022). Routine screening for depression is
Note. All standardized factor loadings estimated were statistically significant (p recommended, yet standardization in screening and management is
< .01). lacking (Cucci et al., 2022). Improving early recognition and assessment
procedures, using reliable tools, can help us to prevent, as well as to
3.3. Measurement invariance of the PHQ-9 scores across gender promote evidence-based psychological treatments for mild and

Since the one-factor model showed a good fit, the measurement

invariance of the unidimensional model of the PHQ-9 was tested as a
function of gender. Goodness-of-fit indices for males and females were
adequate (see Table 3). The configural, metric invariance and scalar
measurement invariance models showed an adequate fit to the data. The
ΔCFI between the constrained and unconstrained models was under
0.01, thus measurement invariance across gender for this unidimen­
sional model was supported.

3.4. Reliability estimation of the PHQ-9 scores

The internal consistency of the PHQ-9 total frequency score, esti­

mated with McDonald’s Omega, was 0.87 (95 % CI: 0.86–0.88). Item Fig. 1. Test information function of the Patient Health Questionnaire-9 (PHQ-
discrimination indices were higher than 0.30. According to the IRT 9).
Note. F1=latent trait. Test information function graphically depict the regions of the
framework, the test information function provides an optimal estimation
latent trait continuum most precisely assessed. Greater information reflects greater
at the medium-high latent trait (values between 0 and 2) (see Fig. 1).
measurement accuracy, or reliability.
The tool reduces its accuracy around the lowest level of the latent trait.

Table 3
Goodness-of-fit indices for the hypothetical models tested and measurement invariance of the Patient Health Questionnaire-9 (PHQ-9) by gender.
Model χ2 df CFI TLI RMSEA (90 % IC) SRMR ΔCFI*

One-factor 203.802 27 0.993 0.991 0.054 (0.054–0.061) 0.043

Measurement invariance
Male (n = 1045) 99.404 27 0.988 0.983 0.051 (0.040–0.062) 0.054
Female (n = 1183) 131.934 27 0.993 0.991 0.057 (0.048–0.067) 0.046
Configural invariance 230.832 54 0.992 0.989 0.054 (0.047–0.067) 0.050
Metric Invariance 275.388 62 0.990 0.988 0.056 (0.049–0.062) 0.054 <0.01
Scalar Invarariance 396.285 79 0.985 0.987 0.060 (0.054–0.066) 0.052 <0.01

Note.
χ2 = Chi square; df = degrees of freedom; CFI = Comparative Fit Index; TLI = Tucker-Lewis Index; RMSEA = Root Mean Square Error of Approximation; IC = Interval
Confidence; SRMR = Standardized Root Mean Square Residual; ΔCFI = Change in Comparative Fix Index.
Good model fit is indicated by a RMSEA ≤ 0.06, CFI and TLI ≥ 0.90 of 0.95, SRMR ≥ 0.08.
*CFI Δ < 0.01 indicates measurement invariance across gender.

4
E. Fonseca-Pedrero et al. Psychiatry Research 328 (2023) 115486

Table 4
Pearson’s correlations between the Patient Health Questionnaire-9 (PHQ-9) and the measures of mental health and quality of life.
PHQ-9 GAD-7 SDQ PREM SDQ PRCD SDQ PRPP SDQ HIP SDQ PROS

GAD-7 0.766**
SDQ PREM 0.709** 0.751**
SDQ PRCD 0.397** 0.389** 0.291**
SDQ PP 0.413** 0.383** 0.396** 0.257**
SDQ HIP 0.474** 0.453** 0.362** 0.446** 0.184**
SDQ PROS − 0.117** − 0.044* 0.034 − 0.294** − 0.214** − 0.141**
KS-10 − 0.552** − 0.471** − 0.485** − 0.248** − 0.316** − 0.300** 0.177**

Note. **p < .01;

PHQ-9= Patient Health Questionnaire-9; GAD-7 = Generalized Anxiety Disorder Assessment-7; SDQ = Strengths and Difficulties Questionnaire; SDQ PREM = SDQ
emotional problems; SDQ PRCD = SDQ conduct problems; SDQ PRPP = SDQ peer problems; SDQ HIP = SDQ hyperactivity; SDQ PROS = SDQ prosocial behavior; KS-
10= KIDSCREEN-10 Index.

moderate to severe depression. Thus, the main objective of the present should be questioned. Comparability between different groups only
study was to validate the PHQ-9 scores in a community-based sample of makes sense if it can be guaranteed that participants interpret and un­
adolescents. The prevention, using reliable screening methods, are derstand the latent construct in a similar manner (Horn and McArdle,
fundamental in the management of this phenomena (Patra and Kumar, 1992).
2023), considered as one of the major barriers for the family, educa­ The reliability, estimated with McDonald’s Omega, for the PHQ-9
tional, health and societal systems. total score was 0.87. This result is convergent with those found in pre­
During the last two weeks, the 12.5 % of the adolescent sample re­ vious studies conducted in adolescent populations (Burdzovic & Brun­
ported, symptoms of depression of moderately severe (8.1 %) and severe borg, 2017; Anum et al., 2019; Leung et al., 2020). In addition, we
(4.4 %). The results found in the present study seem consistent with computed, from IRT, the test information function (TIF). The TIF pro­
previous international reports examining self-reported depression vides an optimal estimation at the medium-high latent trait, that is, the
symptoms in adolescent school samples using the PHQ-9 (Burdzovic and PHQ-9 provided information at middle and higher levels of depression
Brunborg, 2017; Tsai et al., 2014). For instance, 5.8 % prevalence of severity continuum. It is important in the context of ability or true score
clinically-elevated symptoms among Norwegian adolescents or 5.1 %, estimation because the TIF serves as an estimate of the latent trait ac­
among Chinese high-school students (Tsai et al., 2014). Nonetheless, curacies of depression (i.e., the levels of the latent trait are measured
since we used internationally defined cut-off scores but not tested in with less standard error of measurement).
Spain, these results should be considered as preliminary. Furthermore, The PHQ-9 was positively associated with anxiety symptoms and
the PHQ-9 has a frequency-based item response system, which does not emotional and behavioral problems, and negatively associated with
necessarily imply depressive severity. prosocial behavior and quality of life. Similar results have found in prior
The unidimensional factorial model of the PHQ-9 showed adequate research in both adolescent and adult samples. For example, Anum et al.
goodness of fit indices. Similar results have been found in previous (2019) found that the PHQ-9 correlated significantly with measures of
research (Burdzovic and Brunborg, 2017; Anum et al., 2019; Leung anxiety, depression, mental wellbeing, and suicidal behavior. Further­
et al., 2020). For instance, Leung et al. (2020) found, using CFA, that the more, youth depression has been associated with a wide variety of risk
one-factor model with three pairs of item correlations fitted the PHQ-9 and protective factors (e.g. Beck et al., 2021; Thapar et al., 2022). The
data well, and that measurement invariances by age and gender were risk factors identified include, among others, female sex, older age,
supported. In another work, Burdzovic and Brunborg (2017) found a poorer performance at school, lower interpersonal trust, social stress,
single-factor structure for the PHQ-9 and adequate reliability estimation atypicality, anxiety, feelings of incompetence, somatization, exposure to
for both genders. Also, these results are in line with those found in the adverse events such as illness or death of a family member, physical or
adult population (e.g., Bianchi et al., 2022). At this regard, previous sexual abuse, bullying, poor academic achievement, poor sleep, more
studies supported robust evidence for the unidimensional structure of negative body image, more problematic use of social media or computer
PHQ-9 to assess depressive symptoms (Bianchi et al., 2022), and add games, as well as poorer family functioning and inconsistent parental
useful information for most patients (Boothroyd et al., 2019). From a discipline (Beck et al., 2021).
conceptual point of view and given the overlap with other emotional One line of research in the field of depression is based on the idea of
problems and disorders (e.g., anxiety), we should consider, during early detection, prevention and intervention in individuals who report
adolescence, the PHQ-9 total score as a proxy for the general dimension subclinical depression with the aim of mitigating or reducing the impact
of emotional dysregulation or internalizing factor (e.g., Piqueras et al., that the disorder may have on the personal, family, academic, health
2021). This view is fully congruent with current transdiagnostic and and social spheres (Bernaras et al., 2019). Compared to other methods
psychopathology models (e.g., HiTOP) consider that psychological (e.g., clinical interviews), the use of these tools constitutes a rapid,
phenomena as representing unbroken spectra ranging from very low to efficient and non-invasive method of assessment. Moreover, the delay in
very high levels (Eaton et al., 2023). From this broader framework, diagnosis and treatment, the inadequate supply of mental health ser­
subjective distress should be largely determined by the presence of vices, and the adverse consequences of depressive symptoms and dis­
emotional -or internalizing symptoms- such as anxiety and depression orders reinforce the importance of screening and treatment of this
(Piqueras et al., 2021). phenomena (as an internalizing disorder, depression is much less likely
Multi-group CFAs showed that the one-factor model of the PHQ-9 to be detected) at critical stages of human development such as
had strong measurement invariance across gender. Previous studies adolescence. Due to the rising trend of depressive symptoms and the
have found mixed results. For instance, Burdzovic & Brundorg (2017) increasing number of at-risk teenagers, clinicians, researchers and
found no evidence of metric or scalar equality across genders. Amun practitioners should be more vigilant and proactive in their outreach
et al. (2019) conducted a multi-group CFA and supported a one-factor activities to raise awareness and promote access and availability of
structure of the PHQ-9 that was invariant across gender. These results services for this vulnerable group (Shorey et al., 2022). The United
showed that all PHQ-9 items were equivalent across gender (none States Preventive Services Task Force recommends screening for
showed differential items functioning). It should be stressed that if depression in adolescents aged 12 to 18 years in the primary care setting
measurement invariance does not hold, the validity of such scores (Grade B recommendation) (Forman-Hoffman et al., 2016).

5
E. Fonseca-Pedrero et al. Psychiatry Research 328 (2023) 115486

Depression screening and prevention programs for young people properties and correlates. Front. Psychol. 8, 887. https://doi.org/10.3389/
fpsyg.2017.00887.
need to go beyond the clinic walls (Guo and Jhe, 2021). Educational
Cheung, G.W., Rensvold, R.B., 2002. Evaluating goodness-of-fit indexes for testing
settings are at the forefront of mental health promotion and prevention measurement invariance. Struct. Equ. Model 9, 233–255. https://doi.org/10.1207/
during childhood and adolescence. Universal school-based screening S15328007SEM0902_5.
would improve the detection of adolescent depression and reduce the Cucci, K.E., Thompson, J., Derouin, A., 2022. Bridging the gap in adolescent depression:
an action plan intervention. J. Pediatr. Health Care 36, 264–269. https://doi.org/
limited capacity of the healthcare system to provide adequate mental 10.1016/J.PEDHC.2021.10.008.
health care to those who clearly need treatment. Schools are the “nat­ Davis, M., Jones, J.D., So, A., Benton, T.D., Boyd, R.C., Melhem, N., Ryan, N.D., Brent, D.
ural” place for actions to promote mental well-being and, specifically, A., Young, J.F., 2022. Adolescent depression screening in primary care: who is
screened and who is at risk? J. Affect. Disord. 299, 318–325. https://doi.org/
for the prevention of mental health problems. Most adolescents spend 10.1016/J.JAD.2021.12.022.
long periods of time in classrooms, with schools being one of the main El-Den, S., Chen, T.F., Gan, Y.L., Wong, E., O’Reilly, C.L., 2018. The psychometric
agents involved in socialization, as well as in formation and promotion properties of depression screening tools in primary healthcare settings: a systematic
review. J. Affect. Disord. 225, 503–522. https://doi.org/10.1016/J.
of optimal development (Fonseca-Pedrero et al., 2023a). In this regard, JAD.2017.08.060.
the WHO Guidelines on School Health Services (WHO, 2021) highlight Eaton, N.R., Bringmann, L.F., Elmer, T., Fried, E.I., Forbes, M.K., Greene, A.L.,
that schools are essential environments for the acquisition of Krueger, R.F., Kotov, R., McGorry, P.D., Mei, C., Waszczuk, M.A., 2023. A review of
approaches and models in psychopathology conceptualization research. Nat. Rev.
socio-emotional skills (e.g., self-regulation and resilience). In the last Psychol. 1–15. https://doi.org/10.1038/s44159-023-00218-4.
decade, a range of psychological interventions to promote mental health Elosua, P., Aguado, D., Fonseca-Pedrero, E., Abad, F.J., Santamaría, P., 2023. New trends
and prevent mental health problems in schools have been tested with in digital technology-based psychological and educational assessment. Psicothema
35, 50–57. https://doi.org/10.7334/PSICOTHEMA2022.241.
varying degrees of success (González-Roz et al., 2023).
Fatiregun, A.A., Kumapayi, T.E., 2014. Prevalence and correlates of depressive symptoms
Taken together, the results showed that the PHQ-9 is a brief, easy, among in-school adolescents in a rural district in southwest Nigeria. J. Adolesc. 37,
and reliable tool for assessing self-reported depressive symptoms in 197–203. https://doi.org/10.1016/j.adolescence.2013.12.003.
school settings. This research provides further support for the validity of Finning, K., Ukoumunne, O.C., Ford, T., Danielsson-Waters, E., Shaw, L., Romero De
Jager, I., Stentiford, L., Moore, D.A., 2019. The association between child and
the PHQ-9 scores in a large and representative sample of non-clinical adolescent depression and poor attendance at school: a systematic review and meta-
adolescents. In addition, the results indicated that the PHQ-9 could be analysis. J. Affect. Disord. 245, 928–938. https://doi.org/10.1016/J.
a brief and useful tool to assess depression in general population sam­ JAD.2018.11.055.
Fonseca-Pedrero, E., Lemos-Giráldez, S., Paino, M., Villazón-García, U., Muñiz, J., 2009.
ples. Future studies should continue to analyze the protective and risk Validation of the schizotypal personality questionnaire brief form in adolescents.
factors for depression, add new psychometric procedures (e.g., network Schizophr. Res. 111, 53–60. https://doi.org/10.1016/j.schres.2009.03.006.
models) and digital based technologies (Elosua et al., 2023) to prevent Fonseca-Pedrero, E., Díez-Gómez, A., Pérez-Albéniz, A., Lucas-Molina, B., Al-Halabí, S.,
Calvo, P., 2023a. Psychology professionals in educational contexts: an unavoidable
mental health disorders in young people. necessity. Papeles del Psicólogo/Psychologist Papers 44, 112–124. https://doi.org/
10.23923/pap.psicol.3018.
Fonseca-Pedrero, E., Pérez-Albéniz, A., Al-Halabí, S., Lucas-Molina, B., Ortuño-Sierra, J.,
Declaration of Competing Interest Díez-Gómez, A., Pérez-Sáenz, J., Inchausti, F., García, A.V.V., García, A.G.,
Solana, R.A., Ródenas-Perea, G., Clemente, M.P.D.V., López, A.C., Debbané, M.,
2023b. PSICE Project Protocol: evaluation of the unified protocol for transdiagnostic
The authors declare that they have no known competing financial treatment for adolescents with emotional symptoms in school settings. Clínica y
interests or personal relationships that could have appeared to influence Salud 34, 15–22. https://doi.org/10.5093/CLYSA2023A3.
Forman-Hoffman, V., McClure, E., McKeeman, J., Wood, C.T., Middleton, J.C.,
the work reported in this paper. Skinner, A.C., Perrin, E.M., Viswanathan, M., 2016. Screening for major depressive
disorder in children and adolescents: a systematic review for the U.S. preventive
services task force. Ann. Intern. Med. 164, 342–349. https://doi.org/10.7326/M15-
Acknowledgements
2259.
GBD 2019 Mental Disorders Collaborators, 2022. Global, regional, and national burden
This research was funded by a national project awarded by the of 12 mental disorders in 204 countries and territories, 1990–2019: a systematic
Ministry of Science and Innovation of the Government of Spain and the analysis for the Global Burden of Disease Study 2019. Lancet Psychiat. 9, 137–150.
https://doi.org/10.1016/S2215-0366(21)00395-3.
Agency and the European Regional Development Fund (Project González-Blanch, C., Medrano, L.A., Muñoz-Navarro, R., Ruíz-Rodríguez, P., Moriana, J.
“PID2021-127301OB-I00” funded by MCIN / AEI /10.13039/ A., Limonero, J.T., Schmitz, F., Cano-Vindel, A., 2018. Factor structure and
501100011033 FEDER, UE). measurement invariance across various demographic groups and over time for the
PHQ-9 in primary care patients in Spain. PLoS ONE 13, e0193356. https://doi.org/
10.1371/JOURNAL.PONE.0193356.
References González-Roz, A., Martínez-Loredo, V., Maalouf, W., Fernández-Hermida, J.R., Al-
Halabí, S., 2023. Protocol for a trial assessing the efficacy of a universal school-based
prevention program for addictive behaviors. Psicothema 35, 41–49. https://doi.org/
Anum, A., Adjorlolo, S., Kugbey, N., 2019. Depressive symptomatology in adolescents in
10.7334/PSICOTHEMA2022.251.
Ghana: examination of psychometric properties of the Patient Health Questionnaire-
Goodman, R., 1997. The strengths and difficuties questionnaire: a research note. J. Child
9. J. Affect. Disord. 256, 213–218. https://doi.org/10.1016/J.JAD.2019.06.007.
Psychol. Psychiatry 38, 581–586.
Aymerich, M., Berra, S., Guillamón, I., Herdman, M., Alonso, J., Ravens-Sieberer, U.,
Guo, S., Jhe, G.B., 2021. Universal depression screening in schools—promises and
Rajmil, L., 2005. Development of the Spanish version of the KIDSCREEN, a health-
challenges in addressing adolescent mental health need. JAMA Netw. Open 4,
related quality of life instrument for children and adolescent. Gac. Sanit. 19, 93–102.
e2132858. https://doi.org/10.1001/jamanetworkopen.2021.32858.
Beck, A., LeBlanc, J.C., Morissette, K., Hamel, C., Skidmore, B., Colquhoun, H., Lang, E.,
Hambleton, R., Swaminathan, H., Rogers, J., 1991. Fundamentals of Item Response
Moore, A., Riva, J.J., Thombs, B.D., Patten, S., Bragg, H., Colman, I., Goldfield, G.S.,
Theory. Sage.
Nicholls, S.G., Pajer, K., Potter, B.K., Meeder, R., Vasa, P., Hutton, B., Shea, B.J.,
Hankin, B.L., 2015. Depression from childhood through adolescence: risk mechanisms
Graham, E., Little, J., Moher, D., Stevens, A., 2021. Screening for depression in
across multiple systems and levels of analysis. Curr. Opin. Psychol. https://doi.org/
children and adolescents: a protocol for a systematic review update. Syst. Rev. 10
10.1016/j.copsyc.2015.01.003.
https://doi.org/10.1186/s13643-020-01568-3.
Hankin, B.L., Fraley, R.C., Lahey, B.B., Waldman, I.D., 2005. Is depression best viewed as
Bernaras, E., Jaureguizar, J., Garaigordobil, M., 2019. Child and adolescent depression: a
a continuum or discrete category? A taxometric analysis of childhood and adolescent
review of theories, evaluation instruments, prevention programs, and treatments.
depression in a population-based sample. J. Abnorm. Psychol. 114, 96–110. https://
Front. Psychol. 10, 543. https://doi.org/10.3389/FPSYG.2019.00543.
doi.org/10.1037/0021-843X.114.1.96.
Bianchi, R., Verkuilen, J., Toker, S., Schonfeld, I.S., Gerber, M., Brähler, E., Kroenke, K.,
Horn, J.L., McArdle, J.J., 1992. A practical and theoretical guide to measurement
2022. Is the PHQ-9 a unidimensional measure of depression? A 58,272-participant
equivalence in aging research. Exp. Aging Res. 18, 117–144.
study. Psychol. Assess. 34, 595–603. https://doi.org/10.1037/PAS0001124.
Hu, L.-T., Bentler, P.M., 1999. Cut off criteria for fit indexes in covariance structure
Boothroyd, L., Dagnan, D., Muncer, S., 2019. PHQ-9: one factor or two? Psychiatry Res.
analysis: conventional criteria versus new alternatives. Struct. Equ. Model. 6, 1–55.
271, 532–534. https://doi.org/10.1016/J.PSYCHRES.2018.12.048.
Johnson, J.G., Harris, E.S., Spitzer, R.L., Williams, J.B.W., 2002. The Patient Health
Borghero, F., Martínez, V., Zitko, P., Vöhringer, P.A., Cavada, G., Rojas, G., 2018.
Questionnaire for adolescents: validation of an instrument for the assessment of
[Screening depressive episodes in adolescents. Validation of the Patient Health
mental disorders among adolescent primary care patients. J. Adolesc. Heal. 30,
Questionnaire-9 (PHQ-9)]. Rev. Med. Chil. 146, 479–486. https://doi.org/10.4067/
196–204. https://doi.org/10.1016/S1054-139X(01)00333-0.
S0034-98872018000400479.
Kotov, R., Krueger, R.F., Watson, D., Cicero, D.C., Conway, C.C., DeYoung, C.G.,
Burdzovic, A.J., Brunborg, G.S., 2017. Depressive symptomatology among Norwegian
Eaton, N.R., Forbes, M.K., Hallquist, M.N., Latzman, R.D., Mullins-Sweatt, S.N.,
adolescent boys and girls: the patient health Questionnaire-9 (PHQ-9) psychometric

6
E. Fonseca-Pedrero et al. Psychiatry Research 328 (2023) 115486

Ruggero, C.J., Simms, L.J., Waldman, I.D., Waszczuk, M.A., Wright, A.G.C., 2021. Rhew, I.C., Monahan, K.C., Oesterle, S., Hawkins, J.D., 2016. The communities that care
The hierarchical taxonomy of psychopathology (HiTOP): a quantitative nosology brief depression scale: psychometric properties and criterion validity. J. Commun.
based on consensus of evidence. Annu. Rev. Clin. Psychol. 17, 83–108. https://doi. Psychol. 44, 391–398. https://doi.org/10.1002/jcop.21766.
org/10.1146/annurev-clinpsy-081219-093304. Richardson, L.P., McCauley, E., Grossman, D.C., McCarty, C.A., Richards, J., Russo, J.E.,
Kroenke, K., 2021. PHQ-9: global uptake of a depression scale. World Psychiat. 20, Rockhill, C., Katon, W., 2010. Evaluation of the Patient Health Questionnaire (PHQ-
135–136. https://doi.org/10.1002/WPS.20821. 9) for detecting major depression among adolescents. Pediatrics 126, 1117. https://
Kroenke, K., Spitzer, R.L., Williams, J.B.W., 2001. The PHQ-9: validity of a brief doi.org/10.1542/PEDS.2010-0852.
depression severity measure. J. Gen. Intern. Med. 16, 606–613. https://doi.org/ Riglin, L., Petrides, K.V., Frederickson, N., Rice, F., 2014. The relationship between
10.1046/J.1525-1497.2001.016009606.X. emotional problems and subsequent school attainment: a meta-analysis. J. Adolesc.
Leung, D.Y.P., Mak, Y.W., Leung, S.F., Chiang, V.C.L., Loke, A.Y., 2020. Measurement 37, 335–346. https://doi.org/10.1016/J.ADOLESCENCE.2014.02.010.
invariances of the PHQ-9 across gender and age groups in Chinese adolescents. Asia. Shorey, S., Ng, E.D., Wong, C.H.J., 2022. Global prevalence of depression and elevated
Pac. Psychiatry 12. https://doi.org/10.1111/APPY.12381. depressive symptoms among adolescents: a systematic review and meta-analysis. Br.
Muñoz-Navarro, R., Cano-Vindel, A., Moriana, J.A., Medrano, L.A., Ruiz-Rodríguez, P., J. Clin. Psychol. 61, 287–305. https://doi.org/10.1111/BJC.12333.
Agüero-Gento, L., Rodríguez-Enríquez, M., Pizà, M.R., Ramírez-Manent, J.I., 2017. Sinclair-McBride, K., Morelli, N., Gusman, M., 2018. PHQ-9 administration in outpatient
Screening for generalized anxiety disorder in Spanish primary care centers with the adolescent psychiatry services. Psychiatr. Serv. 69, 837–838. https://doi.org/
GAD-7. Psychiatry Res. 256, 312–317. https://doi.org/10.1016/J. 10.1176/appi.ps.201800145.
PSYCHRES.2017.06.023. Solmi, M., Radua, J., Olivola, M., Croce, E., Soardo, L., Salazar de Pablo, G., Il Shin, J.,
NICE Guidance, 2019. Depression in Children and Young people: Identification and Kirkbride, J.B., Jones, P., Kim, J.H., Kim, J.Y., Carvalho, A.F., Seeman, M.V.,
Management. NICE guideline [NG134]. Correll, C.U., Fusar-Poli, P., 2022. Age at onset of mental disorders worldwide: large-
Olino, T.M., Yu, L., Klein, D.N., Rohde, P., Seeley, J.R., Pilkonis, P.A., Lewinsohn, P.M., scale meta-analysis of 192 epidemiological studies. Mol. Psychiatry 27, 281–295.
2012. Measuring depression using item response theory: an examination of three https://doi.org/10.1038/S41380-021-01161-7.
measures of depressive symptomatology. Int. J. Method. Psychiatr. Res. 21, 76–85. Spitzer, R.L., Kroenke, K., Williams, J.B.W., 1999. Validation and utility of a self-report
https://doi.org/10.1002/mpr.1348. version of PRIME-MD: the PHQ primary care study. Primary care evaluation of
Ortuño-Sierra, J., Sebastián-Enesco, C., Pérez-Albéniz, A., Lucas-Molina, B., Fonseca- mental disorders. Patient Health Questionnaire. JAMA 282, 1737–1744. https://doi.
Pedrero, E., 2022. Spanish normative data of the Strengths and Difficulties org/10.1001/JAMA.282.18.1737.
Questionnaire in a community-based sample of adolescents. Int. J. Clin. Health Spitzer, R.L., Kroenke, K., Williams, J.B.W., Löwe, B., 2006. A brief measure for assessing
Psychol. 22 https://doi.org/10.1016/J.IJCHP.2022.100328. generalized anxiety disorder: the GAD-7. Arch. Intern. Med. 166, 1092–1097.
Patra, K.P., Kumar, R., 2023. Screening for depression and suicide in children. StatPearls. https://doi.org/10.1001/ARCHINTE.166.10.1092.
Piqueras, J.A., Garcia-Olcina, M., Rivera-Riquelme, M., Martinez-Gonzalez, A.E., Thapar, A., Eyre, O., Patel, V., Brent, D., 2022. Depression in young people. Lancet 400,
Cuijpers, P., 2021. DetectaWeb-distress scale: a global and multidimensional web- 617–631. https://doi.org/10.1016/S0140-6736(22)01012-1.
based screener for emotional disorder symptoms in children and adolescents. Front. Tsai, F.J., Huang, Y.H., Liu, H.C., Huang, K.Y., Huang, Y.H., Liu, S.I., 2014. Patient health
psychol. 12, 627604 https://doi.org/10.3389/fpsyg.2021.627604. questionnaire for school-based depression screening among Chinese adolescents.
Ravens-Sieberer, U., Erhart, M., Rajmil, L., Herdman, M., Auquier, P., Bruil, J., Pediatrics 133, e402–e409. https://doi.org/10.1542/peds.2013-0204.
Power, M., Duer, W., Abel, T., Czemy, L., Mazur, J., Czimbalmos, A., Tountas, Y., WHO, 2021. WHO Guideline On School Health Services. WHO.
Hagquist, C., Kilroe, J., 2010. Reliability, construct and criterion validity of the World Health Organization, 2022. World mental health report: transforming mental
KIDSCREEN-10 score: a short measure for children and adolescents’ well-being and health for all. WHO.
health-related quality of life. Qual. Life Res. 19, 1487–1500. https://doi.org/
10.1007/S11136-010-9706-5.