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Open Access 01-12-2020 | Generalised Anxiety Disorder | Research article

Are comparisons of mental disorders between Chinese and German students possible? An examination of measurement invariance for the PHQ-15, PHQ-9 and GAD-7

Authors: Yan Zhou, Jing Xu, Winfried Rief

Published in: BMC Psychiatry | Issue 1/2020

Abstract

Background

The Patient Health Questionnaire (PHQ) is one of the most commonly used instruments to assess mental disorders. However, research on its cross-cultural measurement invariance is not yet sufficient. This study examined the measurement invariance of the Chinese and German versions of the PHQ’s somatic symptom severity scale (PHQ-15), depressive symptom severity scale (PHQ-9) and seven-item Generalized Anxiety Disorder (GAD-7) scale as a prerequisite for their use in cross-cultural comparisons.

Methods

We used online data collected from groups of Chinese students in China (n = 413) and German students in Germany (n = 416). Separate measurement models for each group were examined using confirmatory factor analysis and measurement invariance testing was conducted to test the cross-cultural equivalence.

Results

Findings demonstrated that the PHQ-9 and GAD-7 had partial scalar measurement invariance, but the cross-cultural measurement invariance of the PHQ-15 could not be confirmed. Comparisons of latent means did not indicate differences in the levels of depression and anxiety symptoms between Chinese and German samples.

Conclusion

The PHQ-9 and GAD-7 can be used in cross-cultural comparison of prevalence, but the intercultural use of PHQ-15 is more problematic. Findings are discussed from intercultural and methodological perspectives.

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“Since the demographic data of the two samples was significantly different, propensity score matching (by gender and age) was performed to exclude the test effect of gender and age for the purpose of data analysis. However, the results did not differ from those obtained prior to performing the propensity score matching test. The results of the comparison between the underlying structure and the invariant items of the scales remained unchanged. Therefore, we presented the results without conducting propensity score matching, owing to the large sample size” [43].

Partial measurement invariance is declared when at least two items per latent variable (i.e., factor loadings, factor intercepts) are found to be invariant [29].

Bromet E, Andrade LH, Hwang I, et al. Cross-national epidemiology of DSM-IV major depressive episode. BMC Med. 2011;9. https://doi.org/10.1186/1741-7015-9-90.

Demyttenaere K, Bruffaerts R, Posada-Villa J, et al. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization world mental health surveys. J Am Med Assoc. 2004;291(21):2581–90. https://doi.org/10.1001/jama.291.21.2581.CrossRef

Baxter AJ, Scott KM, Vos T, Whiteford HA. Global prevalence of anxiety disorders: a systematic review and meta-regression. Psychol Med. 2013;43(5):897–910. https://doi.org/10.1017/S003329171200147X.CrossRefPubMed

Ferrari AJ, Somerville AJ, Baxter AJ, et al. Global variation in the prevalence and incidence of major depressive disorder: a systematic review of the epidemiological literature. Psychol Med. 2013;43(3):471–81. https://doi.org/10.1017/S0033291712001511.CrossRefPubMed

Hofmann SG, Asnaani A, Hinton DE. Cultural aspects in social anxiety and social anxiety disorder. Depress Anxiety. 2010;27(12):1117–27. https://doi.org/10.1002/da.20759.CrossRefPubMedPubMedCentral

Khoo EM, Mathers NJ, McCarthy SA, Low WY. Somatisation disorder and its associated factors in multiethnic primary care clinic attenders. Int J Behav Med. 2012;19(2):165–73. https://doi.org/10.1007/s12529-011-9164-7.CrossRefPubMed

Liu L, Bi B, Qin X, et al. The prevalence of somatoform disorders in internal medicine outpatient departments of 23 general hospitals in Shenyang, China. Gen Hosp Psychiatry. 2012;34(4):339–44. https://doi.org/10.1016/j.genhosppsych.2012.02.002.CrossRefPubMed

Huang Y, Wang Y, Wang H, Liu Z, Yu X, Yan J. Prevalence of mental disorders in China: a cross-sectional epidemiological study. Lancet Psychiatry. 2019;6(3):211–24. https://doi.org/10.1016/S2215-0366(18)30511-X.CrossRefPubMed

Jacobi F, Höfler M, Strehle J, et al. Twelve-month prevalence, comorbidity and correlates of mental disorders in Germany: the mental health module of the German health interview and examination survey for adults (DEGS1-MH). Int J Methods Psychiatr Res. 2014;23(3):304–19. https://doi.org/10.1002/mpr.1439.CrossRefPubMedPubMedCentral

10.

Busch MA, Maske UE, Ryl L, Schlack R, Hapke U. Prevalence of depressive symptoms and diagnosed depression among adults in Germany. Results of the German health interview and examination survey for adults (DEGS1). Bundesgesundheitsblatt - Gesundheitsforsch - Gesundheitsschutz. 2013;56(5–6):733–9. https://doi.org/10.1007/s00103-013-1688-3.CrossRef

11.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: Author; 2013.CrossRef

12.

World Health Organization. The ICD-10 classification of mental and Behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; 1992.

13.

Simon GE, Goldberg DP, Von Korff M, Üstün TB. Understanding cross-national differences in depression prevalence. Psychol Med. 2002;32:585–94. https://doi.org/10.1017/s0033291702005457.CrossRefPubMed

14.

Löwe B, Spitzer RL, Zipfel S, Herzog W. PHQ-D Gesundheitsfragebogen Für Patienten: Manual Komplettversion Und Kurzform- Autorisierte Deutsche Version Des Prime MD Patient Health Questionnaire (PHQ). 2nd ed. Heidelberg: Pfizer; 2002.

15.

Online Assessment Measures. https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessment-measures. Accessed July 18, 2020.

16.

Chen S, Chiu H, Xu B, et al. Reliability and validity of the PHQ-9 for screening late-life depression in Chinese primary care. Int J Geriatr Psychiatry. 2010;25(11):1127–33. https://doi.org/10.1002/gps.2442.CrossRefPubMed

17.

Gräfe K, Zipfel S, Herzog W, Löwe B. Screening for psychiatric disorders with the patient health questionnaire (PHQ). Results from the German validation study. Diagnostica. 2004;50:171–81. https://doi.org/10.1026/0012-1924.50.4.171.CrossRef

18.

Lee S, Ma YL, Tsang A. Psychometric properties of the Chinese 15-item patient health questionnaire in the general population of Hong Kong. J Psychosom Res. 2011;71(2):69–73. https://doi.org/10.1016/j.jpsychores.2011.01.016.CrossRefPubMed

19.

Löwe B, Decker O, Müller S, et al. Validation and standardization of the generalized anxiety disorder screener ( GAD-7) in the general population. Med Care. 2008;46(3):266–74. https://doi.org/10.1097/MLR.0b013e318160d093.CrossRefPubMed

20.

Martin A, Rief W, Klaiberg A, Braehler E. Validity of the brief patient health questionnaire mood scale (PHQ-9) in the general population. Gen Hosp Psychiatry. 2006;28(1):71–7. https://doi.org/10.1016/j.genhosppsych.2005.07.003.CrossRefPubMed

21.

Tong X, An D, Mcgonigal A, Park S, Zhou D. Validation of the Generalized Anxiety Disorder-7 ( GAD-7 ) among Chinese people with epilepsy. Epilepsy Res. 2016;120:31–6. https://doi.org/10.1016/j.eplepsyres.2015.11.019.CrossRefPubMed

22.

Zhang L, Fritzsche K, Liu Y, et al. Validation of the Chinese version of the PHQ-15 in a tertiary hospital. BMC Psychiatry. 2016;16(89). https://doi.org/10.1186/s12888-016-0798-5.

23.

Ryder AG, Yang J, Zhu X, et al. The cultural shaping of depression: somatic symptoms in China, psychological symptoms in North America? J Abnorm Psychol. 2008;117(2):300–13. https://doi.org/10.1037/0021-843X.117.2.300.CrossRefPubMed

24.

Chang SM, Hahm B, Lee J, et al. Cross-national difference in the prevalence of depression caused by the diagnostic threshold. J Affect Disord. 2008;106(1–2):159–67. https://doi.org/10.1016/j.jad.2007.07.023.CrossRefPubMed

25.

Bieda A, Hirschfeld G, Schönfeld P, Brailovskaia J, Zhang XC, Margraf J. Universal happiness? Cross-cultural measurement invariance of scales assessing positive mental health. Psychol Assess. 2017;29(4):408–21. https://doi.org/10.1037/pas0000353.CrossRefPubMed

26.

Miller MJ, Sheu HB. Conceptual and measurement issues in multicultural psychology research. In: Brown SD, Lent RW, editors. Handbook of counseling psychology. 4th ed: Wiley; 2008. p. 103–20.

27.

Brown TA. Confirmatory factor analysis for applied research. New York: Guilford; 2006.

28.

Bryne BM, Shavelson RJ, Muthén B. Testing for the equivalence of fator covariance and mean structures : the issue of partial measurement in variance. Psychol Bull. 1989;105(3):456–66. https://doi.org/10.1037/0033-2909.105.3.456.CrossRef

29.

Muthén B, Christoffersson A. Simultaneous factor analysis of dichotomous variables in several groups. Psychometrika. 1981;46(4):407–19.CrossRef

30.

Witthöft M, Fischer S, Jasper F, Rist F. Clarifying the latent structure and correlates of somatic symptom distress: A bifactor model approach. Psychol. Assess. 2016;28(1):109–15. https://doi.org/10.1037/pas0000150.CrossRefPubMed

31.

Mewes R, Christ O, Rief W, Brähler E, Martin A, Glaesmer H. Are depression and somatisation equivalent for migrants and native Germans? An investigation of measurement invariance for the PHQ-9 and PHQ-15. Diagnostica. 2010;56:230–9. https://doi.org/10.1026/0012-1924/a000026.CrossRef

32.

Leonhart R, de Vroege L, Zhang L, et al. Comparison of the factor structure of the Patient Health Questionnaire for somatic symptoms (PHQ-15) in Germany, the Netherlands, and China. A transcultural structural equation modeling (SEM) study. Front. Psychiatry. 2018. https://doi.org/10.3389/fpsyt.2018.00240.

33.

Hirsch O, Donner-Banzhoff N, Bachmann V. Measurement equivalence of four psychological questionnaires in native-born Germans, Russian-speaking immigrants, and native-born Russians. J Transcult Nurs. 2013. https://doi.org/10.1177/1043659613482003.

34.

Keum BT, Miller MJ, Inkelas KK. Testing the factor structure and measurement invariance of the PHQ-9 across racially diverse U.S. college students. Psychol Assess. 2018;30(8):1096–106. https://doi.org/10.1037/pas0000550.CrossRefPubMed

35.

Reich H, Rief W, Brähler E, Mewes R. Cross-cultural validation of the German and Turkish versions of the PHQ-9: an IRT approach. BMC Psychol. 2018;6(26). https://doi.org/10.1186/s40359-018-0238-z.

36.

Baas KD, Cramer AOJ, Koeter MWJ, Van De Lisdonk EH, Van Weert HC, Schene AH. Measurement invariance with respect to ethnicity of the patient health Questionnaire-9 (PHQ-9). J Affect Disord. 2011;129(1–3):229–35. https://doi.org/10.1016/j.jad.2010.08.026.CrossRefPubMed

37.

Galenkamp H, Stronks K, Snijder MB, Derks EM. Measurement invariance testing of the PHQ-9 in a multi-ethnic population in Europe: the HELIUS study. BMC Psychiatry. 2017;17(349). https://doi.org/10.1186/s12888-017-1506-9.

38.

Tibubos AN, Beutel ME, Schulz A, et al. Is assessment of depression equivalent for migrants of different cultural backgrounds? Results from the German population-based Gutenberg health study (GHS). Depress Anxiety. 2018;35(12):1178–89. https://doi.org/10.1002/da.22831.CrossRefPubMed

39.

Petersen JJ, Paulitsch MA, Hartig J, Mergenthal K, Gerlach FM, Gensichen J. Factor structure and measurement invariance of the patient health Questionnaire-9 for female and male primary care patients with major depression in Germany. J Affect Disord. 2015;170:138–42. https://doi.org/10.1016/j.jad.2014.08.053.CrossRefPubMed

40.

Doi S, Ito M, Takebayashi Y, Muramatsu K, Horikoshi M. Factorial validity and invariance of the patient health questionnaire (PHQ)-9 among clinical and non-clinical populations. PLoS One. 2018. https://doi.org/10.1371/journal.pone.0199235.

41.

Zeng Q, He Y, Liu H, et al. Reliability and validity of Chinese version of the generalized anxiety disorder 7-item (GAD-7) scale in screening anxiety disorders in outpatients from traditional Chinese internal department. Chinese Ment Heal J. 2013;27:163–8.

42.

Parkerson HA, Thibodeau MA, Brandt CP, Zvolensky MJ, Asmundson GJG. Cultural-based biases of the GAD-7. J Anxiety Disord. 2015;31:38–42. https://doi.org/10.1016/j.janxdis.2015.01.005.CrossRefPubMed

43.

Zhou Y, Lemmer G, Xu J, Rief W. Cross-cultural measurement invariance of scales assessing stigma and attitude to seeking professional psychological help. Front Psychol. 2019. https://doi.org/10.3389/fpsyg.2019.01249.

44.

Kroenke K, Spitzer R, Williams JBW. The PHQ-15 : Validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002;64(2):258–66.CrossRefPubMed

45.

Kroenke K, Spitzer R, Williams W. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13. https://doi.org/10.1046/j.1525-1497.2001.016009606.x.CrossRefPubMedPubMedCentral

46.

Wang W, Bian Q, Zhao Y, et al. Reliability and validity of the Chinese version of the patient health questionnaire (PHQ-9) in the general population. Gen Hosp Psychiatry. 2014;36(5):539–44. https://doi.org/10.1016/j.genhosppsych.2014.05.021.CrossRefPubMed

47.

Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder-the GAD-7. Arch Intern Med. 2006;166:1092–7. https://doi.org/10.1001/archinte.166.10.1092.CrossRefPubMed

48.

Kroenke K, Spitzer RL, Williams JBW, Monahan P, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146(5):317–25. https://doi.org/10.7326/0003-4819-146-5-200703060-00004.CrossRefPubMed

49.

He X, Li C, Qian J, Cui HS. Reliability and validity of a generalized anxiety scale in general hospital outpatients. Shanghai Arch Psychiatry. 2010;22(4):200–3. https://doi.org/10.3969/j.issn.1002-0829.2010.04.002.CrossRef

50.

Muthén LK, Muthén BO. Mplus User ’ s Guide. Muthén & Muthén; 2015.

51.

Hu LT, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ Model. 1999;6(1):1–55. https://doi.org/10.1080/10705519909540118.CrossRef

52.

Bentler PM. Comparative fit indexes in structural models. Psychol Bull. 1990;107(2):238–46.CrossRefPubMed

53.

Weiber R, Mühlhaus D. Strukturgleichungsmodellierung - Eine Anwendungsorientierte Einführung in Die Kausalanalyse Mit Hilfe von AMOS, SmartPLS Und SPSS (Structural Equation Modeling - An Application-Oriented Introduction to Causal Analysis Using AMOS, SmartPLS, and SPSS). 2nd ed. Wiesbaden: Springer Gabler; 2015.

54.

Vandenberg RJ, Lance CE. A review and synthesis of the measurement invariance literature: suggestions, practices, and recommendations for organizational research. Organ Res Methods. 2000;3(1):4–70. https://doi.org/10.1177/109442810031002.CrossRef

55.

Cheung GW, Rensvold RB. Evaluating goodness-of-fit indexes for testing measurement invariance. Struct Equ Model A Multidiscip J. 2002;9(2):233–55. https://doi.org/10.1207/S15328007SEM0902.CrossRef

56.

Ma-Kellams C. Cross-cultural differences in somatic awareness and interoceptive accuracy: a review of the literature and directions for future research. Front Psychol. 2014. https://doi.org/10.3389/fpsyg.2014.01379.

57.

Rimé B, Philippot P, Cisamolo D. Social schemata of peripheral changes in emotion. J Pers Soc Psychol. 1990;59(1):38–49. https://doi.org/10.1037/0022-3514.59.1.38.CrossRefPubMed

58.

Philippot P, Rimé B. The perception of bodily sensations during emotion: a cross-cultural perspective. Polish Psychol Bull. 1997;28(2):175–88.

59.

Greiff S, Scherer R. Still comparing apples with oranges?: some thoughts on the principles and practices of measurement invariance testing. Eur J Psychol Assess. 2018;34:141–4. https://doi.org/10.1027/1015-5759/a000487.CrossRef

60.

Marsh HW, Muthén B, Asparouhov T, et al. Exploratory structural equation modeling, integrating CFA and EFA: application to students’ evaluations of university teaching. Struct Equ Model. 2009;16(3):439–76. https://doi.org/10.1080/10705510903008220.CrossRef

61.

Schmitt N, Kuljanin G. Measurement invariance: review of practice and implications. Hum Resour Manag Rev. 2008;18(4):210–22. https://doi.org/10.1016/j.hrmr.2008.03.003.CrossRef

62.

Leung FKS. Behind the high achievement of east Asian students. Educ Res Eval. 2002;8(1):87–108. https://doi.org/10.1076/edre.8.1.87.6920.CrossRef

63.

Hau K-T, Ho IT. Chinese students’motivation and achievement. In: Bond MH, ed. The Oxford Handbook of Chinese Psychology: Oxford University Press; 2010. p. 187–204.

64.

Parker G, Cheah YC, Roy K. Do the Chinese somatize depression? A cross-cultural study. Soc Psychiatry Psychiatr Epidemiol. 2001;36:287–93. https://doi.org/10.1007/s001270170046.CrossRefPubMed

65.

Westover AN, Marangell LB. A cross-national relationship between sugar consumption and major depression? Depress Anxiety. 2002;16(3):118–20. https://doi.org/10.1002/da.10054.CrossRefPubMed

66.

Balsamo M, Saggino A. Determining a diagnostic cut-off on the Teate depression inventory. Neuropsychiatr Dis Treat. 2014;10:987–95. https://doi.org/10.2147/NDT.S55706.CrossRefPubMedPubMedCentral

67.

Ruscio AM, Hallion LS, Lim CCW, et al. Cross-sectional comparison of the epidemiology of DSM-5 generalized anxiety disorder across the globe. JAMA Psychiatry. 2017;74(5):465–75. https://doi.org/10.1001/jamapsychiatry.2017.0056.Cross-sectional.CrossRefPubMedPubMedCentral

68.

Zhong J, Wang ÃA, Qian M, et al. Shame, personality, and social anxiety symptoms in Chinese and American nonclinical samples: a cross-cultural study. Depress An. 2008;25(5):449–60. https://doi.org/10.1002/da.20358.CrossRef

69.

Balsamo M, Cataldi F, Carlucci L, Padulo C, Fairfield B. Assessment of late-life depression via self-report measures: a review. Clin Interv Aging. 2018;13:2021–44. https://doi.org/10.2147/CIA.S178943.CrossRefPubMedPubMedCentral

70.

Balsamo M, Cataldi F, Carlucci L, Fairfield B. Assessment of anxiety in older adults: a review of self-report measures. Clin Interv Aging. 2018;13:573–93. https://doi.org/10.2147/CIA.S114100.CrossRefPubMedPubMedCentral

Title: Are comparisons of mental disorders between Chinese and German students possible? An examination of measurement invariance for the PHQ-15, PHQ-9 and GAD-7
Authors: Yan Zhou
Jing Xu
Winfried Rief
Publication date: 01-12-2020
Publisher: BioMed Central
Keyword: Generalised Anxiety Disorder
Published in: BMC Psychiatry / Issue 1/2020
Electronic ISSN: 1471-244X
DOI: https://doi.org/10.1186/s12888-020-02859-8

2024 ASCO Annual Meeting

Springer Medicine

Are comparisons of mental disorders between Chinese and German students possible? An examination of measurement invariance for the PHQ-15, PHQ-9 and GAD-7

Abstract

Background

Methods

Results

Conclusion

2024 ASCO Annual Meeting

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

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