{"paper_id":"4ae55a06-ac38-460d-b766-e191966986dc","body_text":"Use of PHQ-4 Tool to Assess Anxiety and Depression in Adolescents and Adults in Medically Underserved Santo Domingo, Ecuador | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Use of PHQ-4 Tool to Assess Anxiety and Depression in Adolescents and Adults in Medically Underserved Santo Domingo, Ecuador Misa Ito, Macey Johnson, Rebecca Agner, Pablo Boada, Aric Schadler, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6629859/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Anxiety and depression are prevalent mental health conditions, yet they often remain underdiagnosed, especially in underserved populations. In Ecuador, mental health disorders are a significant public health concern, with limited access to mental health resources. The Patient Health Questionnaire-4 (PHQ-4) is a widely used, ultra-brief self-reported screening tool for identifying symptoms of anxiety and depression. This study aimed to assess the utility of the PHQ-4 in screening pediatric and adult populations in Santo Domingo, Ecuador, during a medical brigade in August 2020. Methods : The PHQ-4, consisting of two items for depression (PHQ-2) and two items for anxiety (GAD-2), was administered to patients aged 12 and older attending the medical brigade. A total of 380 individuals participated. Screening results were analyzed by age group, sex, and symptom severity, with scores categorized as mild (0-5), moderate (6-8), or severe (9-12). Statistical analysis was performed using IBM SPSS Statistics, including one-way ANOVA, Pearson’s correlation, independent samples t-tests, Pearson’s chi-square, and Fisher’s exact tests Results : The study revealed significant gender differences in anxiety scores, with pediatric females showing a statistically significant higher prevalence of anxiety compared to males (35.8% vs. 12.5%, p < 0.05). While depression scores were higher in females, the difference did not reach statistical significance (33.7% in females vs. 25% in males). Anxiety rates increased with age, while depression rates varied without a significant trend. Notably, the prevalence of anxiety and depression among pediatric patients in this population was higher than the national estimates for Ecuador. Conclusion : The PHQ-4 proved to be an effective screening tool for identifying anxiety and depression in the Santo Domingo population. Significant gender differences in anxiety and depression were observed, with higher rates in females and a noticeable increase in anxiety with age. Given the higher prevalence of mental health disorders in this population, regular use of the PHQ-4 in global medical brigades is recommended to improve the understanding and management of mental health in underserved regions. Anxiety Depression PHQ-4 Screening Pediatric Global Health Ecuador Underserved population Mental Health Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Depression is a prevalent global health issue, with a particularly high burden in low- and middle-income countries (LMICs), including South America 1 . In Ecuador, the prevalence of depression is estimated at 4.6%, contributing to 9.2% of the country's disability-adjusted life years (DALYs) 2 . The prevalence of anxiety in Ecuador is 5.6%, accounting for 5.8% of years lived with disability (YLDs) (WHO, 2017). Despite this high burden, the diagnosis and treatment of depression and anxiety in Ecuador remain suboptimal, with only a small percentage of individuals receiving appropriate care. Studies suggest that just 4.7% of the population in LMICs have access to adequate treatment for depression (Pan American health organization, 2018). Similarly, anxiety disorders are common across all age groups, including adolescents, with significant underdiagnosis and undertreatment in many regions 3–7 . Although the recent increases in the reported rates of depression suggest that there is an increasing awareness to this disease. However, the rates are still substantially lower than elsewhere 8 , as many individuals present with somatic symptoms rather than explicitly reporting mood disturbances in Latin American culture 9 in addition to low awareness and limited access to appropriate assessment and adequate treatments. The underdiagnosis of depression is reflected in the relatively low reported rates of the disorder within the country’s public health system. To address these gaps, tools like the Patient Health Questionnaire-4 (PHQ-4) have been developed to provide a brief and effective screening method for both depression and anxiety 10,11 . The PHQ-4 has been validated in various populations 10–17 , yet it has not been used in Ecuador. This study aimed to assess depression and anxiety in pediatric and adult populations in Ecuador, particularly in the city of Santo Domingo, using PHQ-4 as a screening tool with the goal of identifying high-risk groups and providing better mental health support in underserved areas. Method Study Design and Ethical Considerations This initiative was not originally designed as a research study but was part of a broader medical brigade that integrated medicine, physical therapy, pharmacy, and nursing. A psychology team was included to triage patients for anxiety and depression, assess the feasibility of mental health screening in this setting, and provide on-site intervention as needed. Given the informal nature of the initial data collection, the research team later sought Institutional Review Board (IRB) approval from the University of Kentucky (UK) to analyze the collected data. The IRB approved the retrospective analysis of de-identified data, allowing for post-hoc evaluation of screening outcomes. However, there was no prior IRB approval for a prospective study. Screening Procedure The PHQ-4 was administered at the time of patient registration, and verbal consent was obtained. Medical providers reviewed the PHQ-4 results with each patient. If a patient had moderate to severe symptoms, they were asked if they wanted to speak with a psychologist. Patients who accepted were further assessed and received interventions on-site, with referrals provided as needed. Although patients appeared receptive to mental health screening, no formal data were collected on acceptance rates due to the non-research nature of the initial initiative. The screenings were conducted during a University of Kentucky medical brigade in August 2020, where psychologists administered the PHQ-4 to patients aged 12 and older seen in the clinic. Patient ages were classified into the following categories: 10–21 years (pediatric group), 22–40 years, 41–60 years, 61–80 years, and greater than 80 years of age. The PHQ-4 includes four questions: two assessing anxiety symptoms and two assessing depression symptoms. Each question is rated on a scale from 0 to 3, with a score of 3 or higher indicating a positive result for anxiety or depression. Total scores range from 0 to 12, with 0–5 indicating mild symptoms, 6–8 indicating moderate symptoms, and 9–12 indicating severe symptoms. Psychologists were available to follow up with patients who screened positive. Continuous variables were analyzed between groups using independent samples t-tests or one-way ANOVA using a Bonferroni correction factor on the post hoc analysis as appropriate. Relationships between continuous variables were analyzed using Pearson’s correlation. Categorical variables were analyzed using Pearson’s chi-square or Fisher’s exact test as appropriate. Statistical analysis was completed using IBM SPSS Statistics version 30. An alpha level of 0.05 was used to determine statistical significance. Results The analysis revealed a significant correlation between age and anxiety (Fig. 1 A, p = 0.001). However, no significant correlation was found between age and depression (Fig. 1 B, p = 0.051). Further examination using a chi-square test indicated a significant relationship between age and anxiety status (Fig. 1 A, p = 0.007). In contrast, no significant relationship was found between age and depression status (Fig. 1 B, p = 0.195). Gender differences were also explored in relation to anxiety and depression. A chi-square test revealed a significant relationship between gender and anxiety status (Fig. 2 A, p < 0.001). When analyzing the severity of anxiety and depression, a chi-square test indicated that there was a significant relationship between gender and anxiety severity (Fig. 2 B, p < 0.001), with females reporting more severe anxiety symptoms than males. Additionally, there was a significant association between gender and depression status (Fig. 3 A, p = 0.026). However, there was no significant relationship between gender and depression severity (Fig. 3 B, p = 0.078). In the young and pediatric population, a chi-square test indicated a significant relationship between gender and anxiety status (p = 0.046), with females having more anxiety than males in this age group. However, there was no significant relationship between gender and depression status in the young and pediatric population (p = 0.472). Lastly, a chi-square test revealed no significant relationship between gender and age (Fig. 5 , p = 0.062), suggesting that age distribution was similar across genders in the study population. Discussion A reliable and brief tool for screening anxiety and depression is the Patient Health Questionnaire-4 (PHQ-4), a 4-item self-report instrument that combines the 2-item PHQ-2 for depression and the 2-item Generalized Anxiety Disorder (GAD-2) scale for anxiety 11,15 . The psychometric properties of the PHQ-4 have been well-documented in a range of populations, including Hispanic Americans, Colombians, Germans, Filipinos, Paraguayan and others 10–17 . Our study confirms the utility of this tool in identifying anxiety and depression symptoms in the pediatric population in Santo Domingo, Ecuador. We found that pediatric females had significantly higher rates of anxiety compared to males, while depression rates also trended higher in females, though without statistical significance. Anxiety rates increased with age, while depression rates did not follow a clear age-related trend. Our study confirmed a gender disparity in both anxiety and depression rates, with females exhibiting higher rates of both conditions compared to males. This is consistent with broader epidemiological trends, where depression and anxiety disorders are more prevalent in females than in males, particularly after puberty 18,19 . The prevalence of anxiety and depression in Ecuador, as reported in our study, appears higher than national estimates. This is consistent with the general burden of mental health disorders in low- and middle-income countries (LMICs), where access to mental health care is often limited. In Ecuador, the prevalence of depression is reported to be 4.6%, and anxiety affects 5.6% of the population, yet treatment rates are low, with only a small percentage receiving adequate care 2 (Pan American Health Organization, 2018). The study proved that the Spanish version of the PHQ-9 aid in the screening of the patients with depression in the Ecuadorian public health system 20 . This highlights the need for widespread, accessible screening tools like the PHQ-4 in both clinical and community settings to identify and manage these conditions early on. Conclusion This study demonstrates the utility of the PHQ-4 as a screening tool for depression and anxiety in a primary care setting in Ecuador. The PHQ-4 is an inexpensive and easily administered tool that has utility in underserved populations to screen for anxiety and depression. In Santo Domingo, Ecuador, the PHQ-4 ultra-brief screening tool was useful in evaluating risk of depression and anxiety in patients seen during the August 2020 Brigade. Anxiety and depression rates among pediatric patients particularly among females in this population were higher than the estimated prevalence of anxiety and depression in Ecuador nationally. Future studies should aim to obtain normative data from a broader range of populations within Ecuador, similar to studies conducted in Colombia and other Latin American countries. Routine mental health screening, including the use of tools like the PHQ-4, should be integrated into primary care settings to improve early detection and treatment of mental health disorders, ultimately improving the quality of life for individuals in underserved communities. Abbreviations PHQ-4 Patient Health Questionnaire-4 GAD-2 Generalized Anxiety Disorders LMICs Low- and middle- income countries Declarations This study was conducted in accordance with the ethical standards of the University of Kentucky and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants (for pediatric participants, we obtained from their parent or legal guardian) included in the study. This initiative was not originally designed as a research study but was part of a broader medical brigade that integrated medicine, physical therapy, pharmacy, and nursing. A psychology team was included to triage patients for anxiety and depression, assess the feasibility of mental health screening in this setting, and provide on-site intervention as needed. - Given the informal nature of the initial data collection, the research team later sought Institutional Review Board (IRB) approval from the University of Kentucky (UK). Ethical approval for the study was obtained from IRB. - The PHQ-4 was administered at the time of patient registration, and verbal consent was obtained from the adult patients and their parents or legal guardian with pediatric patients. Although patients appeared receptive to mental health screening, no formal data were collected on acceptance rates due to the non-research nature of the initial initiative. Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interest Funding: no funding Clinical trial number: not applicable. Authors' contributions: M.I. and T.Y. prepared and wrote the manuscript. M.J. R.A. P.B. R.M have collected the data. A.S have analyzed the data. References Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Psychiatry 2022;9(2):137-150. (In eng). DOI: 10.1016/s2215-0366(21)00395-3. Kohn R, Ali AA, Puac-Polanco V, et al. Mental health in the Americas: an overview of the treatment gap. Rev Panam Salud Publica 2018;42:e165. (In eng). DOI: 10.26633/rpsp.2018.165. Walter HJ, Bukstein OG, Abright AR, et al. Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders. J Am Acad Child Adolesc Psychiatry 2020;59(10):1107-1124. (In eng). DOI: 10.1016/j.jaac.2020.05.005. Beharry M. Pediatric Anxiety and Depression in the Time of COVID-19. Pediatr Ann 2022;51(4):e154-e160. (In eng). DOI: 10.3928/19382359-20220317-01. Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management. Pediatrics 2018;141(3) (In eng). DOI: 10.1542/peds.2017-4081. Vermani M, Marcus M, Katzman MA. Rates of detection of mood and anxiety disorders in primary care: a descriptive, cross-sectional study. Prim Care Companion CNS Disord 2011;13(2) (In eng). DOI: 10.4088/PCC.10m01013. Szuhany KL, Simon NM. Anxiety Disorders: A Review. JAMA 2022;328(24):2431-2445. DOI: 10.1001/jama.2022.22744. Kessler RC, Bromet EJ. The epidemiology of depression across cultures. Annu Rev Public Health 2013;34:119-38. (In eng). DOI: 10.1146/annurev-publhealth-031912-114409. Muñoz RA, McBride ME, Brnabic AJ, et al. Major depressive disorder in Latin America: the relationship between depression severity, painful somatic symptoms, and quality of life. J Affect Disord 2005;86(1):93-8. (In eng). DOI: 10.1016/j.jad.2004.12.012. Kroenke K, Spitzer RL, Williams JB, Löwe B. An ultra-brief screening scale for anxiety and depression: the PHQ-4. Psychosomatics 2009;50(6):613-21. (In eng). DOI: 10.1176/appi.psy.50.6.613. Löwe B, Wahl I, Rose M, et al. A 4-item measure of depression and anxiety: Validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. Journal of Affective Disorders 2010;122(1):86-95. DOI: https://doi.org/10.1016/j.jad.2009.06.019. Sanabria-Mazo JP, Useche-Aldana B, Ochoa PP, et al. Social Inequities in the Impact of COVID-19 Lockdown Measures on the Mental Health of a Large Sample of the Colombian Population (PSY-COVID Study). J Clin Med 2021;10(22) (In eng). DOI: 10.3390/jcm10225297. Mills SD, Fox RS, Pan TM, Malcarne VL, Roesch SC, Sadler GR. Psychometric Evaluation of the Patient Health Questionnaire-4 in Hispanic Americans. Hisp J Behav Sci 2015;37(4):560-571. (In eng). DOI: 10.1177/0739986315608126. Mendoza NB, Frondozo CE, Dizon J, Buenconsejo JU. The factor structure and measurement invariance of the PHQ-4 and the prevalence of depression and anxiety in a Southeast Asian context amid the COVID-19 pandemic. Curr Psychol 2022:1-10. (In eng). DOI: 10.1007/s12144-022-02833-5. Kroenke K, Spitzer RL, Williams JB, Löwe B. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry 2010;32(4):345-59. (In eng). DOI: 10.1016/j.genhosppsych.2010.03.006. Caycho-Rodríguez T, Travezaño-Cabrera A, Torales J, et al. Psychometric network analysis of the Patient Health Questionnaire-4 (PHQ-4) in Paraguayan general population. Psicologia: Reflexão e Crítica 2024;37(1):15. DOI: 10.1186/s41155-024-00299-x. Materu J, Kuringe E, Nyato D, et al. The psychometric properties of PHQ-4 anxiety and depression screening scale among out of school adolescent girls and young women in Tanzania: a cross-sectional study. BMC Psychiatry 2020;20(1):321. (In eng). DOI: 10.1186/s12888-020-02735-5. Hyde JS, Mezulis AH, Abramson LY. The ABCs of depression: integrating affective, biological, and cognitive models to explain the emergence of the gender difference in depression. Psychol Rev 2008;115(2):291-313. (In eng). DOI: 10.1037/0033-295x.115.2.291. Thapar A, Collishaw S, Pine DS, Thapar AK. Depression in adolescence. Lancet 2012;379(9820):1056-67. (In eng). DOI: 10.1016/s0140-6736(11)60871-4. Quiñonez-Freire C, Vara MD, Tomás JM, Baños RM. Psychometric properties of the Spanish version of the Patient Health Questionnaire-9 in users of the Ecuadorian public health care system. Revista Latinoamericana de Psicología 2021;53. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-6629859\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":463478953,\"identity\":\"e213c4be-334b-451b-8345-b11c23518bf7\",\"order_by\":0,\"name\":\"Misa Ito\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Kentucky\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Misa\",\"middleName\":\"\",\"lastName\":\"Ito\",\"suffix\":\"\"},{\"id\":463478954,\"identity\":\"6d79ed29-04bd-4690-8428-f476f8832b37\",\"order_by\":1,\"name\":\"Macey 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burden in low- and middle-income countries (LMICs), including South America\\u003csup\\u003e1\\u003c/sup\\u003e. In Ecuador, the prevalence of depression is estimated at 4.6%, contributing to 9.2% of the country's disability-adjusted life years (DALYs)\\u003csup\\u003e2\\u003c/sup\\u003e. The prevalence of anxiety in Ecuador is 5.6%, accounting for 5.8% of years lived with disability (YLDs) (WHO, 2017). Despite this high burden, the diagnosis and treatment of depression and anxiety in Ecuador remain suboptimal, with only a small percentage of individuals receiving appropriate care. Studies suggest that just 4.7% of the population in LMICs have access to adequate treatment for depression (Pan American health organization, 2018). Similarly, anxiety disorders are common across all age groups, including adolescents, with significant underdiagnosis and undertreatment in many regions\\u003csup\\u003e3\\u0026ndash;7\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eAlthough the recent increases in the reported rates of depression suggest that there is an increasing awareness to this disease. However, the rates are still substantially lower than elsewhere\\u003csup\\u003e8\\u003c/sup\\u003e, as many individuals present with somatic symptoms rather than explicitly reporting mood disturbances in Latin American culture\\u003csup\\u003e9\\u003c/sup\\u003e in addition to low awareness and limited access to appropriate assessment and adequate treatments. The underdiagnosis of depression is reflected in the relatively low reported rates of the disorder within the country\\u0026rsquo;s public health system.\\u003c/p\\u003e \\u003cp\\u003eTo address these gaps, tools like the Patient Health Questionnaire-4 (PHQ-4) have been developed to provide a brief and effective screening method for both depression and anxiety\\u003csup\\u003e10,11\\u003c/sup\\u003e. The PHQ-4 has been validated in various populations\\u003csup\\u003e10\\u0026ndash;17\\u003c/sup\\u003e, yet it has not been used in Ecuador. This study aimed to assess depression and anxiety in pediatric and adult populations in Ecuador, particularly in the city of Santo Domingo, using PHQ-4 as a screening tool with the goal of identifying high-risk groups and providing better mental health support in underserved areas.\\u003c/p\\u003e\"},{\"header\":\"Method\",\"content\":\"\\u003cp\\u003eStudy Design and Ethical Considerations\\u003c/p\\u003e \\u003cp\\u003eThis initiative was not originally designed as a research study but was part of a broader medical brigade that integrated medicine, physical therapy, pharmacy, and nursing. A psychology team was included to triage patients for anxiety and depression, assess the feasibility of mental health screening in this setting, and provide on-site intervention as needed.\\u003c/p\\u003e \\u003cp\\u003eGiven the informal nature of the initial data collection, the research team later sought Institutional Review Board (IRB) approval from the University of Kentucky (UK) to analyze the collected data. The IRB approved the retrospective analysis of de-identified data, allowing for post-hoc evaluation of screening outcomes. However, there was no prior IRB approval for a prospective study.\\u003c/p\\u003e \\u003cp\\u003eScreening Procedure\\u003c/p\\u003e \\u003cp\\u003eThe PHQ-4 was administered at the time of patient registration, and verbal consent was obtained. Medical providers reviewed the PHQ-4 results with each patient. If a patient had moderate to severe symptoms, they were asked if they wanted to speak with a psychologist. Patients who accepted were further assessed and received interventions on-site, with referrals provided as needed.\\u003c/p\\u003e \\u003cp\\u003eAlthough patients appeared receptive to mental health screening, no formal data were collected on acceptance rates due to the non-research nature of the initial initiative.\\u003c/p\\u003e \\u003cp\\u003eThe screenings were conducted during a University of Kentucky medical brigade in August 2020, where psychologists administered the PHQ-4 to patients aged 12 and older seen in the clinic. Patient ages were classified into the following categories: 10\\u0026ndash;21 years (pediatric group), 22\\u0026ndash;40 years, 41\\u0026ndash;60 years, 61\\u0026ndash;80 years, and greater than 80 years of age.\\u003c/p\\u003e \\u003cp\\u003eThe PHQ-4 includes four questions: two assessing anxiety symptoms and two assessing depression symptoms. Each question is rated on a scale from 0 to 3, with a score of 3 or higher indicating a positive result for anxiety or depression. Total scores range from 0 to 12, with 0\\u0026ndash;5 indicating mild symptoms, 6\\u0026ndash;8 indicating moderate symptoms, and 9\\u0026ndash;12 indicating severe symptoms. Psychologists were available to follow up with patients who screened positive.\\u003c/p\\u003e \\u003cp\\u003eContinuous variables were analyzed between groups using independent samples t-tests or one-way ANOVA using a Bonferroni correction factor on the post hoc analysis as appropriate. Relationships between continuous variables were analyzed using Pearson\\u0026rsquo;s correlation. Categorical variables were analyzed using Pearson\\u0026rsquo;s chi-square or Fisher\\u0026rsquo;s exact test as appropriate. Statistical analysis was completed using IBM SPSS Statistics version 30. An alpha level of 0.05 was used to determine statistical significance.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eThe analysis revealed a significant correlation between age and anxiety (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eA, p\\u0026thinsp;=\\u0026thinsp;0.001). However, no significant correlation was found between age and depression (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eB, p\\u0026thinsp;=\\u0026thinsp;0.051).\\u003c/p\\u003e \\u003cp\\u003eFurther examination using a chi-square test indicated a significant relationship between age and anxiety status (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eA, p\\u0026thinsp;=\\u0026thinsp;0.007). In contrast, no significant relationship was found between age and depression status (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eB, p\\u0026thinsp;=\\u0026thinsp;0.195).\\u003c/p\\u003e \\u003cp\\u003eGender differences were also explored in relation to anxiety and depression. A chi-square test revealed a significant relationship between gender and anxiety status (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig4\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003eA, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). When analyzing the severity of anxiety and depression, a chi-square test indicated that there was a significant relationship between gender and anxiety severity (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig4\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003eB, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), with females reporting more severe anxiety symptoms than males. Additionally, there was a significant association between gender and depression status (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig6\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003eA, p\\u0026thinsp;=\\u0026thinsp;0.026). However, there was no significant relationship between gender and depression severity (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig6\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003eB, p\\u0026thinsp;=\\u0026thinsp;0.078).\\u003c/p\\u003e\\u003cp\\u003eIn the young and pediatric population, a chi-square test indicated a significant relationship between gender and anxiety status (p\\u0026thinsp;=\\u0026thinsp;0.046), with females having more anxiety than males in this age group. However, there was no significant relationship between gender and depression status in the young and pediatric population (p\\u0026thinsp;=\\u0026thinsp;0.472).\\u003c/p\\u003e \\u003cp\\u003eLastly, a chi-square test revealed no significant relationship between gender and age (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig9\\\" class=\\\"InternalRef\\\"\\u003e5\\u003c/span\\u003e, p\\u0026thinsp;=\\u0026thinsp;0.062), suggesting that age distribution was similar across genders in the study population.\\u003c/p\\u003e \"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eA reliable and brief tool for screening anxiety and depression is the Patient Health Questionnaire-4 (PHQ-4), a 4-item self-report instrument that combines the 2-item PHQ-2 for depression and the 2-item Generalized Anxiety Disorder (GAD-2) scale for anxiety\\u003csup\\u003e11,15\\u003c/sup\\u003e. The psychometric properties of the PHQ-4 have been well-documented in a range of populations, including Hispanic Americans, Colombians, Germans, Filipinos, Paraguayan and others\\u003csup\\u003e10\\u0026ndash;17\\u003c/sup\\u003e. Our study confirms the utility of this tool in identifying anxiety and depression symptoms in the pediatric population in Santo Domingo, Ecuador. We found that pediatric females had significantly higher rates of anxiety compared to males, while depression rates also trended higher in females, though without statistical significance. Anxiety rates increased with age, while depression rates did not follow a clear age-related trend. Our study confirmed a gender disparity in both anxiety and depression rates, with females exhibiting higher rates of both conditions compared to males. This is consistent with broader epidemiological trends, where depression and anxiety disorders are more prevalent in females than in males, particularly after puberty\\u003csup\\u003e18,19\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eThe prevalence of anxiety and depression in Ecuador, as reported in our study, appears higher than national estimates. This is consistent with the general burden of mental health disorders in low- and middle-income countries (LMICs), where access to mental health care is often limited. In Ecuador, the prevalence of depression is reported to be 4.6%, and anxiety affects 5.6% of the population, yet treatment rates are low, with only a small percentage receiving adequate care\\u003csup\\u003e2\\u003c/sup\\u003e (Pan American Health Organization, 2018). The study proved that the Spanish version of the PHQ-9 aid in the screening of the patients with depression in the Ecuadorian public health system\\u003csup\\u003e20\\u003c/sup\\u003e. This highlights the need for widespread, accessible screening tools like the PHQ-4 in both clinical and community settings to identify and manage these conditions early on.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eThis study demonstrates the utility of the PHQ-4 as a screening tool for depression and anxiety in a primary care setting in Ecuador. The PHQ-4 is an inexpensive and easily administered tool that has utility in underserved populations to screen for anxiety and depression. In Santo Domingo, Ecuador, the PHQ-4 ultra-brief screening tool was useful in evaluating risk of depression and anxiety in patients seen during the August 2020 Brigade. Anxiety and depression rates among pediatric patients particularly among females in this population were higher than the estimated prevalence of anxiety and depression in Ecuador nationally.\\u003c/p\\u003e \\u003cp\\u003eFuture studies should aim to obtain normative data from a broader range of populations within Ecuador, similar to studies conducted in Colombia and other Latin American countries.\\u003c/p\\u003e \\u003cp\\u003eRoutine mental health screening, including the use of tools like the PHQ-4, should be integrated into primary care settings to improve early detection and treatment of mental health disorders, ultimately improving the quality of life for individuals in underserved communities.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cul\\u003e\\n \\u003cli\\u003ePHQ-4 Patient Health Questionnaire-4\\u003c/li\\u003e\\n \\u003cli\\u003eGAD-2 Generalized Anxiety Disorders\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eLMICs Low- and middle- income countries\\u0026nbsp;\\u003c/li\\u003e\\n\\u003c/ul\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cul\\u003e\\n \\u003cli\\u003eThis study was conducted in accordance with the ethical standards of the University of Kentucky and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eInformed consent was obtained from all individual participants (for pediatric participants, we obtained from their parent or legal guardian) included in the study.\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eThis initiative was not originally designed as a research study but was part of a broader medical brigade that integrated medicine, physical therapy, pharmacy, and nursing. A psychology team was included to triage patients for anxiety and depression, assess the feasibility of mental health screening in this setting, and provide on-site intervention as needed.\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003e- Given the informal nature of the initial data collection, the research team later sought Institutional Review Board (IRB) approval from the University of Kentucky (UK). Ethical approval for the study was obtained from IRB.\\u003c/p\\u003e\\n\\u003cp\\u003e- The PHQ-4 was administered at the time of patient registration, and verbal consent was obtained from the adult patients and their parents or legal guardian with pediatric patients. \\u0026nbsp;Although patients appeared receptive to mental health screening, no formal data were collected on acceptance rates due to the non-research nature of the initial initiative.\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003eAvailability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\\u003c/li\\u003e\\n \\u003cli\\u003eCompeting interests: The authors declare that they have no competing interest\\u003c/li\\u003e\\n \\u003cli\\u003eFunding: no funding\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eClinical trial number: not applicable.\\u003c/li\\u003e\\n \\u003cli\\u003eAuthors\\u0026apos; contributions: M.I. and T.Y. prepared and wrote the manuscript. M.J. R.A. P.B. R.M have collected the data. A.S have analyzed the data.\\u0026nbsp;\\u003c/li\\u003e\\n\\u003c/ul\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eGlobal, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Psychiatry 2022;9(2):137-150. (In eng). DOI: 10.1016/s2215-0366(21)00395-3.\\u003c/li\\u003e\\n\\u003cli\\u003eKohn R, Ali AA, Puac-Polanco V, et al. Mental health in the Americas: an overview of the treatment gap. Rev Panam Salud Publica 2018;42:e165. (In eng). DOI: 10.26633/rpsp.2018.165.\\u003c/li\\u003e\\n\\u003cli\\u003eWalter HJ, Bukstein OG, Abright AR, et al. Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders. J Am Acad Child Adolesc Psychiatry 2020;59(10):1107-1124. (In eng). DOI: 10.1016/j.jaac.2020.05.005.\\u003c/li\\u003e\\n\\u003cli\\u003eBeharry M. Pediatric Anxiety and Depression in the Time of COVID-19. Pediatr Ann 2022;51(4):e154-e160. (In eng). DOI: 10.3928/19382359-20220317-01.\\u003c/li\\u003e\\n\\u003cli\\u003eZuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management. Pediatrics 2018;141(3) (In eng). DOI: 10.1542/peds.2017-4081.\\u003c/li\\u003e\\n\\u003cli\\u003eVermani M, Marcus M, Katzman MA. Rates of detection of mood and anxiety disorders in primary care: a descriptive, cross-sectional study. Prim Care Companion CNS Disord 2011;13(2) (In eng). DOI: 10.4088/PCC.10m01013.\\u003c/li\\u003e\\n\\u003cli\\u003eSzuhany KL, Simon NM. Anxiety Disorders: A Review. JAMA 2022;328(24):2431-2445. DOI: 10.1001/jama.2022.22744.\\u003c/li\\u003e\\n\\u003cli\\u003eKessler RC, Bromet EJ. The epidemiology of depression across cultures. Annu Rev Public Health 2013;34:119-38. (In eng). DOI: 10.1146/annurev-publhealth-031912-114409.\\u003c/li\\u003e\\n\\u003cli\\u003eMu\\u0026ntilde;oz RA, McBride ME, Brnabic AJ, et al. Major depressive disorder in Latin America: the relationship between depression severity, painful somatic symptoms, and quality of life. J Affect Disord 2005;86(1):93-8. (In eng). DOI: 10.1016/j.jad.2004.12.012.\\u003c/li\\u003e\\n\\u003cli\\u003eKroenke K, Spitzer RL, Williams JB, L\\u0026ouml;we B. An ultra-brief screening scale for anxiety and depression: the PHQ-4. Psychosomatics 2009;50(6):613-21. (In eng). DOI: 10.1176/appi.psy.50.6.613.\\u003c/li\\u003e\\n\\u003cli\\u003eL\\u0026ouml;we B, Wahl I, Rose M, et al. A 4-item measure of depression and anxiety: Validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. Journal of Affective Disorders 2010;122(1):86-95. DOI: https://doi.org/10.1016/j.jad.2009.06.019.\\u003c/li\\u003e\\n\\u003cli\\u003eSanabria-Mazo JP, Useche-Aldana B, Ochoa PP, et al. Social Inequities in the Impact of COVID-19 Lockdown Measures on the Mental Health of a Large Sample of the Colombian Population (PSY-COVID Study). J Clin Med 2021;10(22) (In eng). DOI: 10.3390/jcm10225297.\\u003c/li\\u003e\\n\\u003cli\\u003eMills SD, Fox RS, Pan TM, Malcarne VL, Roesch SC, Sadler GR. Psychometric Evaluation of the Patient Health Questionnaire-4 in Hispanic Americans. Hisp J Behav Sci 2015;37(4):560-571. (In eng). DOI: 10.1177/0739986315608126.\\u003c/li\\u003e\\n\\u003cli\\u003eMendoza NB, Frondozo CE, Dizon J, Buenconsejo JU. The factor structure and measurement invariance of the PHQ-4 and the prevalence of depression and anxiety in a Southeast Asian context amid the COVID-19 pandemic. Curr Psychol 2022:1-10. (In eng). DOI: 10.1007/s12144-022-02833-5.\\u003c/li\\u003e\\n\\u003cli\\u003eKroenke K, Spitzer RL, Williams JB, L\\u0026ouml;we B. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry 2010;32(4):345-59. (In eng). DOI: 10.1016/j.genhosppsych.2010.03.006.\\u003c/li\\u003e\\n\\u003cli\\u003eCaycho-Rodr\\u0026iacute;guez T, Traveza\\u0026ntilde;o-Cabrera A, Torales J, et al. Psychometric network analysis of the Patient Health Questionnaire-4 (PHQ-4) in Paraguayan general population. Psicologia: Reflex\\u0026atilde;o e Cr\\u0026iacute;tica 2024;37(1):15. DOI: 10.1186/s41155-024-00299-x.\\u003c/li\\u003e\\n\\u003cli\\u003eMateru J, Kuringe E, Nyato D, et al. The psychometric properties of PHQ-4 anxiety and depression screening scale among out of school adolescent girls and young women in Tanzania: a cross-sectional study. BMC Psychiatry 2020;20(1):321. (In eng). DOI: 10.1186/s12888-020-02735-5.\\u003c/li\\u003e\\n\\u003cli\\u003eHyde JS, Mezulis AH, Abramson LY. The ABCs of depression: integrating affective, biological, and cognitive models to explain the emergence of the gender difference in depression. Psychol Rev 2008;115(2):291-313. (In eng). DOI: 10.1037/0033-295x.115.2.291.\\u003c/li\\u003e\\n\\u003cli\\u003eThapar A, Collishaw S, Pine DS, Thapar AK. Depression in adolescence. Lancet 2012;379(9820):1056-67. (In eng). DOI: 10.1016/s0140-6736(11)60871-4.\\u003c/li\\u003e\\n\\u003cli\\u003eQui\\u0026ntilde;onez-Freire C, Vara MD, Tom\\u0026aacute;s JM, Ba\\u0026ntilde;os RM. Psychometric properties of the Spanish version of the Patient Health Questionnaire-9 in users of the Ecuadorian public health care system. Revista Latinoamericana de Psicolog\\u0026iacute;a 2021;53.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Anxiety, Depression, PHQ-4, Screening, Pediatric, Global Health, Ecuador, Underserved population, Mental Health\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-6629859/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-6629859/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground\\u003c/strong\\u003e: Anxiety and depression are prevalent mental health conditions, yet they often remain underdiagnosed, especially in underserved populations. In Ecuador, mental health disorders are a significant public health concern, with limited access to mental health resources. The Patient Health Questionnaire-4 (PHQ-4) is a widely used, ultra-brief self-reported screening tool for identifying symptoms of anxiety and depression. This study aimed to assess the utility of the PHQ-4 in screening pediatric and adult populations in Santo Domingo, Ecuador, during a medical brigade in August 2020.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods\\u003c/strong\\u003e: The PHQ-4, consisting of two items for depression (PHQ-2) and two items for anxiety (GAD-2), was administered to patients aged 12 and older attending the medical brigade. A total of 380\\u003cstrong\\u003e \\u003c/strong\\u003eindividuals participated. Screening results were analyzed by age group, sex, and symptom severity, with scores categorized as mild (0-5), moderate (6-8), or severe (9-12). Statistical analysis was performed using IBM SPSS Statistics, including one-way ANOVA, Pearson’s correlation, independent samples t-tests, Pearson’s chi-square, and Fisher’s exact tests\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults\\u003c/strong\\u003e: The study revealed significant gender differences in anxiety scores, with pediatric females showing a statistically significant higher prevalence of anxiety compared to males (35.8% vs. 12.5%, p \\u0026lt; 0.05). While depression scores were higher in females, the difference did not reach statistical significance (33.7% in females vs. 25% in males). Anxiety rates increased with age, while depression rates varied without a significant trend. Notably, the prevalence of anxiety and depression among pediatric patients in this population was higher than the national estimates for Ecuador.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion\\u003c/strong\\u003e: The PHQ-4 proved to be an effective screening tool for identifying anxiety and depression in the Santo Domingo population. Significant gender differences in anxiety and depression were observed, with higher rates in females and a noticeable increase in anxiety with age. Given the higher prevalence of mental health disorders in this population, regular use of the PHQ-4 in global medical brigades is recommended to improve the understanding and management of mental health in underserved regions.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Use of PHQ-4 Tool to Assess Anxiety and Depression in Adolescents and Adults in Medically Underserved Santo Domingo, Ecuador\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-06-03 07:17:46\",\"doi\":\"10.21203/rs.3.rs-6629859/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"b16599d7-dc83-488f-b782-c6caa55f3ef9\",\"owner\":[],\"postedDate\":\"June 3rd, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-08-04T15:23:24+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-06-03 07:17:46\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-6629859\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-6629859\",\"identity\":\"rs-6629859\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}