608126

research-article2015
HJBXXX10.1177/0739986315608126Hispanic Journal of Behavioral SciencesMills et al.

Article
Hispanic Journal of Behavioral Sciences
2015, Vol. 37(4) 560­–571
Psychometric Evaluation © The Author(s) 2015
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DOI: 10.1177/0739986315608126
Questionnaire–4 in hjb.sagepub.com

Hispanic Americans

Sarah D. Mills1, Rina S. Fox1, Tonya M. Pan1,

Vanessa L. Malcarne1,2,3, Scott C. Roesch1,2,
and Georgia Robins Sadler1,3

Abstract
The present study evaluated the psychometric properties of the Patient
Health Questionnaire–4 (PHQ-4), a screener of psychological distress, in
English- and Spanish-speaking Hispanic Americans. Hispanic American adults
(N = 436) completed the PHQ-4, which yields two subscales (Anxiety and
Depression) that can be summed to create a total score. Multiple-group
confirmatory factor analysis was used to evaluate structural validity. The
two-factor structure was the best fit to the data for both English- and
Spanish-speaking Hispanic Americans, and items loaded equivalently across
groups, demonstrating measurement invariance. Internal consistency
reliability was good as measured by coefficient alpha. Construct validity
was evidenced by significant expected relationships with perceived stress.
These findings provide support for the reliability and validity of the PHQ-4
as a brief measure of psychological distress for English- or Spanish-speaking
Hispanic Americans.

1San Diego State University/University of California, San Diego Joint Doctoral Program in
Clinical Psychology, CA, USA
2San Diego State University, CA, USA
3University of California, San Diego Moores Cancer Center, La Jolla, USA

Corresponding Author:
Vanessa L. Malcarne, San Diego State University, 6363 Alvarado Court, Suite 103, San Diego,
CA 92120-4913, USA.
Email: vmalcarne@mail.sdsu.edu

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Mills et al. 561

Keywords
Patient Health Questionnaire–4, Hispanic Americans, psychometrics,
anxiety, depression

The Patient Health Questionnaire–4 (PHQ-4) is a four-item screener of psy-

chological distress (Kroenke, Spitzer, Williams, & Lowe, 2009). The PHQ-4
is a composite of the Patient Health Questionnaire–2 (PHQ-2; Kroenke,
Spitzer, & Williams, 2003) and Generalized Anxiety Disorder–2 (GAD-2;
Kroenke, Spitzer, Williams, Monahan, & Lowe, 2007) scales, two-item
scales designed to screen for depression and anxiety over the prior two weeks,
respectively. Kroenke et al. (2009) noted that depression and anxiety are the
two most common mental health disorders and are often comorbid with each
other. Furthermore, disability has been found to be most severe when depres-
sion and anxiety co-occur. Thus, the PHQ-4 was developed, combining the
PHQ-2 and GAD-2 into a four-item scale to permit efficient screening of both
depression and anxiety using the same, very brief measure.
The PHQ-4 was developed and validated in a United States (U.S.) sample
of 2,149 patients from 15 primary care sites. Patients had a mean age of 47.2
years (SD = 15.4 years) and were predominantly female and non-Hispanic
White. A principal components analysis (PCA) of the four PHQ-4 items indi-
cated that 84% of the total variance was explained by two factors. As
expected, the two anxiety items had the highest factor loadings on one factor,
and the two depression items had the highest factor loadings on the other.
Kroenke et al. (2009) noted that two subscale scores can be calculated, one
each for Anxiety and Depression, along with a total score reflecting psycho-
logical distress. The mean PHQ-4 score for the total sample was 2.5 (SD =
2.8), described by Kroenke et al. (2009) as indicating normal to mild levels
of psychological distress, although determination of cutoff scores was not
described. Internal consistency reliability was good (αs > .80) for the total
score and subscales. The measure also demonstrated strong construct valid-
ity. Higher scores on the PHQ-4 were associated with increasing scores in all
six domains of the Medical Outcomes Study Short-Form General Health
Survey (SF-20; Wells et al., 1987).
The PHQ-4 has also been cross-validated in a large sample (N = 5,036)
from the general population in Germany (Lowe et al., 2010). Participants had
a mean age of 48.4 years (SD = 18 years) and were predominantly female.
Information on the race/ethnicity of participants was not provided. Mean
PHQ-4 scores were 1.76 (SD = 2.06), and internal consistency reliability for

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562 Hispanic Journal of Behavioral Sciences 37(4)

the total score and subscales was good. A two-factor model fit the data well.
Scores on the PHQ-4 correlated at expected magnitudes and directions with
the Rosenberg Self-Esteem Scale (Rosenberg, 1965), the Questionnaire on
Life Satisfaction (Henrich & Herschbach, 2000), and the Resilience Scale
(Schumacher, Leppert, Gunzelmann, Stauß, & Brahler, 2005), demonstrating
convergent validity.
The psychometric properties of the PHQ-4 were recently examined in a
sample of surgical patients attending preoperative anesthesiological assess-
ment clinics (N = 2,852) in Germany (Kerper et al., 2014). Approximately
half of the sample was female (Age: M = 47 years). Race/ethnicity data were
not provided. Clinically significant psychological distress (t score ≥ .63) on
the Brief Symptom Inventory (BSI; Derogatis, 1993) was reported by 14.6%
of the sample. A two-factor model was examined using PCA, and the factors
explained 83% of the total variance. The four items, however, did not load
onto the two factors as expected. The two GAD-2 items had the highest load-
ings on Factor 1, as expected, and Item 1 from the PHQ-2 had the highest
loading on Factor 2 (assessing Depression). However, Item 2 from the PHQ-2
loaded highest on Factor 1, with the two GAD-2 items. Convergent validity
was demonstrated by correlations with the total score and selected subscales
of the BSI, a measure of perceived distress.
The purpose of the present study was to evaluate the psychometric proper-
ties (reliability, structural validity, construct validity) of the PHQ-4 among a
sample of English- and Spanish-speaking Hispanic Americans. The PHQ-4
has yet to be psychometrically evaluated in the Hispanic American popula-
tion, despite being extensively used in research on diverse samples including
Hispanic Americans. Furthermore, the structural invariance of the English
and Spanish versions of the measure across different Hispanic American lan-
guage groups has yet to be examined. Evidence of structural invariance
across these language groups is a critical prerequisite for cross-group com-
parisons (Floyd & Widaman, 1995).

Method
Participants and Procedures
Hispanic American adults (N = 436) were recruited as part of a larger commu-
nity study validating health-related measures. To be eligible for inclusion, indi-
viduals must have self-identified as Hispanic American, been at least 21 years
old, resided in the U.S., and be literate in either English or Spanish. The sponsor-
ing universities’ Institutional Review Boards approved all study procedures and
materials, and participants provided informed consent prior to participation.

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Mills et al. 563

Measures
Demographics. Participant demographic information was provided by
self-report.

PHQ-4. As described above, the PHQ-4 (Kroenke et al., 2009) is a four-item

measure of psychological distress. Total scores range from 0 to 12, with
higher scores indicating greater psychological distress. GAD-2 and PHQ-2
scores can also be calculated by summing the first two items and last two
items of the measure, respectively, with subscales’ scores ranging from 0 to
6. The Spanish versions of the GAD-2 items were previously translated by
García-Campayo et al. (2010). The Spanish versions of the PHQ-2 items
were translated by the Stanford Patient Education Research Center (Spanish
Personal Health Questionnaire (PHQ-8) Depression, n.d.). See Table 1 for
individual items of the PHQ-4 in English and Spanish.

Perceived Stress Scale (PSS). The PSS is a self-report measure of perceived

stress developed by Cohen, Kamarck, and Mermelstein (1983); the Span-
ish version of the measure was drawn from Cohen’s website (PSS Transla-
tions, n.d.). Total scores range from 0 to 40, and higher scores reflect
greater perceived stress. In the present study, internal consistency reliabil-
ity was good (α = .82) for the total sample and acceptable to good when
language preference groups were examined separately (English: α = .87;
Spanish: α = .78.

Table 1. Items From the Patient Health Questionnaire–4 in English and Spanish.

Generalized Anxiety Disorder–2 (English / Spanish)

Over the last 2 weeks, how often have you been bothered by the following
problems? / Señale con qué frecuencia ha sufrido los siguientes problemas en los
últimos 15 días
1. Feeling nervous, anxious, or on edge / Se ha sentido nervioso, ansioso o muy
alterado
2. Not being able to stop or control worrying / No ha podido dejar de preocuparse
Patient Health Questionnaire–2 (English / Spanish)
Over the last 2 weeks, how often have you been bothered by the following
problems? / Durante las últimas 2 semanas, ¿con qué frecuencia le han
molestado los siguientes problemas?
1. Little interest or pleasure in doing things / Tener poco interés o placer en hacer
las cosas
2. Feeling down, depressed, or hopeless / Sentirse desanimada, deprimida, o sin
esperanza

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564 Hispanic Journal of Behavioral Sciences 37(4)

Data Analysis
PHQ-4 total scores were computed for the English and Spanish language
groups separately, and group means were compared with an independent-
samples t test. Internal consistency reliability was evaluated using Cronbach’s
alpha.
Multiple-group confirmatory factor analysis (MCFA) was used to evalu-
ate the comparability of the factor structure of the PHQ-4 across language
groups. Prior investigations have found evidence for a two-factor structure;
thus, a two-factor solution was expected for both language groups in the pres-
ent analysis. The MCFA was conducted in accordance with the approach rec-
ommended by Vandenberg and Lance (2000). Three increasingly restrictive
models were iteratively examined. To establish configural invariance, a
model is examined in which the number of factors and the items contributing
to each factor are constrained across groups, but all other parameters are
freely estimated. Once configural invariance is established, the metric invari-
ance of the structure between groups is examined to determine if each item
loads equivalently onto the same factor in both groups. To establish metric
invariance, a model is examined in which the loading of each item onto its
respective factor is constrained across groups, but factor variances, factor
covariances, and error variances, are freely estimated. Finally, once metric
invariance is established and deemed to be a superior fit to the data than the
configural invariance model, the factor variance/covariance invariance of
the structure is examined across groups. In this most restrictive iteration, the
loading of each item onto its respective factor is again constrained across
groups, as are the variances and covariances of each factor; error variances
are freely estimated. To determine which model is the optimal fit to the
observed data, each model that is deemed to adequately fit the data is statisti-
cally compared with the prior, next less restrictive iteration using a chi-square
difference test.
Multiple indicators of overall model fit were examined, including (a) the
comparative fit index (CFI; Bentler, 1990), an absolute index of model fit; (b)
the root mean square error of approximation (RMSEA; Steiger, 1990), a par-
simony-adjusted index of model fit; and (c) the standardized root mean resid-
ual (SRMR; Hu & Bentler, 1999), an absolute index of model fit. For the
CFI, values > 0.95 indicated good model fit, and values > 0.90 indicated
acceptable model fit. For the RMSEA and SRMR, values < 0.08 indicated
acceptable model fit, and values < 0.05 indicated good model fit. A model
was determined to adequately fit the observed data if at least two of the three
descriptive fit indices met acceptable model fit criteria. The likelihood ratio
chi-square was also reported, however, it did not serve as the only indicator

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Mills et al. 565

of model fit because it is highly influenced by sample size and does not dem-
onstrate degree of fit (Gerbing & Anderson, 1992).
The construct validity of PHQ-4 total and subscale scores was evaluated by
examining Pearson product–moment correlations with scores on the PSS. The
MCFA was conducted using MPlus version 7.11 (Muthén & Muthén, 1998-
2010). All other analyses were completed in SPSS version 20 (IBM, 2011).

Results
Descriptive Statistics
Descriptive statistics can be found in Table 2. Spanish language group PHQ-4
scores (M = 2.94, SD = 2.94) were significantly higher than English language
group scores (M = 2.07, SD = 2.59), t(432) = −3.26, p = .001. The majority of
the sample (61.5%) had PHQ-4 scores indicative of normal levels of psycho-
logical distress (≤2), while 8.6% of the sample had scores indicative of severe
levels (≥9). Overall, the Spanish language group had lower income, were less
educated, and less likely to be employed in comparison with the English lan-
guage group.

Table 2. Sample Characteristics.

English (n = 210) Spanish (n = 226)

Age*a 38.50 (13.74) 46.24 (13.37)
Genderb
Female 107 (51.0%) 112 (49.6%)
Male 103 (49.0%) 114 (50.4%)
Education*b
Less than bachelor’s degree
   Less than high school 13 (6.2%) 108 (47.7%)
  High school/trade 39 (18.6%) 48 (21.2%)
school
  Some college/ 81 (38.5%) 41 (18.2%)
associates degree
Bachelor’s degree or higher
  Bachelor’s degree 57 (27.1%) 17 (7.5%)
  Postgraduate 18 (8.6%) 7 (3.1%)
   Missing/do not know 2 (1.0%) 5 (5.3%)
Employment status*b
Employed 141 (68.1%) 106 (46.5%)
Not employed for wages

(continued)

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566 Hispanic Journal of Behavioral Sciences 37(4)

Table 2. (continued)

English (n = 210) Spanish (n = 226)

  Unemployed 30 (14.2%) 42 (18.6%)
  Homemaker 6 (2.9%) 30 (13.3%)
  Student/retired/ 19 (9.0%) 29 (12.7%)
disabled
  Social security/SSI 4 (1.9%) 9 (4.0%)
Missing/do not know 10 (3.9%) 10 (4.9%)
Marital statusb
Married 95 (45.2%) 116 (51.3%)
Not married
  Single 65 (31.0%) 59 (26.1%)
   Living with partner 15 (7.1%) 14 (6.2%)
  Divorced/separated 32 (15.2%) 27 (11.9%)
  Widowed 3 (1.4%) 9 (4.0%)
Missing 0 (0.0%) 1 (0.5%)
Income*b
US$0-US$24,999 61 (29%) 121 (53.5%)
US$25,000-US$49,999 59 (28.1%) 60 (26.5%)
US$50,000-US$74,999 41 (19.5%) 11 (4.9%)
>US$75,000 34 (16.2%) 9 (4%)
Missing/do not know 15 (7.2%) 25 (11.1%)
aM (SD).
bn (%).
*Independent-sample t tests resulted in a significant difference at p < .01 (two-tailed) between
language preference groups.
SSI = supplemental security income.

Reliability
For the total sample, internal consistency reliability was good for the PHQ-4 (α =
.86) and its subscale scores (PHQ-2: α = .80; GAD-2: α = .81). For the English
language group, internal consistency reliability was good for the PHQ-4 (α = .85)
and acceptable to good for its subscale scores (PHQ-2: α = .81; GAD-2: α = .77).
For the Spanish language group, internal consistency reliability was good for the
PHQ-4 (α = .86) and its subscale scores (PHQ-2: α = .80; GAD-2: α = .82).

MCFA Models
Preliminary analyses demonstrated that the data were significantly multivari-
ately non-normal. Therefore, the Satorra-Bentler chi-square test statistic
(S-Bχ2; Satorra & Bentler, 2001) was evaluated.

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Mills et al. 567

Configural invariance. The baseline configural invariance model demon-

strated that the two-factor structure fit the observed data well for both
language groups (Table 3). For the English language sample, all estimated
unstandardized factor loadings for both the PHQ-2 (Item 1: 0.89; Item 2:
1.13, p < .05) and the GAD-2 (Item 1: 0.74; Item 2: 1.35, p < .05) sub-
scales were statistically significant, as were the variances for both factors
2 2
( σPHQ-2 = 0.35, σGAD-2 = 0.29, all ps < .01). The covariance between the
two factors was also statistically significant (r = .27, p < .01), indicating
that the two dimensions of psychological distress were positively related
to one another.
For the Spanish language sample, all estimated unstandardized factor
loadings for both the PHQ-2 (Item 1: 0.93; Item 2: 1.08, p < .05) and the
GAD-2 (Item 1: 0.93; Item 2: 1.08, p < .05) subscales were statistically sig-
nificant, and the factor variances for both factors were also significant
( σ2PHQ-2 = 0.43, σGAD-2
2
= 0.55, all ps < .01). Furthermore, the covariance
between the two factors was again statistically significant (r = .41, p < .01).

Metric invariance. The metric invariance model fit the data well (Table 3).
When this model was statistically compared with the configural invariance
model, the metric invariance model was a superior fit to the data (ΔS-Bχ2 =
2.777, Δdf = 2, p = .250).

Factor variance/covariance invariance. This most restrictive model fit the data
well. When this model was compared with the metric invariance model, the
factor variance/covariance invariance model was the best fit to the data (ΔS-
Bχ2 = 2.785, Δdf = 3, p = .426.

Table 3. Fit Statistics for Configural Invariance, Metric Invariance, and Factor
Variance/Covariance Invariance Models of the PHQ-4.
Reference
model
Model S-Bχ2 df p CFIa SRMRb RMSEAb number ΔS-Bχ2 Δdf Δp

1. Configural 20.590 4 <.01 0.966 0.035 0.138

2. Metric 21.821 6 <.01 0.968 0.044 0.110 1 2.7774 2 .250
3. Factor 22.286 9 <.01 0.973 0.071 0.082 2 2.7851 3 .426

Note. PHQ-4 = Patient Health Questionnaire–4; S-Bχ2 = Satorra-Bentler chi-square test; CFI = comparative
fit index; SRMR = standardized root mean square residual; RMSEA = root mean square error of
approximation.
aPlausible fit > .90, good fit > .95.
bPlausible fit < .08, good fit < .05.

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568 Hispanic Journal of Behavioral Sciences 37(4)

Construct Validity
As expected, there was a strong positive correlation between PHQ-4 total and
subscale scores and scores on the PSS (PHQ-4: r = .63, p < .01; PHQ-2: r =
.57, p < .01; GAD-2: r = .60, p < .01).

Discussion
These findings suggest that the PHQ-4 is a reliable and valid measure of
psychological distress for use with English- and Spanish-speaking Hispanic
Americans. Internal consistency reliability was strong. Results from the
MCFA indicate that the PHQ-4 consists of two factors, one reflecting symp-
toms of anxiety and the other symptoms of depression. The MCFA indicated
that the factor variance/covariance invariance model was the best fit to the
data. Thus, these results suggest that the PHQ-4 can be used to measure the
construct of psychological distress equivalently across English- and Spanish-
speaking Hispanic Americans and that scores on the PHQ-4 can be compared
across these language groups. In addition, higher PHQ-4 total and subscale
scores were strongly associated with higher perceived stress, demonstrating
construct validity.
These results should be interpreted while recognizing study limitations.
The present sample did not include a large sample of participants with moder-
ate or severe levels of distress. In addition, the sample was predominantly
Mexican American and lived in a metropolitan border city, further limiting
the generalizability of study findings. Despite these limitations, the results
support the PHQ-4 as a good choice for researchers and health care profes-
sionals who wish to quickly screen for psychological distress in Hispanic
Americans.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The authors disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: This study was funded by the National
Cancer Institute grant R25CA130869, with additional support from NCI P30
CA023100, NIH/NCMHD P60 MD000220, NIH U56 CA92079/U56 CA92081, and
U54 CA132379/U54 CA132384. Sarah D. Mills was supported by the University of
California, San Diego (UCSD) Cota-Robles Fellowship. Tonya M. Pan was supported
by the UCSD fellowship.

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Mills et al. 569

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Author Biographies
Sarah D. Mills is a doctoral student at the San Diego State University/University of
California, San Diego (SDSU/UCSD) Joint Doctoral Program in Clinical Psychology,
specializing in behavioral medicine. Her research interests include coping with
chronic illness, ethnic minority health disparities, and measure development and
validation.
Rina S. Fox is a doctoral student at the SDSU/UCSD Joint Doctoral Program in
Clinical Psychology, specializing in behavioral medicine. Her research interests
include assessing mechanisms for coping with the stresses of chronic illness, dimin-
ishing cultural health disparities, and psychometrics.
Tonya M. Pan is a doctoral student at the SDSU/UCSD Joint Doctoral Program in
Clinical Psychology, specializing in behavioral medicine. Her research interests
include exploring the psychosocial aspects of cancer survivorship among medically
underserved communities; child, adolescent, and young adult cancer survivors; and
family members/caregivers of people with cancer.
Vanessa L. Malcarne is a professor of psychology at San Diego State University, and
core faculty in the SDSU/UCSD Joint Doctoral Program in Clinical Psychology. Her
research focuses on chronic illness, including prevention, quality of life, and dispari-
ties. She is also interested in measure development and validation, especially across
diverse groups. She received her PhD in clinical psychology from the University of
Vermont.

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Mills et al. 571

Scott C. Roesch is a professor of psychology at San Diego State University, and core
faculty in the SDSU/UCSD Joint Doctoral Program in Clinical Psychology. His
research focuses on trait-state models of stress and coping, coping with physical ill-
ness, and cultural, ethnic, and acculturation differences in stress and coping. He is also
interested in cross-ethnic measurement equivalence, structural equation modeling,
and meta-analysis. He received his PhD in psychology from the University of
Nebraska–Lincoln.
Georgia Robins Sadler is a professor of surgery at the UCSD School of Medicine
and the associate director for Community Outreach at the UCSD Moores Cancer
Center. Her research focuses on developing ways to reduce health disparities. Working
through community-campus partnerships, her research is focused on creating and
evaluating cost-effective strategies for addressing health disparities within the African
American, Asian American and Pacific Islander, Hispanic American, and Deaf com-
munities. She received her BSN from the University of Pennsylvania, her MBA from
Wharton Graduate School, and her PhD from the Union Institute and University. She
did her postgraduate work at the University of London while a Thouron British
American Scholar.

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