Validity of the Chinese Language Patient Health Questionnaire 2 and 9: A Systematic Review

Chinese Americans with limited English proficiency have higher mental health needs than English speakers but are more likely to be undiagnosed and undertreated for depression. Increasing anti-Asian hate crimes during the COVID-19 pandemic has increased the urgency to accurately detect depressive symptoms in this community. This systematic review examines the validity of the Patient Health Questionnaire (PHQ)-2/9 for depression screening in Chinese-speaking populations.

We queried PubMed, Web of Science, Embase, and PsycINFO databases, examining studies through September 2021. Studies were included if they evaluated the Chinese language PHQ-2 or PHQ-9 and diagnosed depression using a clinical interview. Two investigators independently extracted study data and assessed quality using the QUADAS-2. Study sensitivities and specificities were combined in random effects meta-analyses.

Of 513 articles, 20 met inclusion criteria. All examined the PHQ-9; seven also examined the PHQ-2. Studies were conducted in Mainland China (17), Hong Kong (1), Taiwan (1), and the United States (1). Fourteen studies were published in English; six in Chinese. Studies were diverse in setting, participant age, and comorbidities. For the Chinese language PHQ-9, Cronbach's alpha ranged from 0.765 to 0.938 for included studies (optimal cutoff scores ranged from 6 to 11). For the PHQ-2, Cronbach's alpha ranged from 0.727 to 0.785 (optimal cutoff scores 1-3). Overall, the PHQ-9 pooled sensitivity was 0.88 (95% CI 0.86-0.90), and pooled specificity was 0.87 (95% CI 0.83-0.91). Similarly, the pooled PHQ-2 sensitivity was 0.84 (95% CI 0.80-0.87), and pooled specificity was 0.87 (95% CI 0.78-0.93). The overall risk of bias was low (12 studies) or indeterminate (8 studies).

While limited by missing study information, the Chinese language PHQ-9 appears to be a valid depression screening tool among Chinese-speaking populations across geographic and clinical settings. Further research should explore optimal cutoff scores for this population for routine depression screening and the validity of the tool to measure response to depression treatment.