Validity and Reliability of the Arabic Version of the Patient Health Questionnaire-9 (PHQ-9) in Patients with Heart Failure (HF) in Lebanon

Abstract

Background: Depression has been recognized as a common comorbidity in heart failure (HF). The significant presence of depression has been associated with increased mortality among patients with HF (Fan et al., 2014). Depression screening is now recommended by the European Society of Cardiology and the Italian Geriatric Cardiology Society's HF guidelines. The use of self-reported screening tools for patients is a major method of examining for depression. The Patient Health Questionnaire-9 (PHQ-9) is one of the most commonly used and approved self-reporting questionnaires for screening patients for depression. The PHQ-9 has been clinically validated in the HF population, making it an increasingly relevant clinical and research tool. The PHQ-9 was translated to Arabic and used to screen for depression in a Saudi community sample and in Lebanese cardiac patients. However, no research validating the properties of the Arabic PHQ-9 in cardiac patients has been reported in Lebanon.

Study aim: The overall aim of this study was to examine the psychometric properties and cultural validity of an Arabic version of the PHQ-9 as a depression screening tool in HF patients in Lebanon.

Design: This is a secondary data analysis. The study used interview data collected in two studies. The first study used an observational cross-sectional design to evaluate the psychometric properties of the Minnesota Living with Heart Failure questionnaire in Lebanese patients with HF. The second study used a correlational descriptive design to describe self-care behaviors and their determinants in a sample of Lebanese patients with HF.

Sample: The current study sample included a total of 208 patients who were included in the two studies described above.

Procedure: IRB approval was secured. The two data sets were then de-identified and merged. Statistical analysis included the calculation of the Cronbach’s alpha coefficient. Two experts in cardiology and one patient were asked to evaluate the cultural appropriateness of the Arabic version of the PHQ-9 in the Lebanese population and its relevance to depression by rating each item on a 4-point scale, and an index was calculated for each item of the PHQ-9 and the overall scale. We also compared patients with different New York Heart Association (NYHA) classes on their PHQ-9 scores using an ANOVA test to test the hypothesis that patients with a higher NYHA class will have higher depression scores. Furthermore, the Pearson correlation coefficient was used to evaluate the association between the PHQ-2 (a short version of the PHQ-9) and PHQ-9 scores. Since socioeconomic status and educational attainment have been linked to depression, ANOVA was used to compare PHQ-9 means across different groups of education and income, in addition to the t-test to compare PHQ-9 means by gender and comorbidity status.

Results: Out of the 208 patients, 37 (17.78%) were positively screened for depression by PHQ-9 at a cutoff ≥ 10. The psychometric assessment of the PHQ-9 showed acceptable internal consistency (Cronbach’s alpha = 0.823). Two experts and a HF patient evaluated the Arabic version of the PHQ-9 in the Lebanese population to be culturally appropriate, overall. The Exploratory Factor Analysis yielded two factors: psychosomatic and cognitive. Furthermore, there were significant differences in PHQ-9 categories by NYHA class. The questionnaire was found to be reliable and valid, with potential for minor adjustments for cultural appropriateness.

Conclusion: These results can inform the implementation of depression screening in HF clinics in Lebanon, with advanced practice nurses using the Arabic PHQ-9 to assess patients, refer them to psychiatry when needed, and monitor their response to treatment over time.