Journal Pre-proof

Screening for depression in primary care with Patient Health

Questionnaire-9 (PHQ-9): a systematic review

Luigi Costantini , Cesira Pasquarella , Anna Odone ,

Maria Eugenia Colucci , Alessandra Costanza , Gianluca Serafini ,
Andrea Aguglia , Martino Belvederi Murri , Vlasios Brakoulias ,
Mario Amore , S. Nassir Ghaemi , Andrea Amerio

PII: S0165-0327(20)32828-7
DOI: https://doi.org/10.1016/j.jad.2020.09.131
Reference: JAD 12535

To appear in: Journal of Affective Disorders

Received date: 12 March 2020

Revised date: 17 August 2020
Accepted date: 27 September 2020

Please cite this article as: Luigi Costantini , Cesira Pasquarella , Anna Odone ,
Maria Eugenia Colucci , Alessandra Costanza , Gianluca Serafini , Andrea Aguglia ,
Martino Belvederi Murri , Vlasios Brakoulias , Mario Amore , S. Nassir Ghaemi , Andrea Amerio ,
Screening for depression in primary care with Patient Health Questionnaire-9 (PHQ-9): a systematic
review, Journal of Affective Disorders (2020), doi: https://doi.org/10.1016/j.jad.2020.09.131

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition
of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of
record. This version will undergo additional copyediting, typesetting and review before it is published
in its final form, but we are providing this version to give early visibility of the article. Please note that,
during the production process, errors may be discovered which could affect the content, and all legal
disclaimers that apply to the journal pertain.

© 2020 Elsevier B.V. All rights reserved.

Screening for depression in primary care with Patient Health Questionnaire-9 (PHQ-9): a systematic review

Running title: Screening for depression in primary care with PHQ-9.

Luigi Costantinia1, Cesira Pasquarellaa, Anna Odoneb, Maria Eugenia Coluccia, Alessandra Costanzac,d, Gianluca Serafinie,f, Andrea Agugliae,f,

Martino Belvederi Murrig, Vlasios Brakouliash, Mario Amoree,f, S. Nassir Ghaemii,j, Andrea Amerioe,f,i

a. Department of Medicine and Surgery, University of Parma, Parma, Italy

b. Vita-Salute San Raffaele University, Milan, Italy

c. Department of Psychiatry, Faculty of Medicine, University of Geneva (UNIGE), Geneva, Switzerland

d. Department of Psychiatry, ASO Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy

e. Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry,

University of Genoa, Genoa, Italy

f. IRCCS Ospedale Policlinico San Martino, Genoa, Italy

g. Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy

1
Corresponding author at: Department of Medicine and Surgery, University of Parma, c/o Ospedale Maggiore, Via A. Gramsci 14, 43126 Parma,
Italy. Phone: +39 0521 903831 Fax: +39 0521 903832. Email address: luigi.costantini1@studenti.unipr.it (L. Costantini)
 h. School of Medicine, Western Sydney University, Blacktown Hospital, Sydney, NSW, Australia

i. Mood Disorders Program, Tufts Medical Center, Boston, MA, USA

j. Department of Psychiatry, Tufts University Medical School, Boston, MA, USA

HIGHLIGHTS

- Patient Health Questionnaire 9 (PHQ-9) has been widely validated for depression screening in primary care in high- and low-income
countries.
- A two-stage screening is recommended for depression.
- A Mental Health Professional (MHP) should confirm the diagnosis by use of a semi-structured diagnostic interview.
- Systematic review according to PRISMA statement.

ABSTRACT Word count: 223

Background: Depression is a leading cause of disability. International guidelines recommend screening for depression and the Patient Health

Questionnaire 9 (PHQ-9) has been identified as the most reliable screening tool. We reviewed the evidence for using it within the primary care

setting.

Methods: We retrieved studies from MEDLINE, Embase, PsycINFO, CINAHL and the Cochrane Library that carried out primary care-based
depression screening using PHQ-9 in populations older than 12, from 1995 to 2018.

Results: Forty-two studies were included in the systematic review. Most of the studies were cross-sectional (N=40, 95%), conducted in high-

income countries (N=27, 71%) and recruited adult populations (N=38, 90%). The accuracy of the PHQ-9 was evaluated in 31 (74%) studies with a

two-stage screening system, with structured interview most often carried out by primary care and mental health professionals. Most of the

studies employed a cut-off score of 10 (N=24, 57%, total range 5 – 15). The overall sensitivity of PHQ-9 ranged from 0.37 to 0.98, specificity from

0.42 to 0.99, positive predictive value from 0.09 to 0.92, and negative predictive value from 0.8 to 1.

Limitations: Lack of longitudinal studies, small sample size, and the heterogeneity of primary-care settings limited the generalizability of our

results.

Conclusions: PHQ-9 has been widely validated and is recommended in a two-stage screening process. Longitudinal studies are necessary to

provide evidence of long-term screening effectiveness.

Key words: depression, screening, primary care, PHQ-9.

Word count: 3257

INTRODUCTION

Depression represents a significant contributor to the global burden of disease and affects more than 300 million people in all communities

across the world (World Health Organization, 2018). One in five people experiences a period of depression in their lives and it is the leading

cause of disability worldwide. Burden of disease is a complex concept with different connotations, and covers the burden to the patient,

caregiver, the health system, society and economy. Aside from the personal cost to sufferers and their families, the impact on the economy is

vast, with the cost in Europe alone amounting to €92 billion a year, much of which is down to lost productivity (The Economist, 2014).

Conversely, the recent economic crisis has overloaded the burden of mental disease and posed a further challenge to the prevention of

psychiatric disorders (Odone et al., 2018)

International guidelines recommend screening for depression starting from primary care settings (Siu et al., 2016), while some concerns

about possible harms of a massive screening have been raised (Thombs et al., 2012). A broad variety of depression screening tools have been

proposed and validated. Nevertheless, there is urgent need of choosing one tool to reach a standardized and globally accepted approach (El-Den

et al., 2018). Recently, the 9-item version of the Patient Health Questionnaire (PHQ-9) has been identified as the most reliable screening tool for

depression (El-Den et al., 2018; Levis et al., 2019).

 In recent years, the research around the diagnostic accuracy and psychometric properties of PHQ-9 has flourished within the

international scientific community and several studies have been published (El-Den et al., 2018; Levis et al., 2017; Manea et al., 2017; Wu et al.,

2019). This systematic review is the first to investigate how screening has been implemented in primary care settings using the PHQ-9.

Aim of the study

We systematically reviewed the literature to determine the clinical utility of the PHQ-9 as a screening tool for major depressive disorder

within the primary care setting.

MATERIAL AND METHODS

This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)

guidelines (Liberati et al., 2009), as previously done (Amerio et al., 2016; Amerio et al., 2018).

Information sources and search strategy

Studies were identified searching the electronic databases MEDLINE, Embase, PyscInfo, CINAHL, and the Cochrane Library. We combined

free text terms and MeSH heading as following: ((primary[tiab] AND (care*[tiab] OR healthcare*[tiab] OR health[tiab])) OR ((general[tiab] OR
family[tiab]) AND (practitioner*[tiab] OR physician*[tiab] OR medic*[tiab])) OR GP[tiab] OR "Physicians, Primary Care"[Mesh] OR "Primary

Health Care"[Mesh]) AND (Screening[tiab] OR (screening[tiab] AND (tool*[tiab] OR test*[tiab] OR instrument*[tiab] OR scale*[tiab] OR

intervention**tiab+)) OR “secondary prevention”*tiab+ OR "Mass Screening"*Mesh+) AND (“Patient Health Questionnaire”*tiab+ OR PHQ*[tiab] OR

"Patient Health Questionnaire"*Mesh+) AND (Depress**tiab+ OR ((unipolar*tiab+ OR major*tiab+) AND (depress**tiab+ OR (“mood

disorder*”*tiab+))) OR "Depression/prevention and control"*Mesh+ OR “Depression”*Mesh+ OR "Depressive Disorder"*Mesh+). The strategy was

first developed in MEDLINE and then adapted for use in the other databases (Appendix). Studies in English, published from January 1st, 1995 to

October 31st, 2018 were included. In addition, further studies were retrieved from reference listing of relevant articles and consultation with

experts in the field.

Study population and study designs

We considered studies recruiting participants from primary care settings that focused on PHQ-9 screening of major depressive disorder

(American Psychiatric Association, 2013; World Health Organization, 2004) in primary care settings. Studies conducted using other screening

tools were excluded. Studies examining populations of both sexes older than 12 years of age were included.

Studies that focused on specific populations or that were carried out in specialized settings (e.g. hospital inpatient specialties) were

excluded.
 Studies that compared the PHQ-9 with a diagnostic tool based on DSM or ICD were included as well as studies that performed a

screening without diagnostic comparison.

Both observational and experimental studies were included. Grey literature was considered. Secondary literature reports and book

chapters were excluded. Studies included in former relevant systematic reviews and meta-analyses were individually evaluated. Studies not

applying correct epidemiological methodology were excluded.

Outcomes

Primary outcomes were PHQ-9 sensitivity and specificity for the presence of major depressive disorder according to DSM or ICD criteria.

Literature on the PHQ-9 suggests to adopt a cut-off score of 10 in a 2-stage screening, that is consistent with moderate severity of depression

symptoms (Kroenke et al., 2010).

However, we also included studies using other cut-off values that yielded sensitivity above specificity, keeping the latter equal or above

75%. These are suggested as the optimal characteristics in order to use PHQ-9 by the authors of the questionnaire (Lowe et al., 2004; Spitzer et

al., 1999).

Study selection and data extraction

 Identified studies were independently reviewed for eligibility by two authors (LC, AA) in a two-step process: a first screening was

performed based on titles and abstracts, then full texts were retrieved for a second screening. Disagreement was resolved by consensus.

Data were extracted by two reviewers (LC, AA) with the supervision of another author (AO) using an ad-hoc developed data extraction

spreadsheet.

Data items

Information was extracted from each included study on: 1) study design, time and country of intervention, sample size and possible

subsets; 2) demographic characteristics of the sample, such as age, sex, ethnicity, educational level, income, employment status, and health

insurance coverage; 3) setting, language, and method of administration of PHQ-9, screening stages, positive and negative aspects highlighted in

the reports; 4) reference diagnostic interview, cut-off scores considered, sensitivity, specificity, positive and negative predictive values.

Quality assessment

The same authors who performed data extraction (LC, AA) independently assessed the quality of selected studies using the checklist

developed by Downs and Black both for randomized and non-randomized studies (Downs and Black, 1998). Disagreements by reviewers were

resolved by consensus. Table 1 shows the quality assessment total score assigned to each study.
RESULTS

Study selection

One thousand fourteen potential studies were identified from the selected databases and after cross-checking references of relevant

articles. Six hundred seventy-one studies were retrieved after duplicate removal. Studies were screened and selected as described in Figure 1.

The search identified 42 studies that were included in the systematic review.

Study characteristics

Characteristics of included studies are reported in Table 1. Forty (95%) studies were cross-sectional (Ahmad et al., 2016; Azah et al., 2005;

Ballou et al., 2016; Becker et al., 2002; Bhatta et al., 2018; Carey et al., 2014; Chen et al., 2016; Chen et al., 2010; Chen et al., 2013; Chen et al.,

2006; Cheng and Cheng, 2007; Chowdhury et al., 2004; Fogarty et al. 2008; Ganguly et al., 2013; Gelaye et al., 2013; Gilbody et al., 2007; Harriss

et al., 2018; Hong, 2018; Husain et al., 2007; Inagaki et al., 2013; Indu et al., 2018; Karekla et al., 2012; Kohrt et al., 2016; Kroenke et al., 2001;

Kujawska-Danecka et al., 2016; Liu et al., 2011; Lotrakul et al., 2008; Lowe et al., 2004; Muñoz-Navarro et al., 2017; Muramatsu et al., 2007;

Pilowsky et al., 2006; Rancans et al., 2018; Richardson et al., 2010; Sherina et al., 2012; Spitzer et al., 1999; Sung et al., 2013; Vrublevska et al.,

2018; Wulsin et al., 2002; Yeung et al., 2008; Zuithoff et al., 2010), one was prospective cohort study (Aalsma et al., 2018) and one included
prospective, focus-group, and cross-sectional designs (Hanlon et al., 2015). The study sample sizes ranged from 93 to 3417 patients, with a total

sample size of 35464 patients.

Studies were conducted between 1997 and 2017. Four studies did not report the time of implementation and were assumed to be

carried out two years before their publication dates (Ballou et al., 2016; Chowdhury et al., 2004; Ganguly et al., 2013; Indu et al., 2018).

Demographics

Thirty-eight (90%) studies were carried out on adults, four (10%) on adolescents. With regard to the former subset, twenty-seven (71%)

studies were carried out in high income countries (Ahmad et al., 2016; Ballou et al., 2016; Becker et al., 2002; Carey et al., 2014; Chen et al.,

2016; Chen et al., 2006; Cheng and Cheng, 2007; Fogarty et al., 2008; Gilbody et al., 2007; Hanlon et al., 2015; Harriss et al., 2018; Hong, 2018;

Inagaki et al., 2013; Karekla et al., 2012; Kroenke et al., 2001; Kujawska-Danecka et al., 2016; Liu et al., 2011; Lowe et al., 2004; Muñoz-Navarro

et al., 2017; Muramatsu et al., 2007; Pilowsky et al., 2006; Rancans et al., 2018; Richardson et al., 2010; Spitzer et al., 1999; Sung et al., 2013;

Vrublevska et al., 2018; Yeung et al., 2008; Zuithoff et al., 2010), as defined by the World Bank (World Bank, 2019). Eighteen (66%) of those 27

studies were conducted in the USA . Three (75%) studies conducted in adolescents were carried out in high income countries. Two of those

were conducted in the USA. The comprehensive rate of females across the studies ranged between 64% and 74% in adults, between 46% and

58% in adolescents.
 Twenty-two (52%) studies reported additional relevant demographic information, such as educational level (N=18, 43%), ethnic or

linguistic composition (N=12, 29%), occupational status (N=8, 19%), health insurance (N=4, 11%), and residence (N=1, 3%) (Ahmad et al., 2016;

Aalsma et al., 2018; Becker et al., 2002; Bhatta et al., 2018; Carey et al., 2014; Chen et al., 2016; Chen et al., 2013; Chen et al., 2006; Fogarty et

al., 2008; Gelaye et al., 2013; Hanlon et al., 2015; Hong, 2018; Indu et al., 2018; Kohrt et al., 2016; Kroenke et al., 2001; Lotrakul et al., 2008;

Muñoz-Navarro et al., 2017; Pilowsky et al., 2006; Rancans et al., 2018; Spitzer et al., 1999; Sung et al., 2013; Vrublevska et al., 2018). According

to available data, on a subset of 15852 patients (45% out of the comprehensive sample size), the rate of individuals with educational level higher

than Primary Education (UNESCO, 2011) was 71% (N=11247). Data on health insurance coverage were available for a subset of 6603 (20%)

patients with a public health insurance coverage rate accounted for 57% (N=3780).

PHQ-9 screening process

Table 2 shows the characteristics of screening process drawn from the included studies, divided by age group to highlight the differences

in depression screening among adolescents and adults (Siu et al., 2016).

The majority of the studies were carried out in community-based primary care practices (N=28, 67%); other settings were hospital-based

primary care outpatient clinics (N=4, 10%), rural clinics (N=3, 7%), school-based programs (N=3, 7%), community-based prevention programs

(N=2, 5%), a private-insurance healthcare facility (N=1, 2%), and a community pharmacy (N=1, 2%).
PHQ-9 was self-reported by patients in 34 studies (81%) and administered as an interview in the remaining eight studies (19%). PHQ-9 was

validated in 20 languages besides English.

We retrieved information about implementation stages for 40 (95%) studies. Two studies included an ultra-brief screening scale before

PHQ-9 was administered (Aalsma et al., 2018; Chen et al., 2006). The PHQ-9 was administered by General Practitioners (GPs), nurses, or medical

students in ten studies (24%) (Becker et al., 2002; Bhatta et al., 2018; Chen et al., 2010; Chen et al., 2013; Chen et al., 2006; Cheng and Cheng,

2007; Gelaye et al., 2013; Spitzer et al., 1999; Sung et al., 2013; Wulsin et al., 2002). Most of the studies (N=31, 74%) adopted a two-stage

screening system, in which a clinical interview confirmed or refused the preliminary PHQ-9 assessment. A Mental Health Professional (MHP),

who was blind to PHQ-9 results, performed the diagnostic interview in 18 (43%) studies (Azah, 2005; Becker et al., 2002; Chen et al., 2010; Cheng

and Cheng, 2007; Chowdhury et al., 2004; Gelaye et al., 2013; Hanlon et al., 2015; Hong, 2018; Indu et al., 2018; Kohrt et al., 2016; Kroenke et

al., 2001; Muñoz-Navarro et al., 2017; Pilowsky et al., 2006; Rancans et al., 208; Spitzer et al., 1999; Vrublevska et al., 2018; Yeung et al., 2008;

Zuithoff et al., 2010). Some studies developed a protocol for immediate referral of emergent cases such as suicidal ideation (N=2, 5%) (Ballou et

al., 2016; Chen et al., 2010), implemented a formal staff training before carrying out the survey (N=5, 12%) (Bhatta et al., 2018; Chen et al., 2010;

Chen et al., 2006; Cheng and Cheng, 2007; Chowdhury et al., 2004), and analyzed the staff compliance throughout the screening process (N=1,

2%) (Bhatta et al., 2018).

PHQ-9 Operating Characteristics

Table 3 shows the accuracy data of the PHQ-9 as evaluated in 31 (74%) studies that used different diagnostic interviews on 13459

participants. Fully structured and semi-structured interviews were considered separately. The main standardized diagnostic rating scales used

were the Mini-International Neuropsychiatric Interview (MINI) (4004 patients, 30%), the Composite International Diagnostic Interview (CIDI)

(2623 patients, 19%), the Structured Clinical Interview for DSM-IV (SCID) (2853 patients, 21%), and the Structured Clinical Assessment in

Neuropsychiatry (SCAN) (2529 patients, 19%).

Overall, the cut-off scores ranged from a minimum of 5 to a maximum of 15 points, sensitivity from 0.37 to 0.98, specificity from 0.42 to

0.99, positive predictive value from 0.09 to 0.92, and negative predictive value from 0.8 to 1. A 10-point cut-off was applied in many of the

studies (N=24, 57%). Considering 20 studies applying a 10-point cut-off and performing either a fully structured or semi-structured interview,

sensitivity was 0.85 or higher in 9 studies (45%) (Bhatta et al., 2018; Chen et al., 2010; Chen et al., 2006; Cheng and Cheng, 2007; Chowdhury et

al., 2004; Muñoz-Navarro et al., 2017) and specificity was 0.75 or more in 16 studies (80%) (Azah, 2005; Becker et al., 2002; Chen et al., 2016;

Chen et al., 2010; Chen et al., 2013; Gilbody et al., 2007; Inagaki et al., 2013; Kroenke et al., 2001; Liu et al., 2011; Lotrakul et al., 2008;

Muramatsu et al., 2007; Rancans et al., 2018; Spitzer et al., 1999; Vrublevska et al., 2018; Wulsin et al., 2002; Zuithoff et al., 2010). Sensitivity

was higher than 0.9 in three studies that performed either SCID or CIDI (Gilbody et al., 2007; Kohrt et al., 2016; Muñoz-Navarro et al., 2017).
DISCUSSION

The PHQ-9 has been widely used in different primary care settings for the screening of depression. Most of the included studies were

cross-sectional (N=40, 95%), conducted in high income countries (N=27, 71%) in adult population (N=38, 90%). PHQ-9 accuracy was evaluated in

31 (74%) studies with a two-stage screening system carried out by primary care and mental health professionals with either fully structured or

semi-structured interviews.

Based on the results of our systematic review some observations can be made.

Cut-off score

The cut-off score approach proved to be more useful than the algorithm approach (He et al., 2019). In the last 20 years many of the

researchers have used a cut-off score of 10 or higher, which is also the most represented among the reviewed studies. According to previous

reviews, that was consistent with a severity measure of depressive symptoms evaluated with the same questionnaire (Kroenke et al., 2010). A

meta-analysis defined acceptable cut-off points between 8 and 11 (Manea et al., 2012). Besides, an individual-participant data meta-analysis

demonstrated that a retrospective selection of optimal cut-off led to the paradox of an increasing in sensitivity when the cut-off severity

increased (Levis et al., 2017). The operating characteristics were maximized at a 10-point cut-off (Levis et al., 2019). Our review suggests that

more variability across studies is to be expected in sensitivity than specificity.

 Some authors emphasized the impact of age, context, educational level and social stigma on the choice of the cut-off in each specific

setting (Chen et al., 2016; Gelaye et al., 2013). Authors of previous reviews analyzed this issue and recommended that researchers report the

operating characteristics for the whole range of possible cut-off scores (Levis et al., 2017; Manea et al., 2012).

Diagnostic interviews

Given the complexity of the spectrum of depressive disorders (Amerio et al., 2014), the use of a structured interview based on DSM

(Diagnostic and Statistical Manual of Mental Disorders) (American Psychiatric Association, 2013) criteria is recommended as a reliable way to

validate a screening questionnaire. Nevertheless, a recent individual participant data meta-analysis showed that fully structured interviews

tended to identify more cases of mild depression, whereas semi-structured interviews were more sensitive to severe cases (Levis et al., 2018).

Differences have also been reported among fully structured interviews: MINI, developed as a rapid diagnostic tool, tended to diagnose

depression two times more than CIDI that provided a deeper diagnosis of depression (Levis et al., 2018). Similar issues have been reported in the

selected studies (Zuithoff et al., 2010).

Role and training of primary care operators

Few studies clearly reported the role of GPs and other primary care professionals throughout the screening process. Primary care

operators should be trained in explaining the meaning of the score to the patients, in order to reduce possible harms from misinterpretation.
GPs should make use of the screening tool to detect and deepen the patient’s experience of illness.

Studies that included a staff training or a compliance analysis suggested that such procedures can help addressing organizational

factors that might affect screening efficiency and effectiveness.

Integration between mental health and primary care services

Many of the selected studies included a structured diagnostic interview performed by an MHP. That is a screening model that should be

recommended in order to increase homogeneity and reliability of the reference test. Therefore, a real integration between Mental Health and

Primary Care Services is essential to ensure a prompt patient-centered care. Structured diagnostic interviews should be timely performed, in

order to lower the emotional consequences of positive screening results and lead patients to early treatments.

Future directions

New technologies could speed up the screening process, as reported in previous studies (Aalsma et al., 2018; Harriss et al., 2018). A

digital implementation could be the best and simple way to administer PHQ-9, increasing the study sample size.

Few studies acted as spin-off examples of PHQ-9 application and adaptability to different settings including community pharmacies

(Ballou et al., 2016), school-based programs (Bhatta et al., 2018) and community health campaigns (Harriss et al., 2018; Kujawska-Danecka et al.,
2016). These new settings might be taken in account in the near future and they may be the only access to health care for a substantial part of

population. New settings coupled with the use of a valid screening tool provide a valuable opportunity to perform widespread screening for

depressive disorders.

LIMITATIONS

The main strengths of this study are the extent of the review, the total sample size and systematic approach that was used to review the

literature. A meta-analysis was not possible as the data lacked homogeneity. Also, results may be sensible to the methodological shortcomings

of the primary studies. Inclusion of participants with current psychiatric diagnoses and comorbidities or currently taking psychotropic medication

could have overestimated the clinical utility of the screening tool (Rice et al., 2016). Lack of longitudinal studies and small sample sizes tended to

reduce the power of studies largely affecting their quality. Thirty-two (86%) studies were assigned a score equal or lower than 24/31 on the

Downs and Black quality scale (Downs and Black, 1998). The studies adopted different approaches for the PHQ-9 administration and sequential

study stages. Moreover, ultra-brief pre-screening yielded high risk of recall bias in two studies.

The heterogeneity of primary care services also limits the generalizability of the results. Primary care services are different across countries and

this is more evident when comparing countries with high, middle, and low-income economies.
CONCLUSIONS

The PHQ-9 has been tested extensively for depression screening. It was widely validated as a screening tool in primary care services in

such different countries and its psychometric reliability is established by now. Recently, a shorter 8-item equivalent has been validated (Wu et

al., 2019). Our systematic review suggests that a two-stage screening carried out by primary care and mental health professionals is

recommended. Longitudinal studies are necessary to provide evidence of long-term screening effectiveness.

SUPPLEMENTARY MATERIAL

The complete search strategy is available in the supplementary material of this article.
CONTRIBUTORS

Authors LC, CP, MEC, AC, MBM and AA designed the study and wrote the protocol. Studies were identified and independently reviewed for

eligibility by two authors (LC, AA) in a two-step-based process. Data were extracted by two authors (LC, AA) and supervised by a third author

(AO) using an ad-hoc developed data extraction spreadsheet. Authors LC, GS, MA, VB, AA, and SNG wrote the first draft of the manuscript.

AUTHOR AGREEMENT

Our manuscript has been approved by all authors.

ACKNOWLEDGMENTS

None.

CONFLICTS OF INTEREST

Dr. Costantini, Prof. Pasquarella, Prof. Odone, Prof. Colucci, Dr. Costanza, Prof. Serafini, Dr. Aguglia, Dr. Belvederi Murri, Prof. Brakoulias, Prof.

Amore, and Dr. Amerio report no conflicts of interest. Prof. Ghaemi is employed by Novartis Institutes for Biomedical Research and holds equity

in Novartis.
FUNDING SOURCE DECLARATION

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

REFERENCES

Aalsma, M.C., Zerr, A.M., Etter, D.J., Ouyang, F., Gilbert, A.L., Williams, R.L., Hall, J.A., Downs, S.M., 2018. Physician Intervention to Positive
Depression Screens Among Adolescents in Primary Care. Journal of Adolescent Health 62, 212-218.

Ahmad, F., Shakya, Y., Ginsburg, L., Lou, W., Ng, P.T., Rashid, M., Ferrari, M., Ledwos, C., McKenzie, K., 2016. Burden of common mental
disorders in a community health centre sample. Canadian Family Physician 62, e758-e766.

American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition. American Psychiatric Association, Arlington, VA.
Amerio, A., Odone, A., Marchesi, C., Ghaemi, S.N., 2014. Is depression one thing or many? British Journal of Psychiatry 204, 488-488.

Amerio, A., Ossola, P., Scagnelli, F., Odone, A., Allinovi, M., Cavalli, A., Iacopelli, J., Tonna, M., Marchesi, C., Ghaemi, S.N., 2018. Safety and
efficacy of lithium in children and adolescents: A systematic review in bipolar illness. European Psychiatry 54, 85-97.

Amerio, A., Stubbs, B., Odone, A., Tonna, M., Marchesi, C., Nassir Ghaemi, S., 2016. Bipolar I and II Disorders; A Systematic Review and Meta-
Analysis on Differences in Comorbid Obsessive-Compulsive Disorder. Iran J Psychiatry Behav Sci 10, e3604-e3604.

Azah, M., Shah, M., Juwita, S., Bahri, I., Rushidi, W., Jamil, Y., 2005. Validation of the Malay version brief patient health Questionnaire (PHQ-9)
among adult attending family medicine clinics. International Medical Journal 12, 259-263.

Ballou, J., Roark, A., Chapman, A., Huie, C., Marciniak, M., 2016. Implementation of depression screening in an independent community
pharmacy. Journal of the American Pharmacists Association 56, e77.

Becker, S., Al Zaid, K., Al Faris, E., 2002. Screening for somatization and depression in Saudi Arabia: A validation study of the PHQ in primary care.
International Journal of Psychiatry in Medicine 32, 271-283.

Bhatta, S., Champion, J.D., Young, C., Loika, E., 2018. Outcomes of Depression Screening Among Adolescents Accessing School-based Pediatric
Primary Care Clinic Services. Journal of Pediatric Nursing 38, 8-14.

Carey, M., Jones, K.A., Yoong, S.L., D'Este, C., Boyes, A.W., Paul, C., Inder, K.J., Sanson-Fisher, R., 2014. Comparison of a single self-assessment
item with the PHQ-9 for detecting depression in general practice. Family Practice 31.

Chen, I.P., Liu, S.I., Huang, H.C., Sun, F.J., Huang, C.R., Sung, M.R., Huang, Y.P., 2016. Validation of the Patient Health Questionnaire for
Depression Screening Among the Elderly Patients in Taiwan. International Journal of Gerontology 10, 193-197.

Chen, S., Chiu, H., Xu, B., Ma, Y., Jin, T., Wu, M., Conwell, Y., 2010. Reliability and validity of the PHQ-9 for screening late-life depression in
Chinese primary care. International journal of geriatric psychiatry 25, 1127-1133.
Chen, S., Fang, Y., Chiu, H., Fan, H., Jin, T., Conwell, Y., 2013. Validation of the nine-item Patient Health Questionnaire to screen for major
depression in a Chinese primary care population. Asia-Pacific Psychiatry 5, 61-68.

Chen, T.M., Huang, F.Y., Chang, C., Chung, H., 2006. Using the PHQ-9 for depression screening and treatment monitoring for Chinese Americans
in primary care. Psychiatric Services 57, 976-981.

Cheng, C.M., Cheng, M., 2007. To validate the Chinese version of the 2Q and PHQ-9 questionnaires in Hong Kong Chinese patients. Hong Kong
Practitioner 29, 381-390.

Chowdhury, A.N., Ghosh, S., Sanyal, D., 2004. Bengali adaptation of Brief Patient Health Questionnaire for screening depression at primary care.
Journal of the Indian Medical Association 102, 544-547.

Downs, S.H., Black, N., 1998. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-
randomised studies of health care interventions. Journal of epidemiology and community health 52, 377-384.

El-Den, S., Chen, T.F., Gan, Y.L., Wong, E., O'Reilly, C.L., 2018. The psychometric properties of depression screening tools in primary healthcare
settings: A systematic review. Journal of affective disorders 225, 503-522.

Fogarty, C.T., Sharma, S., Chetty, V.K., Culpepper, L., 2008. Mental health conditions are associated with increased health care utilization among
urban family medicine patients. Journal of the American Board of Family Medicine 21, 398-407.

Ganguly, S., Samanta, M., Roy, P., Chatterjee, S., Kaplan, D.W., Basu, B., 2013. Patient health questionnaire-9 as an effective tool for screening of
depression among indian adolescents. Journal of Adolescent Health 52, 546-551.

Gelaye, B., Williams, M.A., Lemma, S., Deyessa, N., Bahretibeb, Y., Shibre, T., Wondimagegn, D., Lemenhe, A., Fann, J.R., Vander Stoep, A.,
Andrew Zhou, X.H., 2013. Validity of the patient health questionnaire-9 for depression screening and diagnosis in East Africa. Psychiatry
Research 210, 653-661.
Gilbody, S., Richards, D., Barkham, M., 2007. Diagnosing depression in primary care using self-completed instruments: UK validation of PHQ-9
and CORE-OM. British Journal of General Practice 57, 650-652.

Hanlon, C., Medhin, G., Selamu, M., Breuer, E., Worku, B., Hailemariam, M., Lund, C., Prince, M., Fekadu, A., 2015. Validity of brief screening
questionnaires to detect depression in primary care in Ethiopia. Journal of affective disorders 186, 32-39.

Harriss, L.R., Kyle, M., Connolly, K., Murgha, E., Bulmer, M., Miller, D., Munn, P., Neal, P., Pearson, K., Walsh, M., Campbell, S., Berger, M.,
McDermott, R., McDonald, M., 2018. Screening for depression in young Indigenous people: building on a unique community initiative. Australian
Journal of Primary Health 24, 343-349.

He, C., Levis, B., Riehm, K.E., Saadat, N., Levis, A.W., Azar, M., Rice, D.B., Krishnan, A., Wu, Y., Sun, Y., Imran, M., Boruff, J., Cuijpers, P., Gilbody,
S., Ioannidis, J.P.A., Kloda, L.A., McMillan, D., Patten, S.B., Shrier, I., Ziegelstein, R.C., Akena, D.H., Arroll, B., Ayalon, L., Baradaran, H.R., Baron,
M., Beraldi, A., Bombardier, C.H., Butterworth, P., Carter, G., Chagas, M.H.N., Chan, J.C.N., Cholera, R., Clover, K., Conwell, Y., de Man-van Ginkel,
J.M., Fann, J.R., Fischer, F.H., Fung, D., Gelaye, B., Goodyear-Smith, F., Greeno, C.G., Hall, B.J., Harrison, P.A., Harter, M., Hegerl, U., Hides, L.,
Hobfoll, S.E., Hudson, M., Hyphantis, T.N., Inagaki, M., Ismail, K., Jette, N., Khamseh, M.E., Kiely, K.M., Kwan, Y., Lamers, F., Liu, S.I., Lotrakul, M.,
Loureiro, S.R., Lowe, B., Marsh, L., McGuire, A., Mohd-Sidik, S., Munhoz, T.N., Muramatsu, K., Osorio, F.L., Patel, V., Pence, B.W., Persoons, P.,
Picardi, A., Reuter, K., Rooney, A.G., da Silva Dos Santos, I.S., Shaaban, J., Sidebottom, A., Simning, A., Stafford, L., Sung, S., Tan, P.L.L., Turner, A.,
van Weert, H., White, J., Whooley, M.A., Winkley, K., Yamada, M., Thombs, B.D., Benedetti, A., 2019. The Accuracy of the Patient Health
Questionnaire-9 Algorithm for Screening to Detect Major Depression: An Individual Participant Data Meta-Analysis. Psychotherapy and
psychosomatics, 1-13.

Hong, S., Heng, Sheng, 2018. Use of patient health questionnaires (phq-9, phq-2 & phq-1) for depression screening in singapore primary care.
The Singapore Family Physician 44, 6.

Husain, N., Waheed, W., Tomenson, B., Creed, F., 2007. The validation of personal health questionnaire amongst people of Pakistani family
origin living in the United Kingdom. Journal of affective disorders 97, 261-264.
Inagaki, M., Ohtsuki, T., Yonemoto, N., Kawashima, Y., Saitoh, A., Oikawa, Y., Kurosawa, M., Muramatsu, K., Furukawa, T.A., Yamada, M., 2013.
Validity of the Patient Health Questionnaire (PHQ)-9 and PHQ-2 in general internal medicine primary care at a Japanese rural hospital: A cross-
sectional study. General Hospital Psychiatry 35, 592-597.

Indu, P.S., Anilkumar, T.V., Vijayakumar, K., Kumar, K.A., Sarma, P.S., Remadevi, S., Andrade, C., 2018. Reliability and validity of PHQ-9 when
administered by health workers for depression screening among women in primary care. Asian journal of psychiatry 37, 10-14.

Karekla, M., Pilipenko, N., Feldman, J., 2012. Patient health questionnaire: Greek language validation and subscale factor structure.
Comprehensive Psychiatry 53, 1217-1226.

Kohrt, B.A., Luitel, N.P., Acharya, P., Jordans, M.J., 2016. Detection of depression in low resource settings: validation of the Patient Health
Questionnaire (PHQ-9) and cultural concepts of distress in Nepal. BMC Psychiatry 16, 58.

Kroenke, K., Spitzer, R.L., Williams, J.B., Lowe, B., 2010. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a
systematic review. Gen Hosp Psychiatry 32, 345-359.

Kroenke, K., Spitzer, R.L., Williams, J.B.W., 2001. The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine
16, 606-613.

Kujawska-Danecka, H., Nowicka-Sauer, K., Hajduk, A., Wierzba, K., Krzemioski, W., Zdrojewski, Z., 2016. The prevalence of depression symptoms
and other mental disorders among patients aged 65 years and older – screening in the rural community. Family Medicine and Primary Care
Review 18, 274-277.

Levis, B., Benedetti, A., Levis, A.W., Ioannidis, J.P.A., Shrier, I., Cuijpers, P., Gilbody, S., Kloda, L.A., McMillan, D., Patten, S.B., Steele, R.J.,
Ziegelstein, R.C., Bombardier, C.H., de Lima Osorio, F., Fann, J.R., Gjerdingen, D., Lamers, F., Lotrakul, M., Loureiro, S.R., Lowe, B., Shaaban, J.,
Stafford, L., van Weert, H., Whooley, M.A., Williams, L.S., Wittkampf, K.A., Yeung, A.S., Thombs, B.D., 2017. Selective Cutoff Reporting in Studies
of Diagnostic Test Accuracy: A Comparison of Conventional and Individual-Patient-Data Meta-Analyses of the Patient Health Questionnaire-9
Depression Screening Tool. American journal of epidemiology 185, 954-964.

Levis, B., Benedetti, A., Riehm, K.E., Saadat, N., Levis, A.W., Azar, M., Rice, D.B., Chiovitti, M.J., Sanchez, T.A., Cuijpers, P., Gilbody, S., Ioannidis,
J.P.A., Kloda, L.A., McMillan, D., Patten, S.B., Shrier, I., Steele, R.J., Ziegelstein, R.C., Akena, D.H., Arroll, B., Ayalon, L., Baradaran, H.R., Baron, M.,
Beraldi, A., Bombardier, C.H., Butterworth, P., Carter, G., Chagas, M.H., Chan, J.C.N., Cholera, R., Chowdhary, N., Clover, K., Conwell, Y., de Man-
van Ginkel, J.M., Delgadillo, J., Fann, J.R., Fischer, F.H., Fischler, B., Fung, D., Gelaye, B., Goodyear-Smith, F., Greeno, C.G., Hall, B.J., Hambridge,
J., Harrison, P.A., Hegerl, U., Hides, L., Hobfoll, S.E., Hudson, M., Hyphantis, T., Inagaki, M., Ismail, K., Jette, N., Khamseh, M.E., Kiely, K.M.,
Lamers, F., Liu, S.I., Lotrakul, M., Loureiro, S.R., Lowe, B., Marsh, L., McGuire, A., Mohd Sidik, S., Munhoz, T.N., Muramatsu, K., Osorio, F.L., Patel,
V., Pence, B.W., Persoons, P., Picardi, A., Rooney, A.G., Santos, I.S., Shaaban, J., Sidebottom, A., Simning, A., Stafford, L., Sung, S., Tan, P.L.L.,
Turner, A., van der Feltz-Cornelis, C.M., van Weert, H.C., Vohringer, P.A., White, J., Whooley, M.A., Winkley, K., Yamada, M., Zhang, Y., Thombs,
B.D., 2018. Probability of major depression diagnostic classification using semi-structured versus fully structured diagnostic interviews. The
British journal of psychiatry : the journal of mental science 212, 377-385.

Levis, B., Benedetti, A., Thombs, B.D., 2019. Accuracy of Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression:
individual participant data meta-analysis. BMJ (Clinical research ed.) 365, l1476.

Liberati, A., Altman, D.G., Tetzlaff, J., Mulrow, C., Gotzsche, P.C., Ioannidis, J.P., Clarke, M., Devereaux, P.J., Kleijnen, J., Moher, D., 2009. The
PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and
elaboration. PLoS medicine 6, e1000100.

Liu, S.I., Yeh, Z.T., Huang, H.C., Sun, F.J., Tjung, J.J., Hwang, L.C., Shih, Y.H., Yeh, A.W.C., 2011. Validation of Patient Health Questionnaire for
depression screening among primary care patients in Taiwan. Comprehensive Psychiatry 52, 96-101.

Lotrakul, M., Sumrithe, S., Saipanish, R., 2008. Reliability and validity of the Thai version of the PHQ-9. BMC Psychiatry 8.

Lowe, B., Spitzer, R.L., Grafe, K., Kroenke, K., Quenter, A., Zipfel, S., Buchholz, C., Witte, S., Herzog, W., 2004. Comparative validity of three
screening questionnaires for DSM-IV depressive disorders and physicians' diagnoses. Journal of affective disorders 78, 131-140.
Manea, L., Gilbody, S., McMillan, D., 2012. Optimal cut-off score for diagnosing depression with the Patient Health Questionnaire (PHQ-9): a
meta-analysis. Cmaj 184, E191-196.

Muñoz-Navarro, R., Cano-Vindel, A., Medrano, L.A., Schmitz, F., Ruiz-Rodríguez, P., Abellán-Maeso, C., Font-Payeras, M.A., Hermosilla-Pasamar,
A.M., 2017. Utility of the PHQ-9 to identify major depressive disorder in adult patients in Spanish primary care centres. BMC Psychiatry 17.

Muramatsu, K., Miyaoka, H., Kamijima, K., Muramatsu, Y., Yoshida, M., Otsubo, T., Gejyo, F., 2007. The patient health questionnaire, Japanese
version: validity according to the mini-international neuropsychiatric interview-plus. Psychol Rep 101, 952-960.

Odone, A., Landriscina, T., Amerio, A., Costa, G., 2018. The impact of the current economic crisis on mental health in Italy: evidence from two
representative national surveys. Eur J Public Health 28, 490-495.

Pilowsky, D.J., Olfson, M., Gameroff, M.J., Wickramaratne, P., Blanco, C., Feder, A., Gross, R., Neria, Y., Weissman, M.M., 2006. Panic disorder
and suicidal ideation in primary care. Depression and Anxiety 23, 11-16.

Rancans, E., Trapencieris, M., Ivanovs, R., Vrublevska, J., 2018. Validity of the PHQ-9 and PHQ-2 to screen for depression in nationwide primary
care population in Latvia. Annals of General Psychiatry 17, N.PAG-N.PAG.

Rice, D.B., Thombs, B.D., 2016. Risk of Bias from inclusion of currently diagnosed or treated patients in studies of depression screening tool
accuracy: A cross-sectional analysis of recently published primary studies and meta-analyses. PLoS ONE 11.

Richardson, L.P., McCauley, E., Grossman, D.C., McCarty, C.A., Richards, J., Russo, J.E., Rockhill, C., Katon, W., 2010. Evaluation of the patient
health questionnaire-9 item for detecting major depression among adolescents. Pediatrics 126, 1117-1123.

Sherina, M.S., Arroll, B., Goodyear-Smith, F., 2012. Criterion validity of the PHQ-9 (Malay version) in a primary care clinic in Malaysia. The
Medical journal of Malaysia 67, 309-315.
Siu, A.L., Bibbins-Domingo, K., Grossman, D.C., Baumann, L.C., Davidson, K.W., Ebell, M., García, F.A.R., Gillman, M., Herzstein, J., Kemper, A.R.,
Krist, A.H., Kurth, A.E., Owens, D.K., Phillips, W.R., Phipps, M.G., Pignone, M.P., 2016. Screening for depression in adults: US preventive services
task force recommendation statement. JAMA - Journal of the American Medical Association 315, 380-387.

Spitzer, R.L., Kroenke, K., Williams, J.B., 1999. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary
Care Evaluation of Mental Disorders. Patient Health Questionnaire. Jama 282, 1737-1744.

Sung, S.C., Low, C.C.H., Fung, D.S.S., Chan, Y.H., 2013. Screening for major and minor depression in a multiethnic sample of Asian primary care
patients: A comparison of the nine-item Patient Health Questionnaire (PHQ-9) and the 16-item Quick Inventory of Depressive Symptomatology -
Self-Report (QIDS-SR16). Asia-Pacific Psychiatry 5, 249-258.

The Economist, 2014. The Global Crisis of Depression. The Low of 21st Century? Summary Report, The Economist Events, p. 14.

Thombs, B.D., Coyne, J.C., Cuijpers, P., De Jonge, P., Gilbody, S., Ioannidis, J.P.A., Johnson, B.T., Patten, S.B., Turner, E.H., Ziegelstein, R.C., 2012.
Rethinking recommendations for screening for depression in primary care. CMAJ 184, 413-418.

UNESCO, 2011. International Standard Classification of Education (ISCED).

Vrublevska, J., Trapencieris, M., Rancans, E., 2018. Adaptation and validation of the Patient Health Questionnaire-9 to evaluate major depression
in a primary care sample in Latvia. Nordic journal of psychiatry 72, 112-118.

World Bank, 2019. World Bank List of Economies, 07/2019 ed, Washington.

World Health Organization, 2004. ICD-10 : international statistical classification of diseases and related health problems : tenth revision.

World Health Organization, 2018. Fact Sheet on Depression.

Wu, Y., Levis, B., Riehm, K.E., Saadat, N., Levis, A.W., Azar, M., Rice, D.B., Boruff, J., Cuijpers, P., Gilbody, S., Ioannidis, J.P.A., Kloda, L.A.,
McMillan, D., Patten, S.B., Shrier, I., Ziegelstein, R.C., Akena, D.H., Arroll, B., Ayalon, L., Baradaran, H.R., Baron, M., Bombardier, C.H.,
Butterworth, P., Carter, G., Chagas, M.H., Chan, J.C.N., Cholera, R., Conwell, Y., de Man-van Ginkel, J.M., Fann, J.R., Fischer, F.H., Fung, D., Gelaye,
B., Goodyear-Smith, F., Greeno, C.G., Hall, B.J., Harrison, P.A., Harter, M., Hegerl, U., Hides, L., Hobfoll, S.E., Hudson, M., Hyphantis, T., Inagaki,
M.D., Jette, N., Khamseh, M.E., Kiely, K.M., Kwan, Y., Lamers, F., Liu, S.I., Lotrakul, M., Loureiro, S.R., Lowe, B., McGuire, A., Mohd-Sidik, S.,
Munhoz, T.N., Muramatsu, K., Osorio, F.L., Patel, V., Pence, B.W., Persoons, P., Picardi, A., Reuter, K., Rooney, A.G., Santos, I.S., Shaaban, J.,
Sidebottom, A., Simning, A., Stafford, M.D., Sung, S., Tan, P.L.L., Turner, A., van Weert, H.C., White, J., Whooley, M.A., Winkley, K., Yamada, M.,
Benedetti, A., Thombs, B.D., 2019. Equivalency of the diagnostic accuracy of the PHQ-8 and PHQ-9: a systematic review and individual
participant data meta-analysis. Psychol Med, 1-13.

Wulsin, L., Somoza, E., Heck, J., 2002. The feasibility of using the Spanish PHQ-9 to screen for depression in primary care in Honduras. Primary
Care Companion to the Journal of Clinical Psychiatry 4, 191-195.

Yeung, A., Fung, F., Yu, S.C., Vorono, S., Ly, M., Wu, S., Fava, M., 2008. Validation of the Patient Health Questionnaire-9 for depression screening
among Chinese Americans. Comprehensive Psychiatry 49, 211-217.

Zuithoff, N.P., Vergouwe, Y., King, M., Nazareth, I., van Wezep, M.J., Moons, K.G., Geerlings, M.I., 2010. The Patient Health Questionnaire-9 for
detection of major depressive disorder in primary care: consequences of current thresholds in a crosssectional study. BMC family practice 11, 98.

Table 1. Characteristics of included studies and populations

Reference Country Time Sample Age Sex Other Demographic Data Study Design Quality
Size (mean±SD (♀) Score
or range)

1.1. Studies carried out in high-income economies (GNI per capita ≥ $12,376$ )
Table 1. Characteristics of included studies and populations

Reference Country Time Sample Age Sex Other Demographic Data Study Design Quality
Size (mean±SD (♀) Score
or range)

Aalsma, M. USA 2014- 2038 14±2 53% Main ethnicity/language group: Afro-American Prospective cohort 18/31
C., 2018 2015 (60%) study
Public Insurance coverage: 53.2%

Ahmad, F., Canada 2014 75 36.5±12.7 65% Main ethnicity/language group: Latin America Cross-sectional 19/31
2016 (32.0%)
Unemployment: 49%

Ballou, J., USA 150 >17 Abstract of a

2016 prospective cross-
sectional study

Becker, S., Saudi Arabia 2000- 431 18-80 54% Higher than Primary Education: 11.4% Cross-sectional 16/31
2002 2001

Bhatta, S., USA 2017 144 14.8±13.4 58% Main ethnicity/language group: Hispanic (93%) Cross-sectional 15/31
2018 Public Insurance coverage: 69.1%

Carey, M., Australia 2010- 1004 52.4±18.3 61% Higher than Primary Education: 70.3% Cross-sectional 20/31
2014 2014 Public Insurance coverage: 21.7%

Chen, T. M., USA 2003 3417 43.16±14.79 55% Main ethnicity/language group: Chinese (98.6%) Cross-sectional 17/31
2006 Public Insurance coverage: 69.6%
Table 1. Characteristics of included studies and populations

Reference Country Time Sample Age Sex Other Demographic Data Study Design Quality
Size (mean±SD (♀) Score
or range)

Chen, I. P., Taiwan 2009- 634 >18 59% Higher than Primary Education: 37% Cross-sectional 26/31
2016 2012 Unemployment: 36%

Cheng, C. Hong Kong 2004 357 18-90 59% Multi-center cross- 18/31
M., 2007 SAR, China sectional

Fogarty, C. USA 2001- 367 18-44 61% Main ethnicity/language group: Afro-American Cross-sectional 17/31
T., 2008 2002 (68.8%) (46.8%)
Higher than Primary Education: 83.4%

Gilbody, S., UK 2006 96 42.5±13.6 77% Cross-sectional 23/31

2007

Harriss, L. Australia 2016 199 15-25 35% Cross-sectional 14/31

R., 2018

Hong, C. L. Singapore 2011 400 21-65 65% Main ethnicity/language group: Chinese (52%) Cross-sectional 14/31
C. 2018 Higher than Primary Education: 92.7%
Unemployment 18.8%

Husain, N., UK 2006 218 16-64 Cross-sectional 14/31

2007

Inagaki, M., Japan 2010 511 21-102 59% Cross-sectional 23/31

2013
Table 1. Characteristics of included studies and populations

Reference Country Time Sample Age Sex Other Demographic Data Study Design Quality
Size (mean±SD (♀) Score
or range)

Karekla, M., Cyprus 2010 520 21.67±4.94 74% Cross-sectional 19/31

2012

Kroenke, K., USA 1997- 3000 >18 66% Main ethnicity/language group: Caucasian (79%) Cross-sectional 24/31
2001 1998 Higher than Primary Education: 87%

Kujawska- Poland 2005- 93 >65 63% Cross-sectional. 14/31

Danecka, H, 2007
2016

Liu, S. I., Taiwan 2007- 1532 >18 61% Cross-sectional 25/31

2011 2008

Löwe, B., Germany 2000- 1619 41.7±13.8 67% Cross-sectional 26/31

2004 2001

Muñoz- Spain 2014 260 18-65 71% Higher than Primary Education: 61.1% Cross-sectional
Navarro, R., Unemployment: 43.4%
2017

Muramatsu, Japan 2001- 131 43.4±16.4 60% Cross-sectional 17/31

K., 2007 2002

Pilowsky, D. USA 1998- 2043 51.7±12.3 76% Main ethnicity/language group: Hispanic Cross-sectional 14/31
J., 2006 2003 (78.6%)
Table 1. Characteristics of included studies and populations

Reference Country Time Sample Age Sex Other Demographic Data Study Design Quality
Size (mean±SD (♀) Score
or range)

Higher than Primary Education: 61.1%

Unemployment: 16.6%

Rancans, E., Latvia 2014- 1467 53.57±29.97 69% Higher than Primary Education: 84.6% Cross-sectional 24/31
2018 2017

Richardson, USA 2007- 442 13-17 Main ethnicity/language group: Caucasian (71%) Cross-sectional 17/31
L.P., 2010 2008

Spitzer, R. USA 1997- 3000 46±17.2 66% Main ethnicity/language group: Caucasian (79%) Cross-sectional 25/31
L., 1999 1998

Sung, S. C., Singapore 2011 400 36±10.5 65% Main ethnicity/language group: Chinese (52%) Cross-sectional 21/31
2013 Higher than Primary Education: 96%
Unemployment: 18.8%

Vrublevska, Latvia 2014 324 >18 66% Main ethnicity/language group: Latvian 60% Cross-sectional 20/31
J., 2017 Higher than Primary Education: 85.2%

Yeung, A., USA 2004- 1940 50±17 79% Cross-sectional 18/31

2008 2005

Zuithoff, Netherlands 2003- 1338 51±17 63% Cross-sectional 22/31

N.P., 2010 2004
Table 1. Characteristics of included studies and populations

Reference Country Time Sample Age Sex Other Demographic Data Study Design Quality
Size (mean±SD (♀) Score
or range)

1.2. Studies carried out in upper middle-income economies (GNI per capita: $3,996 - $12,375$)

Azah, N., Malaysia 2001- 265 18-79 62% Cross-sectional 16/31

2005 2003

Chen, S., China 2008 364 >60 57% Higher than Primary Education: 45.8% Cross-sectional 18/31
2010

Chen, S., China 2009- 2639 44.8±13.2 56% Higher than Primary Education: 83.6% Multi-center, cross- 20/31
2013 2010 Unemployment: 37.1% sectional

Lotrakul, Thailand 2006- 924 45±14.3 74% Higher than Primary Education: 37.7% Cross-sectional 19/31
M., 2008 2007

Sherina, M. Malaysia 2009- 895 18-81 100% Cross-sectional 17/31

S., 2012 2010

1.3. Studies carried out in lower middle-income economies (GNI per capita: $1,026 - $3,995$)
Table 1. Characteristics of included studies and populations

Reference Country Time Sample Age Sex Other Demographic Data Study Design Quality
Size (mean±SD (♀) Score
or range)

Chowdhury, India 200 37±11 >50% Cross-sectional 15/31

A. N., 2004

Ganguly, S., India 233 14-18 46% Cross-sectional 20/31

2013

Indu, P. S., India 238 18-60 100% Higher than Primary Education: 80.8% Cross-sectional 17/31
2018

Wulsin, L., Honduras 2001 199 32.30 100% 14/31

2002

1.4. Studies carried out in low income economies (GNI per capita≤ $1,025$) Cross-sectional

Gelaye, B., Ethiopia 2011 926 61% Higher than Primary Education: 56.8% Cross-sectional 15/31
2013

Hanlon, C., Ethiopia 2013 306 32.27±16.34 62% Residence: Urban (63.3%), Rural (36.7%) Prospective, Focus 21/31
2015 Higher than Primary Education: 56.9% group, Cross-
Unemployment 3.9% sectional

Kohrt, B.A., Nepal 2013 125 >18 50% Higher than Primary Education: 39% 17/31
2016
Table 1. Characteristics of included studies and populations

Reference Country Time Sample Age Sex Other Demographic Data Study Design Quality
Size (mean±SD (♀) Score
or range)
$
World Bank Classification, 2018-2019
Table 2. Characteristics of PHQ-9 screening in included studies.

Reference Setting Administration Language Study Stages Highlights

2.1. Studies carried out in adolescent populations (age: 12-17)

Aalsma, M. C., Electronic Medical Electronic Self- English 1) Recruitment in waiting room Implementing a
2018 Records (EMR) from report 2) Pre-screening: PHQ-2 depression screening
pediatric primary care 3) PHQ-9 filled out, only if positive PHQ-2 algorithm within an
clinics -Automatic computerized scoring existing Computer
4) PCP prompts and automatic feedback on his Decision Support
indications System is feasible.
Need to mechanisms
to ensure adolescent
self-report.
Organizational factors
must be studied.

Bhatta, S., Pediatric school- Self-report English 1) Formal education training of clinic staff Improved awareness
2018 based primary care 2) PHQ-9 filled out in a private exam room of adolescents about
clinic 3) Weekly documentation of staff compliance depression and
4) Post-implementation retrospective chart mental health status.
review Human and
5) Screening protocol included a diagram of Organizational factors
interventions. can affect the
screening efficiency.
Electronic
Table 2. Characteristics of PHQ-9 screening in included studies.

Reference Setting Administration Language Study Stages Highlights

implementation may
be desirable.
Episodic illness may
have been
confounding factors.

Ganguly, S., Four English medium Self-report English 1) PHQ-9 and other scales filled out PHQ-9 may provide a
2013 schools 2) PCP results analysis and clinical interview measure of
depression severity.

Richardson, Private insurance Phone interview English 1) Sending of invitation letter PHQ-9 does not
L.P., 2010 healthcare facilities 2) Screening phone interview with PHQ-2/PHQ-9 investigate irritability,
3) Diagnostic phone interview on a subset of which is included in
patients DSM-IV criteria for
depression in youth.

2.2. Studies carried out in adult and elderly populations (age: ≥18)
Table 2. Characteristics of PHQ-9 screening in included studies.

Reference Setting Administration Language Study Stages Highlights

Ahmad, F., Community health Digital English 1) PHQ-9 administered in waiting rooms High rates of probable
2016 centres Self-report Spanish depression justify a
2) Scoring systematic
assessment in primary
care and readiness to
case management.
E-health-mediated
assessments enhance
the screening capacity
of primary care clinics.

Azah, N., 2005 Family clinic Self-report Malay 1) PHQ-9 filled out in waiting room Socio-cultural
2) PHQ review and scoring differences, education
3) MHP diagnostic interview of all positive cases level and need of
and a subset of negative cases guidance in
4) Follow up of positive cases completing the
questionnaire may
affect the result.
Classification of
depression is different
between CIDI (ICD-10)
and PHQ-9 (DMS-IV).
Table 2. Characteristics of PHQ-9 screening in included studies.

Reference Setting Administration Language Study Stages Highlights

Ballou, J., 2016 Independent, Self-report (2/3) English 1) PHQ-9 administration PHQ-9 administration
community pharmacy Interview (1/3) 2) Pharmacist's score interpretation and can be implemented
counselling in a community
3) Positive cases referred to their primary care pharmacy workflow
provider and increases access
-Emergency protocol for urgent/emergent crises to care.

Becker, S., Primary care hospital- Self-report Arabic 1) PHQ-9 filled out Prevalence of
2002 based outpatient 2) PCP visit depressive disorder is
clinic 3) MHP diagnostic interview on a subset of similar in developing
patients and developed
countries.

Carey, M., 12 general practices Electronic self- English 1) PHQ-9 filled out at reception
2014 report

Chen, T. M., Community Health Self-report unless English 1) Staff training PHQ may measure
2006 Centre difficulty with Chinese 2)Pre-screening: three-item questionnaire depression severity
reading 3)PHQ-9 interview of positive pre-screening and monitor
patients by nurses. treatment progress.
4) Primary care physician's diagnosis
confirmation and treatment discussion.
Table 2. Characteristics of PHQ-9 screening in included studies.

Reference Setting Administration Language Study Stages Highlights

Chen, S., 2010 Primary care clinics Self-report Chinese 1) Nurse-assisted PHQ-9 administration Straightforward
2) MHP interview of eligible subjects administration.
-Emergency measures for severe depression and Minimal training time.
suicidal ideation High subject
acceptance.
Urban samples may
not be representative
of rural population.

Chen, S., 2013 100 primary care Self-report Chinese 1) Random selection of Primary Care Clinics Urban primary care
clinics 2) Nurse training settings are not
3) Screening: PHQ-9 representative of
4) Diagnostic interview on 10% Pts in 10% PCCs rural areas.

Chen, I. P., Primary care and Self-report Chinese 1) Recruitment in waiting room Psychometric
2016 hospital-based 2) PHQ-9 filled out measures need to be
outpatient clinics 3) Research staff diagnostic interview validated according to
different cultural and
age contexts.
This should be
emphasized when
relating to a specific
cutoff score.
Table 2. Characteristics of PHQ-9 screening in included studies.

Reference Setting Administration Language Study Stages Highlights

Cheng, C. M., 14 general practices Self-report Chinese 1) MHP training of PCPs Two-stage screening
2007 2) PHQ-9 filled out proposed: PHQ-2 ->
3) PCP diagnostic interview PHQ-9.
-MHP available for support

Chowdhury, A. A general hospital Self-report Bengali 1) PHQ-9 filled out Training of physician
N., 2004 and an outdoor clinic 2) MHP diagnostic interview would require little
time.

Fogarty, C. T., Urban family Self-report or English 1) PHQ-9 filled out in waiting rooms Mental health
2008 medicine practices assisted disorders were
2) Data analysed associated with
increases in primary
care visits.

Gelaye, B., Outpatient General Interview Ethiopian 1) Nurse PHQ-9 interview Educational level may
2013 Hospital 2) MHP diagnostic interview affect the accuracy of
PHQ-9.
It would be useful to
determine the
minimal clinical
modifying factors for
PHQ-9.
Table 2. Characteristics of PHQ-9 screening in included studies.

Reference Setting Administration Language Study Stages Highlights

Gilbody, S., Primary care setting Self-report English 1) PHQ-9 and other scales filled out
2007 2) Trained researcher diagnostic interview

Hanlon, C., Urban, semi-urban Interview Amharic 1) Data-collector PHQ-9 interview Cut-off may not be
2015 and rural primary 2) MHP diagnostic interview the same in low
health care facilities income countries as in
high income
countries.

Harriss, L. R., Annual Young Staff-assisted Adapted for 1) PHQ-9 filled out Little available
2018 Person's Health self-report Aboriginal 2) Referral of positive cases (cutoff >10) and information about
Check communities identification of self-harm identification to an prevalence of
onsite physician depression in checked
communities.

Hong, C. L. C. Private primary care Self-report English 1) Recruitment in waiting room PCPs should be
2018 clinic 2) PHQ-9 filled out adequately trained in
3) MHP diagnostic interview diagnosis and
treatment of
depression.
Table 2. Characteristics of PHQ-9 screening in included studies.

Reference Setting Administration Language Study Stages Highlights

Husain, N., General Practice Self-report or staff English 1) PHQ-9 filled out in waiting room
2007 assisted as needed Urdu 2) Diagnostic interview

Inagaki, M., Outpatient clinic Self-report Japanese 1) PHQ-9 filled out Stigma and
2013 within a rural hospital 2) Psychiatric interview prevalence of somatic
symptoms may lead
to underestimation of
depressive disorder.

Indu, P. S., Primary health center Staff-assisted Malayalam 1) PHQ-9 filled out Different settings may
2018 2) MHP interview need different cut-off
points.

Karekla, M., University clinic Self-report Greek

2012

Kohrt, B.A., Primary care rural Interview Nepali 1) Researcher screening interview: local idiom of Combination of local
2016 facilities distress, PHQ-9 idiom analysis
2) MHP diagnostic interview reduced PHQ-9
completion by 50%.
Questionnaires
developed in high
income countries
Table 2. Characteristics of PHQ-9 screening in included studies.

Reference Setting Administration Language Study Stages Highlights

have limited
application for
population with low
literacy.

Kroenke, K., General Internal Self-report English 1) PHQ-9 filled out in waiting room Using PHQ as a
2001 Medicine and Primary 2) MHP diagnostic phone interview severity measure
Care Clinics need a deep analysis
of its sensitivity to
change. This requires
longitudinal studies.

Kujawska- Rural cardiovascular Polish Patients willing to

Danecka, H, prevention campaign participate to
2016 screening could be
the ones who care
most about their
health.

Liu, S. I., 2011 Community-based Self-report Chinese 1) PHQ-9 filled out in waiting room
primary care facilities 2) Researcher diagnostic interview
Table 2. Characteristics of PHQ-9 screening in included studies.

Reference Setting Administration Language Study Stages Highlights

Lotrakul, M., Primary care hospital Self-report Thai 1) PHQ-9 filled out in waiting room Screening without
2008 2) Researcher diagnostic interview clear care protocols is
not effective and can
increase the burden
on GPs.
Need to consider
financial and
institutional
constraints.

Löwe, B., 2004 Outpatient clinics and Self-report German 1) PHQ-9 filled out A two-stage approach
General Practices 2) Diagnostic interview on a subset of is desirable for clinical
participants use, whereas a one-
stage is more fit for
research and
epidemiological
studies.

Muñoz- Primary care clinics Self-report or Spanish 1) Individual meeting for PHQ-9 Patients diagnosed
Navarro, R., assisted completion with depression need
2017 to be referred to
2) Diagnostic interview scheduled within specialists promptly.
two weeks
Table 2. Characteristics of PHQ-9 screening in included studies.

Reference Setting Administration Language Study Stages Highlights

Muramatsu, K., Primary care facilities Self-report Japanese 1) PHQ-9 filled out at home and returned to PCP Validity and utility like
2007 and a General in 48 hours that in other
Hospital 2) Researcher diagnostic interview countries.

Pilowsky, D. J., Primary care practice Interview English 1) PHQ-9 screening interview in waiting room Using PHQ as an
2006 Spanish 2) MHP Diagnostic interview interview rather than
a screening
instrument may have
affected the results.

Rancans, E., Primary care clinics Self-report Latvian 1) PHQ-9 administrated in waiting rooms Established cut-off
2018 Russian 2) Interview with socio-demographic scores and risk factors
questionnaire for depression should
3) Diagnostic interview within two weeks be taken into account.

Sherina, M. S., Primary care clinic Self-report Malay 1) PHQ-9 filled out in waiting room -supervision
2012 of research assistant
2) Diagnostic interview on a weighted sample of
participants
Table 2. Characteristics of PHQ-9 screening in included studies.

Reference Setting Administration Language Study Stages Highlights

Spitzer, R. L., 5 general internal Self-report English 1) PHQ-9 filled out in waiting room
1999 medicines and 3 2) PCP clinical examination and score review
family practices 3) Questionnaire filled out about PHQ-9
perceived value (Pts.) and impact on decision
making (PCP)
4) MHP diagnostic interview

Sung, S. C., Peace Family Clinic Self-report Chinese 1) PHQ-9 filled out in waiting room The optimal cut-off
2013 Indian 2) PCP diagnostic interview was lower than other
Malay -Supervision of a senior MHP studies and did not
allow to distinguish
between major and
minor depression.

Vrublevska, J., Primary care facility Self-report Latvian 1) PHQ-9 filled out in waiting room Larger and
2017 Russian -MHP available for support longitudinal studies
2) MHP diagnostic interview are needed to confirm
the effectiveness of
screening.

Wulsin, L., 5 rural clinics Interview Spanish 1) PHQ-9 interview by PCPs and medical
2002 students
2) Diagnostic interview on a weighted sample
Table 2. Characteristics of PHQ-9 screening in included studies.

Reference Setting Administration Language Study Stages Highlights

Yeung, A., 2008 Community Health Self-report Chinese 1) PHQ-9 filled out in waiting room PHQ-9 functions well
Centre English 2) MHP telephonic interpretation of results in trans-cultural
3) MHP diagnostic interview settings.

Zuithoff, N.P., 7 general practices Self-report Dutch 1) PHQ-9 filled out at home and returned to PCP PHQ-9 scores were
2010 by mail consistent with
2) MHP diagnostic interview functional status, sick
days, number of GP
consultations.

MHP: Mental Health Professional; GP: General Practitioner; PCP: Primary Care Physician; PHQ-9: 9-item Patient Health Questionnaire.
Table 3. Operating Characteristics of PHQ-9 against
reference diagnostic interviews.

Refer Study Samp Diag Cut Sensitivit Specificit PPV NPV LR( LR
ence Desig le nosti - y y n, 95% n, 95% CI +)$ (-
n Size c off n, 95% CI n, 95% CI CI )$
Inter
view

3.1 Studies performing a fully structured diagnostic interview,

divided by interview

Hanlo Cross- 306 MINI 5 0. 0. 0. 0.9 3. 0.2

n, C., sectio 8 7 1 9 32 3
2015 nal 3 5 7

Hong, Cross- 400 MINI 6 0. 0. 0. 1 3. 0.1

C. L. sectio 9 7 0 29 1
C. nal 2 2 9
2018

Inaga Cross- 511 MINI 10 0. 0. 0. 0.9 45 0.5

ki, M., sectio 4 9 7 6 .0 6
2013 nal 5 9 2 0

5 0. 0. 0. 0.9 5. 0.1
8 8 3 9 73 6
6 5 2

Indu, Cross- 238 MINI 9 0. 0.72 0. 0.85 0. 0.6 0.9 0.90 8. 0.1
P. S., sectio 8 - 9 - 7 2- 4 - 30 9
2018 nal 3 0.93 0 0.96 3 0.8 0.98
4
Table 3. Operating Characteristics of PHQ-9 against
reference diagnostic interviews.

Refer Study Samp Diag Cut Sensitivit Specificit PPV NPV LR( LR
ence Desig le nosti - y y n, 95% n, 95% CI +)$ (-
n Size c off n, 95% CI n, 95% CI CI )$
Inter
view

Lotrak Cross- 279% MINI 10 0. 0. 0. 0.9 4. 0.3

ul, sectio 7 8 2 8 93 1
M., nal 4 5 7
2008
9 0. 0. 0. 0.9 3. 0.2
8 7 2 9 65 1
4 7 1

Mura Cross- 131 MINI 10 0. 0. 0. 0.9 16 0.1

matsu sectio -Plus 8 9 8 4 .8 7
, K., nal 4 5 7 0
2007

Ranca Cross- 1467 MINI 10

ns, E., sectio Latv 6 9 6. 0.4
ian: Latvia
2018 nal 0. 1. n:
84 3
Rus
sian
8 1 Russi 6. 0.3
: 6 8 an: 59 6
7. 9.
7 7

Sung, Cross- 400 MINI 6 0. 0. 0. 1 3. 0.1

S. C., sectio 9 7 9 29 1
2013 nal 2 2 2
Table 3. Operating Characteristics of PHQ-9 against
reference diagnostic interviews.

Refer Study Samp Diag Cut Sensitivit Specificit PPV NPV LR( LR
ence Desig le nosti - y y n, 95% n, 95% CI +)$ (-
n Size c off n, 95% CI n, 95% CI CI )$
Inter
view

Vrubl Cross- 272% MINI 10 0. 0. 7. 0.1

evska, sectio 8 8 82 6
J., nal 6 9
2017
8 0. 0. 3. 0.0
9 7 88 4
7 5

Azah, Cross- 265 CIDI 9 0. 0. 0. 2. 0.7

N., sectio depr 3 8 7 85 2
2005 nal essio 9 3 3
n of
any 10 0. 0. 0. 3. 0.4
sever 3 8 7 21 8
7 7 7
ity

CIDI 9 0. 0. 0. 2. 0.7
sever 6 7 3 29 3
e 3 8 5
depr
essio 10 0. 0. 0. 2. 0.7
6 8 3 85 2
n
1 1 8
Table 3. Operating Characteristics of PHQ-9 against
reference diagnostic interviews.

Refer Study Samp Diag Cut Sensitivit Specificit PPV NPV LR( LR
ence Desig le nosti - y y n, 95% n, 95% CI +)$ (-
n Size c off n, 95% CI n, 95% CI CI )$
Inter
view

Kohrt, Cross- 125 CIDI 10 0. 0. 0. 0.9 4. 0.0

B.A., sectio 9 8 4 9 70 8
2016 nal 4 2

Sheri Prosp 895 CIDI 10 0. 0.71 0. 0. 0.9 4. 0.1

na, ective 8 - 8 0.74 1 9 83 6
M. S., Cross- 7 0.95 2 - 5
2012 sectio 0.88
nal

Zuith Cross- 1338 CIDI 10 0. 0.42 0. 0.94 0. 0.5 0.9 0.92 9. 0.5
off, sectio 4 - 9 - 5 1- 3 - 80 4
N.P., nal 9 0.56 5 0.96 9 0.6 0.94
2010 7

5 0. 0.81 0. 0.73 0. 0.3- 0.9 0.96 3. 0.1

8 - 7 - 3 0.3 7 - 44 9
6 0.91 5 0.77 4 8 0.98

3.2 Studies performing a semi-structured diagnostic

interview, divided by interview

Becke Cross- 173% SCID- 0. 0. 12 0.4

r, S., sectio R 6 9 .4 0
Table 3. Operating Characteristics of PHQ-9 against
reference diagnostic interviews.

Refer Study Samp Diag Cut Sensitivit Specificit PPV NPV LR( LR
ence Desig le nosti - y y n, 95% n, 95% CI +)$ (-
n Size c off n, 95% CI n, 95% CI CI )$
Inter
view

2002 nal 2 5 0

Chen, Cross- 77% SCID 10 0. 0. 6. 0.2

S., sectio 7 8 82 8
2010 nal 5 9

8 0. 0. 4. 0.1
9 8 50 3

Chen, Multi- 280% SCID 10 0. 0. 4. 0.1

S., center 8 8 58 6
2013 , 7 1
cross-
sectio 9 0. 0. 3. 0.0
9 7 80 7
nal
5 5

Gilbo Cross- 96 SCID 10 0. 0. 4. 0.1

dy, S., sectio 9 7 18 0
2007 nal 2 8

Kroen Cross- 580% SCID 10 0. 0. 0. 0.9 7. 0.1

ke, K., sectio 8 8 3 9 33 4
2001 nal 8 8 5
Table 3. Operating Characteristics of PHQ-9 against
reference diagnostic interviews.

Refer Study Samp Diag Cut Sensitivit Specificit PPV NPV LR( LR
ence Desig le nosti - y y n, 95% n, 95% CI +)$ (-
n Size c off n, 95% CI n, 95% CI CI )$
Inter
view

Löwe, Cross- 501% SCID 11 0. 0.92 0. 0.76 4. 0.0

B., sectio 9 - 8 - 90 3
2004 nal 8 1.00 0.83

Muño Cross- 178% SCID- 10 0. 0.89 0. 0.53 0. 0.8 2. 0.0

z- sectio I 9 - 6 - 8 3 90 8
Navar nal 5 0.97 7 0.79 8
ro, R.,
2017

Spitze Cross- 585% SCID 10 0. 0.59 0. 0.96 36 0.2

r, R. sectio 7 - 9 - .5 8
L., nal 3 0.87 8 1.00 0
1999

Wulsi Cross- 199 SCID 10 0. 0. 1 0.8 77 0.2

n, L., sectio 7 9 * 8* .0 3
2002 nal 7 9 * * 0

Yeung Cross- 184% CB- 15 0. 0. 0. 0.9 40 0.1

, A., sectio SCID- 8 9 9 5 .5 9
2008 nal I/P 1 8 2 0

Chen, Cross- 634 SCAN 10 0. 0. 2 99. 19 0.2

I. P., sectio 7 9 8. 5 .7 2
Table 3. Operating Characteristics of PHQ-9 against
reference diagnostic interviews.

Refer Study Samp Diag Cut Sensitivit Specificit PPV NPV LR( LR
ence Desig le nosti - y y n, 95% n, 95% CI +)$ (-
n Size c off n, 95% CI n, 95% CI CI )$
Inter
view

2016 nal 9 6 2 5

6 1 0. 6. 0.0
8 67 0
5

Gelay Cross- 363% SCAN 10 0. 0.78 0. 0.61 0. 0.4 0.9 0.89 2. 0.2
e, B., sectio 8 - 6 - 4 0- 3 - 61 1
2013 nal 6 0.92 7 0.73 8 0.5 0.96
6

11 0. 0.7- 0. 0.53 0. 0.4 0.8 0.85 3. 0.2

7 0.87 7 5 5- 9 - 04 8
9 4 4 0.6 0.93
3

Liu, S. Cross- 1532 SCAN 10 0. 0. 14 0.1

I., sectio 8 9 .3 5
2011 nal 6 4 3

3.3 Studies performing other

diagnostic interviews

Cheng Multi- 357 CHDS 10 0. 0. 4 98 10 0.2

, C. center 8 9 8 .0 2
Table 3. Operating Characteristics of PHQ-9 against
reference diagnostic interviews.

Refer Study Samp Diag Cut Sensitivit Specificit PPV NPV LR( LR
ence Desig le nosti - y y n, 95% n, 95% CI +)$ (-
n Size c off n, 95% CI n, 95% CI CI )$
Inter
view

M., cross- 2 0
2007 sectio
nal

Chow Cross- 200 DSM- 10 0. 0. 0. 0.9 1. 0.0

dhury sectio IV 9 4 3 8 69 5
, A. nal criter 8 2 7
N., ia
13 0. 0. 0. 0.9 2. 0.1
2004
9 6 4 6 79 2
2 7 9

Gang Cross- 233 ICD- 10 0. 0.41 0. 0.94 0. 0.9 29 0.4

uly, sectio 10 5 - 9 - 7 4 .0 3
S., nal Code 8 0.74 8 0.99 8 0
2013 s
5 0. 0.71 0. 0.74 0. 0.9 4. 0.1
8 - 8 - 4 8 35 6
7 0.95 0.85

Husai Cross- 218 PAS 7 0. 0. 0. 0.8 6. 0.3

n, N., sectio 7 8 8 1 54 4
2007 nal 0 9 3

Richar Cross- 442 DISC- 10 0. 0. 0. 0.9 3. 0.1

dson, sectio IV 9 7 1 9 21 4
Table 3. Operating Characteristics of PHQ-9 against
reference diagnostic interviews.

Refer Study Samp Diag Cut Sensitivit Specificit PPV NPV LR( LR
ence Desig le nosti - y y n, 95% n, 95% CI +)$ (-
n Size c off n, 95% CI n, 95% CI CI )$
Inter
view

L.P., nal 2 3
2010

11 0. 0. 4. 0.1
9 7 09 3
8
$
: Measures were added by reviewers, based on available data.
%
: Diagnostic interviews were carried out in a weighted subset of patients. For whole sample size,
see Table 1.
CHDS: Chinese Hamilton Depression Scale - CIDI: Composite International Diagnostic Interview -
DISC-IV: Diagnostic International Schedule for Children - DSM-IV: 4th edition of Diagnostic Statistical
Manual of Psychiatric Disorders - ICD-10: 10th edition of International Classification of Diseases -
LR(+): Positive Likelihood Ratio - LR(-): Negative Likelihood Ratio - MINI: Mini-International
Neuropsychiatric Interview - NPV: Negative Predictive Value - PAS: Psychiatric Assessment Schedule
- PPV: Positive Predictive Value - SCAN: Structured Clinical Assessment in Neuropsychiatry - SCID:
Structured Clinical Interview for DSM-IV.
FIGURES

Figure 1. Flow diagram of selected articles.

[insert
Fig.1 here]
$
Search strategy limited from January 1st, 1995 to October 31st, 2018, English language,

human subjects older than 12.