Validation of the ultra-brief self-report Patient Health Questionnaire-4 (PHQ-4) to measure anxiety and depression in Arabic-speaking adults

Validation of the ultra-brief self-report Patient Health Questionnaire-4 (PHQ-4) to measure anxiety and depression in Arabic-speaking adults | 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 Validation of the ultra-brief self-report Patient Health Questionnaire-4 (PHQ-4) to measure anxiety and depression in Arabic-speaking adults Sahar Obeid, Ali Hemade, Diana Malaeb, Fouad Sakr, Mariam Dabbous, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4200473/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Jul, 2024 Read the published version in BMC Psychiatry → Version 1 posted 12 You are reading this latest preprint version Abstract Background: Anxiety and depression are psychiatric disorders that often coexist and share some features. Developing a simple and cost-effective tool to assess anxiety and depression in the Arabic-speaking population, predominantly residing in low- and middle-income nations where research can be arduous, would be immensely beneficial. The study aimed to translate the four-item composite Patient Health Questionnaire – 4 (PHQ-4) into Arabic and evaluate its psychometric properties, including internal reliability, sex invariance, composite reliability, and correlation with measures of psychological distress. Methods: 587 Arabic-speaking adults were recruited between February and March 2023. An anonymous self-administered Google Forms link was distributed via social media networks. We utilized the FACTOR software to explore the factor structure of the Arabic PHQ-4. Results: Confirmatory factor analysis (CFA) indicated that fit of the two-factor model of the PHQ-4 scores was modest ( χ 2 / df = .13/1 = .13, RMSEA = .001, SRMR = .002, CFI = 1.005, TLI = 1.000). Internal reliability was excellent (McDonald’s omega = .86; Cronbach’s alpha = .86). Indices suggested that configural, metric, and scalar invariance were supported across sex. No significant difference was found between males and females in terms of the PHQ-4 total scores, PHQ-4 anxiety scores, and PHQ-4 depression scores. The total score of the PHQ-4 and its depression and anxiety scores were significantly and moderately-to-strongly associated with lower wellbeing and higher Depression Anxiety and Stress Scale (DASS) total and subscales scores. Conclusion: The PHQ-4 proves to be a reliable, valid, and cost-effective tool for assessing symptoms related to depression and anxiety. To evaluate the practical effectiveness of the Arabic PHQ-4 and to further enhance the data on its construct validity, future studies should assess the measure in diverse contexts and among specific populations. Anxiety Depression Patient Health Questionnaire Arabic Psychometric properties Validation Figures Figure 1 INTRODUCTION Anxiety and depression are psychiatric disorders that often coexist and share some features. Both conditions are highly prevalent, with anxiety affecting approximately one in 15 persons annually and depression affecting one in 20 persons annually [ 1 ]. The prevalence of anxiety and depression varies across different populations and settings. In primary healthcare settings, the prevalence of anxiety and depression disorders is high, with 91% of patients exhibiting depression and anxiety disorders of various severities [ 2 ]. Among college students in Kathmandu, Nepal, the prevalence of anxiety was 53.97% and the prevalence of depression was 39.88% [ 3 ]. Among individuals with type 2 diabetes, the prevalence of anxiety and depression was 57.9% and 43.5%, respectively [ 4 ]. In populations exposed to war, the aggregate prevalence of depression and anxiety during times of conflict or war was 28.9%, 30.7% and 23.5%, respectively [ 5 ]. Comorbidity of anxiety and depression may be present as the full clinical picture of the two syndromes or as limited symptoms from both two syndromes. Anxiety disorders typically present first [ 6 ]. In a study conducted in the Netherlands, 63% of individuals with depressive disorder had a current comorbid anxiety disorder, while 63% of individuals with anxiety disorder had a current depressive disorder [ 7 ]. Anxiety and depression also share similar risk factors, including female gender, family history, and perinatal factors [ 8 ]. Neurobiological research has shown consistent abnormalities across both anxiety and depression, particularly in amygdala hyperactivity [ 9 ]. Anxiety and depression can lead to functional disability [ 10 ], including impaired physical functioning, role limitations due to emotional health problems, and decreased social functioning. A research has shown that both anxiety and depressive symptoms are associated with a reduced quality of life [ 11 ]. Compared with those without anxiety, individuals with moderate to severe anxiety were less likely to meet ideal levels of physical activity. Similarly, individuals with moderate to severe depression were less likely than those without depression to meet ideal levels of physical activity, body mass index, sleep, and blood pressure [ 12 ]. Furthermore, one study showed that people with low depression and high anxiety, with high depression and low anxiety, and with high depression and high anxiety were at 2.46, 26.32 and 54.77 times more risk for suicide, compared to subjects with low depression and low anxiety [ 13 ]. Treatment options including antidepressants and cognitive behavioral therapy are similar for anxiety and depression [ 14 ]. Results from 51,547 respondents in a World Health Organization (WHO) study revealed that only 9.8% of individuals with anxiety disorder received adequate treatment, and only 27.6% received any form of treatment at all [ 15 ]. Several instruments have been developed for measuring depression, including the Beck Depression Inventory [ 16 ], Hamilton Depression Rating Scale [ 17 ], Montgomery-Åsberg Depression Rating Scale [ 18 ], and Lebanese Depression Scale [ 19 ]. A commonly used brief depression severity scale is the Patient Health Questionnaire – 9 (PHQ-9) [ 20 ], which has been shortened into the two-item PHQ-2 [ 21 ]. Similarly, other scales were developed to measure clinical anxiety, such as the Beck Anxiety Inventory [ 22 ], Lebanese Anxiety Scale [ 23 ], and Generalized Anxiety Disorder Scale – 7 (GAD–7) [ 24 ]. The 7-item GAD-7 scale was shortened into the 2-item GAD-2 [ 25 ]. However, these previous scales either measure depression or anxiety separately, but do not measure both. Considering the high comorbidity of these two disorders, there was a need for a validated and reliable scale that measures both depression and anxiety. From this perspective, the four-item composite Patient Health Questionnaire – 4 (PHQ-4) was developed by combining the PHQ-2 and GAD-2 scales [ 26 ], which containing two core anxiety items and two core depression items. In the original study [ 26 ], the PHQ-4 demonstrated construct validity, factorial validity, and internal reliability, proving to be an efficient ultra-brief tool for screening for anxiety, depression, or both. Higher scores on the PHQ-4 scale indicate a need for further assessment for anxiety, depression, or both. Ultra brief assessment tools such as the PHQ-4 are essential for busy clinicians, patient follow-up after treatment, and time-restricted research. Numerous studies have shown that ultra-short two- or three-question tests perform comparably to their longer counterparts [ 27 – 29 ]. In fact, the PHQ-4 has shown comparable performance to longer depression and anxiety measures in terms of correlating well with measures of quality of life, disability days, and healthcare utilization [ 26 ]. The PHQ-4 has been validated and proved to be reliable for use in various populations, including the general population [ 30 ], college students [ 31 ], pregnancy [ 32 ] and attention-deficit/hyperactivity disorder (ADHD) patients [ 33 ]. Multiple languages including Spanish [ 34 ], Portuguese [ 35 ], Greek [ 36 ], Korean [ 37 ], and Colombian [ 38 ] has been translated and validated. Numerous studies have proven a cross-cultural validation of the PHQ-4 [ 39 , 40 ]. Yet, to date, no efforts have been made to validate the PHQ-4 in Arabic. Besides participating in the cross-national body of work on this scale, we believe that providing a validated Arabic version of the PHQ-4 is critical for many reasons. Firstly, mental disorders are a leading cause of disability in the Arab region, which encompasses 5.54% of the global population [ 41 ]. Secondly, Arab individuals are less likely to have access to mental health services due to insufficient planning, inadequate community services, and ongoing military conflicts [ 42 ]. Out of 20 Arab countries, six lack mental health legislation, and two lack a mental health policy [ 43 ]. Thirdly, Arab countries produce only 1% of the global output of peer-reviewed mental health related publications [ 41 ]. In Lebanon alone, research has shown that 17% of individuals met the criteria for a 12-month mental disorder, and 27% were classified as serious [ 44 ], and half of the respondents had a history of exposure to war-related traumatic events. The availability of a psychometrically validated ultra-brief scale such as the PHQ-4 in Arabic will assist clinicians in screening for anxiety and depression, provide a valuable follow-up tool to assess intervention efficacy, enhance augment mental health research in the Arab world, and contribute to a broader cross-cultural validation of the PHQ-4. Therefore, the aim of this study was to translate the PHQ-4 into Arabic and determine the psychometric properties of this translation, including internal reliability, sex invariance, composite reliability, and its correlation with measures of psychological distress and well-being. We hypothesize that our translation of the PHQ-4 will demonstrate a fit for a two-factor solution similar to the original scale [ 26 ], good internal consistency reliability, adequate convergent and concurrent validity, as well as cross-sex invariance. METHODS Participants and procedures All data were collected via a Google Form link, between February and March 2023. After being trained by the research team, five university students were asked to collect data via the snowball sampling technique. Students were instructed to forward the link to acquaintances, who were asked to forward the link to other family members and friends. Inclusion criteria for participation included being of a resident and citizen of Lebanon of adult age. Exclusion criteria were those who refused to fill out the questionnaire. Internet protocol (IP) addresses were monitored to prevent duplicate survey responses. Participants provided digital informed consent before completing the survey instruments, which were presented in a pre-randomized order to control for order effects. The survey was anonymous and participation was voluntary and without remuneration. A total of 587 participants completed the survey (mean age of 34.48 ± 15.06 years, 69.4% females, 42.7% married and 74.0% with a university level of education). Translation Procedure According to Beaton’s guidelines [ 45 ], the forward-backward translation approach was employed for the scale. Initially, the English version was translated into Arabic by two Lebanese translators who were unaffiliated with the study. Subsequently, two Lebanese psychologists who were proficient in English, back-translated the Arabic version back into English. To ensure the accuracy of the translation, the original English version and the translated one were compared, and any inconsistencies were identified and corrected by a committee of experts comprising the research team and the translators [ 46 ]. Furthermore, an adaptation of the measure to the Arab context was conducted to ascertain any potential misunderstanding of the item wordings and the ease of item interpretation, ensuring the conceptual equivalence between the original and Arabic scale in both contexts [ 47 ]. Following translation and adaptation of the scale, a pilot study was conducted with 20 participants to confirm comprehension of all questions; no alterations were made after the pilot study. Measures Patient Health Questionnaire (PHQ-4). The PHQ-4 is a concise 4-item questionnaire designed to assess anxiety and depressive symptoms experienced over the past two weeks [ 26 ]. It comprises two subscales: anxiety (e.g. “ Feeling nervous, anxious or on edge ”) and depression (e.g. “ Little interest or pleasure in doing things ”), each consisting of two items. Each item is rated on a 4-point Likert scale ranging from 0 (not at all) to 3 (nearly every day). To calculate the total PHQ-4 score, the scores from all four items are summed. The cut-off score for the PHQ-4’s subscales is greater than or equal to 3. A total PHQ-4 score of 6 or higher, or individual scores of 3 or higher on either the anxiety or depression subscales, suggest the presence of depression or an anxiety disorder. The Depression Anxiety and Stress Scale-8 items (DASS-8) : This instrument has been developed and validated in Arabic by Ali et al. [ 48 ]. It is composed of eight items and three dimensions: (1) stress (two items; e.g. “ I felt that I was using a lot of nervous energy” ), (2) anxiety (three items; e.g. “ I felt scared without any good reason” ), and (3) depression (three items; “ I was unable to become enthusiastic about anything” ). Higher scores reflect higher level of symptom affirmation. WHO-5 Wellbeing Index. Validated in Lebanon [ 49 ], formed of 5 items scored on a 6-point Likert scale with anchors ranging from “at no time” to “all the time” (e.g. “ In the last two weeks, I have felt cheerful in good spirits” ). Items are summed on a scale from 0 to 25, with higher scores reflecting higher wellbeing [ 50 ]. Analytic Strategy Data treatment. There were no missing responses in the dataset. To examine the factor structure of the PHQ-4, we conducted a confirmatory factor analysis (CFA) using the data from the total sample via SPSS and AMOS (version 29) software. A minimum sample size of 80 participants was needed, based on 20 participants per item on the scale was deemed necessary to conduct the CFA [ 51 ]. Parameter estimates were obtained using the maximum likelihood method. Calculated fit indices were the normed model chi-square ( χ² / df ), the Steiger-Lind root mean square error of approximation (RMSEA), standardized root mean square residual (SRMR), the Tucker–Lewis index (TLI) and the comparative fit index (CFI). Values ≤ 5 for χ² / df , ≤ .08 for RMSEA, ≤ .05 for SRMR and ≥ .95 for CFI and TLI indicate good fit of the model to the data [ 52 ]. Multivariate normality was verified (Bollen-Stine p = .752). Convergent validity was confirmed via an average extracted variance (AVE) value > 0.5. Sex invariance. To examine sex invariance of the PHQ-4 scores, we conducted multi-group CFA using the total sample [ 53 ]. Measurement invariance was assessed at the configural, metric and scalar levels [ 54 ]. We accepted ΔCFI ≤ .010 and ΔRMSEA ≤ .015 or ΔSRMR ≤ .010 as evidence of invariance [ 53 ], Comparison between males and females was done using the Student t-test only if scalar or partial scalar invariance held. Further analyses. Composite reliability in both subsamples was assessed using McDonald’s omega (ω) and Cronbach’s alpha (α), with values greater than .70 reflecting adequate composite reliability [ 55 ]. The normality of the PHQ-4 score was verified, since the skewness and kurtosis values for each item of the scale varied between − 1 and + 1 [ 56 ]. To assess concurrent validity, Pearson’s correlation coefficient was used to correlate the PHQ-4 scores with DASS-8 and WHO-5. Correlation coefficients values ≤ .10 were considered weak, ~ .30 were considered moderate, and ~ .50 were considered strong correlations [ 57 ]. RESULTS Five hundred eighty-seven participants completed the survey, with a mean age of 34.48 ± 15.06 years, 69.4% females, 42.7% married and 74.0% with a university level of education. Moreover, according to the PHQ-4 cut-off, 24.0% of the participants reported no depression, whereas 37.2%, 30.2% and 8.6% of the participants showed mild, moderate and severe psychological distress respectively. Confirmatory factor analysis CFA indicated that the fit of the two-factor model of the PHQ-4 scores was modest: χ 2 / df = .13/1 = .13, RMSEA = .001 (90% CI < .001, .078), SRMR = .002, CFI = 1.005, TLI = 1.000. The standardized estimates of factor loadings were all adequate (Fig. 1 ). Internal reliability was excellent (McDonald’s ω = .86; Cronbach’s α = .86). The AVE value was satisfactory at = .65. Sex invariance The indices suggested that configural, metric, and scalar invariance were supported across sex (Table 1 ). No significant difference was found between males and females in terms of the PHQ-4 total scores (4.75 ± 3.16 vs 4.67 ± 3.00, t (590) = .30, p = .762), PHQ-4 anxiety scores (2.31 ± 1.66 vs 2.27 ± 1.71, t(590) = .24, p = .807), and PHQ-4 depression scores (2.44 ± 1.68 vs 2.40 ± 1.57, t(590) = .32, p = .751). Table 1 Measurement invariance across sex in the total sample. Model CFI RMSEA SRMR Model Comparison ΔCFI ΔRMSEA ΔSRMR Configural 1.000 < .001 .004 Metric .995 .047 .025 Configural vs metric .005 .047 .021 Scalar .991 .053 .025 Metric vs scalar .004 .006 < .001 Note. CFI = Comparative fit index; RMSEA = Steiger-Lind root mean square error of approximation; SRMR = Standardized root mean square residual. Convergent and concurrent validity The PHQ-4 total score and the PHQ-4 depression and anxiety scores were significantly and moderately-to-strongly associated with lower wellbeing and higher DASS total and subscales scores (Table 2 ). Table 2 Pearson correlation matrix Mean ± SD 1 2 3 4 5 6 7 1. PHQ-4 total 4.69 ± 3.05 1 2. PHQ-4 anxiety 2.28 ± 1.69 .93*** 1 3. PHQ-4 depression 2.41 ± 1.60 .92*** .71*** 1 4. DASS total 10.42 ± 6.07 .56*** .53*** .51*** 1 5. DASS depression 3.79 ± 2.47 .52*** .47*** .49*** .92*** 1 6. DASS anxiety 3.52 ± 2.68 .50*** .48*** .43*** .91*** .76*** 1 7. DASS stress 3.11 ± 1.69 .46*** .44*** .41*** .80*** .65*** .59*** 1 8. Well-being 13.68 ± 5.60 − .50*** − .46*** − .47*** − .36*** − .36*** − .24*** − .39*** *** p < .001 DISCUSSION The findings from this study suggest that an ultra-brief 4-item measure can reliably and validly measure depression and anxiety in the general population. Overall, the results support the reliability and validity of the instrument, as well as its suitability for use in Arabic-speaking adults from the general population. It is important to note the PHQ-4 serves only serve as a screening tool, and individuals with elevated PHQ–4 scores should undergo further assessment to determine whether they meet the full diagnostic criteria for either disorder or if intervention is warranted. Though depression and anxiety often coexist [ 58 , 59 ], assessment for both conditions seems necessary. Consistent with prior research conducted in various countries, such as Germany [ 30 ], Colombia [ 38 ], the United States [ 26 , 34 ], Spain [ 60 ], and Iran [ 61 ], our study reaffirmed the two-factor structure of the PHQ-4, indicating distinct subscales for anxiety and depression. Hence, our findings support the differentiation between the two scales, PHQ-2 and GAD-2, rather than relying solely on one of them or the total PHQ-4 score. However, these finding contrasts with a study conducted among a sample of Quechua speakers, which supported a one-dimensional model, where anxiety and depression items combined to form a single latent variable of emotional problems [ 62 ]. Given the brevity of the PHQ-4, its reliability was notably high. In our study, internal reliability was excellent (McDonald's ω = .86; Cronbach's α = .86), slightly surpassing those reported in the German validation study for the PHQ-2 (α = 0.75) and GAD-2 (α = 0.82) [ 30 ], and to some extent similar to the values from previous studies conducted across various other populations [ 26 , 30 – 32 , 34 , 37 , 38 ]. This suggests that the PHQ-4 is equally effective in measuring symptoms of depression and anxiety in the Arabic-speaking population as it is in other demographic groups. Another finding of our research is that the factor loadings of the Arabic PHQ-4 remained consistent across sex at the three levels (configural, metric, and scalar). Consequently, comparisons between sex groups showed no statistically significant variances in PHQ-4 total scores and two subscores within our sample. Put differently, individuals of both genders comprehend and interpret the significance of PHQ-4 items similarly. Consistent with our findings, studies conducted in Colombia [ 38 ], Germany [ 30 ], and Greece [ 36 ] have also provided evidence supporting the consistency of measurement across sexes. Our findings also revealed that the PHQ-4 depression and anxiety scores were significantly and moderately-to-strongly associated with depression, anxiety and stress scores as measured using another brief scale, i.e. the DASS-8, thus confirming the convergent validity of the Arabic PHQ-4. Furthermore, the PHQ-4 total score and the PHQ-4 depression and anxiety scores were linked to lower levels of well-being, in line with a previous study [ 63 ]. Indeed, the presence of both anxiety and depressive disorders has been shown to have negative impacts on various aspects of an individual's life, including perceived well-being, satisfaction in relationships [ 64 – 66 ], poorer occupational outcomes [ 67 ], and more loneliness [ 68 ]. These negative impacts may be attributed to the common characteristics observed in individuals experiencing depressive and anxiety symptoms, such as fatigue, loss of energy, feeling slowed down or agitated, poor attention and concentration, slow thinking, distractibility, impaired memory, and indecisiveness [ 69 ], all of which contribute to a diminished well-being. Our study showed that, according to the PHQ-4 cut-off, 24.0% of the participants had no depression, while 37.2%, 30.2% and 8.6% of the participants exhibited mild, moderate and severe psychological distress respectively. These findings are consistent with a prior study indicating a depression prevalence of 34.44% in the Southeast Asian context [ 70 ], as well as recent meta-analytic studies by Bueno-Notivol et al. [ 71 ] and Salari et al. [ 72 ]. Nevertheless, our results are higher than those reported in a German study, which suggested that 6.5% and 7.0% of participants had probable anxiety and depression, respectively [ 73 ]. Lebanon has recently experienced a series of profound tragedies, including the COVID-19 pandemic and the devastating explosion at the Beirut port on August fourth, which stands as the world's most powerful non-nuclear explosion [ 74 ]. Additionally, Lebanon is grappling with its worst economic crisis in modern history, characterized by the rapid devaluation of the national currency, one of the highest inflation rates globally, and severe shortages of essential resources such as electricity and fuel. All those factors are significantly impacting the well-being and contributing to an increase in psychological disorders among the Lebanese population. Consequently, interventions aimed at early detection and treatment may play a crucial role in reducing the persistence or severity of primary anxiety and depressive disorders and preventing the onset of secondary disorders. Clinical Implications Providing a reliable and valid Arabic version of the PHQ-4 could help gather precise epidemiological information regarding anxiety and depression symptoms in Arab nations. This initiative could enhance awareness surrounding mental health (anxiety and depression) screening and diagnosis in Arab contexts, and guide the creation of culturally appropriate interventions grounded in evidence. Limitations Firstly, the snowball sampling method was used, which may have introduced sampling bias and restricted the representation of the general population. Hence, future studies should aim to employ more diverse and representative sampling techniques to enhance the external validity of the findings. Secondly, using cross-sectional data precludes the ability to assess the predictive validity and test–retest reliability of the PHQ-4. Additionally, despite the utilization of a substantial community sample of Lebanese participants in this study, access to the survey was restricted to individuals with internet connectivity, potentially leading to an incomplete representation of the entire adult general population. Finally, this study was conducted exclusively in Lebanon, thereby restricting the generalizability of our results to Arab-speaking individuals in other Arab and non-Arab countries. CONCLUSION The PHQ-4 proves to be a reliable, valid, and cost-effective tool for assessing symptoms related to depression and anxiety. Using reliable mental health screening instruments lessens the load on participants in extensive data gathering, facilitates swift estimation by researchers of the prevalence and intensity of mental health symptoms, assists in timely interventions and psychological support, and provides a sustainable method for monitoring and assessing mental health symptoms amidst economic crises and other humanitarian disasters. To evaluate the practical effectiveness of the Arabic PHQ-4 and to further enhance the data on its construct validity, future studies should assess the measure in diverse contexts and among specific populations. Declarations Ethics Approval and Consent to Participate: Ethics approval for this study was obtained from the ethics committee of the School of Pharmacy at the Lebanese International University (2023RC-006-LIUSOP). When filling out the online form, each participant provided written informed consent, as did their parents or legal guardian(s) if they were study participants under the age of sixteen. Every step of the process was carried out in compliance with all applicable laws and rules (such as the Declaration of Helsinki). Consent for publication: Not applicable. Availability of data and materials : All data generated or analyzed during this study are not publicly available due the restrictions from the ethics committee, but are available upon a reasonable request from the corresponding author. Competing interests: The authors have nothing to disclose. Funding: None. Author contributions: FFR, SO and SH designed the study; SO and AH drafted the manuscript; SH carried out the analysis and interpreted the results; DM, FS, and MD collected the data. JX, YY, CJ, and RM authors reviewed the paper for intellectual content; all authors reviewed the final manuscript and gave their consent. 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Cohen J: Quantitative methods in psychology: A power primer . In: Psychological bulletin: 1992 : Citeseer; 1992. Olfson M, Shea S, Feder A, Fuentes M, Nomura Y, Gameroff M, Weissman MM: Prevalence of anxiety, depression, and substance use disorders in an urban general medicine practice . In . , vol. 9. United States; 2000: 876. Schonfeld WH, Verboncoeur CJ, Fifer SK, Lipschutz RC, Lubeck DP, Buesching DP: The functioning and well-being of patients with unrecognized anxiety disorders and major depressive disorder . Journal of affective disorders 1997, 43 (2):105-119. Cano-Vindel A, Muñoz-Navarro R, Medrano LA, Ruiz-Rodríguez P, González-Blanch C, Gómez-Castillo MD, Capafons A, Chacón F, Santolaya F, Psic APRG: A computerized version of the Patient Health Questionnaire-4 as an ultra-brief screening tool to detect emotional disorders in primary care . Journal of affective disorders 2018, 234 :247-255. Ghaheri A, Omani-Samani R, Sepidarkish M, Hosseini M, Maroufizadeh S: The Four-item Patient Health Questionnaire for Anxiety and Depression: A Validation Study in Infertile Patients . International journal of fertility & sterility 2020, 14 (3):234-239. Carranza Esteban RF, Caycho Rodríguez T, Mamani Benito OJ, Cjuno J, Vilca Quiro LW, Barrios I, Tito Betancur M, Torales J: Adaptation and Validation of the Patient Health Questionnaire for Depression and Anxiety (PHQ-4) in a sample of Quechua-speaking Peruvians . Medicina clínica y social 2024, 8 (1):63-74. Malone C, Wachholtz A: The Relationship of Anxiety and Depression to Subjective Well-Being in a Mainland Chinese Sample . Journal of religion and health 2018, 57 (1):266-278. Stein MB, Heimberg RG: Well-being and life satisfaction in generalized anxiety disorder: comparison to major depressive disorder in a community sample . Journal of affective disorders 2004, 79 (1):161-166. Postler KB, Helms HM, Anastopoulos AD: Examining the linkages between marital quality and anxiety: A meta‐analytic review . Family process 2022, 61 (4):1456-1472. Huh HJ, Kim S-Y, Yu JJ, Chae J-H: Childhood trauma and adult interpersonal relationship problems in patients with depression and anxiety disorders . Annals of general psychiatry 2014, 13 (1):26-26. Deady M, Collins D, Johnston D, Glozier N, Calvo R, Christensen H, Harvey S: The impact of depression, anxiety and comorbidity on occupational outcomes . Occupational Medicine 2022, 72 (1):17-24. Gabarrell-Pascuet A, García-Mieres H, Giné-Vázquez I, Moneta MV, Koyanagi A, Haro JM, Domènech-Abella J: The association of social support and loneliness with symptoms of depression, anxiety, and posttraumatic stress during the COVID-19 pandemic: a meta-analysis . Int J Environ Res Public Health 2023, 20 (4):2765. Tiller JW: Depression and anxiety . The Medical Journal of Australia 2013, 199 (6):S28-S31. Mendoza NB, Frondozo CE, Dizon JIWT, 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 . Current psychology (New Brunswick, NJ) 2022:1-10. Bueno-Notivol J, Gracia-García P, Olaya B, Lasheras I, López-Antón R, Santabárbara J: Prevalence of depression during the COVID-19 outbreak: A meta-analysis of community-based studies . International journal of clinical and health psychology 2021, 21 (1):100196. Salari N, Hosseinian-Far A, Jalali R, Vaisi-Raygani A, Rasoulpoor S, Mohammadi M, Rasoulpoor S, Khaledi-Paveh B: Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: a systematic review and meta-analysis . Globalization Health 2020, 16 :1-11. Wicke FS, Krakau L, Löwe B, Beutel ME, Brähler E: Update of the standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population . J Affective Disord 2022, 312 :310-314. Farran N: Mental health in Lebanon: Tomorrow's silent epidemic . Mental health & prevention 2021, 24 :200218. Additional Declarations No competing interests reported. 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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-4200473","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":287119809,"identity":"ec00c0aa-b5ea-40e3-80b1-9ac9c30a966e","order_by":0,"name":"Sahar 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12:01:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4200473/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4200473/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12888-024-05978-8","type":"published","date":"2024-07-30T15:58:02+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":54184657,"identity":"4140fcad-48d5-44d9-bff3-fc9e1d3ad891","added_by":"auto","created_at":"2024-04-05 17:21:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":75703,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eStandardized Estimates of Factor Loadings from the Confirmatory Factor Analysis in the total sample.\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4200473/v1/3d2ec6d5fc7b91baa83af62e.png"},{"id":61793754,"identity":"3c1b85f6-25ff-44c8-9201-87a1e78391b5","added_by":"auto","created_at":"2024-08-05 16:15:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2545108,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4200473/v1/a5b0a041-7e36-4510-8ca6-0f3188e505f6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Validation of the ultra-brief self-report Patient Health Questionnaire-4 (PHQ-4) to measure anxiety and depression in Arabic-speaking adults","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAnxiety and depression are psychiatric disorders that often coexist and share some features. Both conditions are highly prevalent, with anxiety affecting approximately one in 15 persons annually and depression affecting one in 20 persons annually [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The prevalence of anxiety and depression varies across different populations and settings. In primary healthcare settings, the prevalence of anxiety and depression disorders is high, with 91% of patients exhibiting depression and anxiety disorders of various severities [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Among college students in Kathmandu, Nepal, the prevalence of anxiety was 53.97% and the prevalence of depression was 39.88% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Among individuals with type 2 diabetes, the prevalence of anxiety and depression was 57.9% and 43.5%, respectively [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In populations exposed to war, the aggregate prevalence of depression and anxiety during times of conflict or war was 28.9%, 30.7% and 23.5%, respectively [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Comorbidity of anxiety and depression may be present as the full clinical picture of the two syndromes or as limited symptoms from both two syndromes. Anxiety disorders typically present first [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In a study conducted in the Netherlands, 63% of individuals with depressive disorder had a current comorbid anxiety disorder, while 63% of individuals with anxiety disorder had a current depressive disorder [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Anxiety and depression also share similar risk factors, including female gender, family history, and perinatal factors [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Neurobiological research has shown consistent abnormalities across both anxiety and depression, particularly in amygdala hyperactivity [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnxiety and depression can lead to functional disability [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], including impaired physical functioning, role limitations due to emotional health problems, and decreased social functioning. A research has shown that both anxiety and depressive symptoms are associated with a reduced quality of life [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Compared with those without anxiety, individuals with moderate to severe anxiety were less likely to meet ideal levels of physical activity. Similarly, individuals with moderate to severe depression were less likely than those without depression to meet ideal levels of physical activity, body mass index, sleep, and blood pressure [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Furthermore, one study showed that people with low depression and high anxiety, with high depression and low anxiety, and with high depression and high anxiety were at 2.46, 26.32 and 54.77 times more risk for suicide, compared to subjects with low depression and low anxiety [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Treatment options including antidepressants and cognitive behavioral therapy are similar for anxiety and depression [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Results from 51,547 respondents in a World Health Organization (WHO) study revealed that only 9.8% of individuals with anxiety disorder received adequate treatment, and only 27.6% received any form of treatment at all [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral instruments have been developed for measuring depression, including the Beck Depression Inventory [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], Hamilton Depression Rating Scale [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], Montgomery-\u0026Aring;sberg Depression Rating Scale [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], and Lebanese Depression Scale [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A commonly used brief depression severity scale is the Patient Health Questionnaire \u0026ndash; 9 (PHQ-9) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], which has been shortened into the two-item PHQ-2 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Similarly, other scales were developed to measure clinical anxiety, such as the Beck Anxiety Inventory [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], Lebanese Anxiety Scale [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and Generalized Anxiety Disorder Scale \u0026ndash; 7 (GAD\u0026ndash;7) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The 7-item GAD-7 scale was shortened into the 2-item GAD-2 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. However, these previous scales either measure depression or anxiety separately, but do not measure both. Considering the high comorbidity of these two disorders, there was a need for a validated and reliable scale that measures both depression and anxiety. From this perspective, the four-item composite Patient Health Questionnaire \u0026ndash; 4 (PHQ-4) was developed by combining the PHQ-2 and GAD-2 scales [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], which containing two core anxiety items and two core depression items. In the original study [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], the PHQ-4 demonstrated construct validity, factorial validity, and internal reliability, proving to be an efficient ultra-brief tool for screening for anxiety, depression, or both. Higher scores on the PHQ-4 scale indicate a need for further assessment for anxiety, depression, or both.\u003c/p\u003e \u003cp\u003eUltra brief assessment tools such as the PHQ-4 are essential for busy clinicians, patient follow-up after treatment, and time-restricted research. Numerous studies have shown that ultra-short two- or three-question tests perform comparably to their longer counterparts [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In fact, the PHQ-4 has shown comparable performance to longer depression and anxiety measures in terms of correlating well with measures of quality of life, disability days, and healthcare utilization [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The PHQ-4 has been validated and proved to be reliable for use in various populations, including the general population [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], college students [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], pregnancy [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] and attention-deficit/hyperactivity disorder (ADHD) patients [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Multiple languages including Spanish [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], Portuguese [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], Greek [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], Korean [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], and Colombian [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] has been translated and validated. Numerous studies have proven a cross-cultural validation of the PHQ-4 [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Yet, to date, no efforts have been made to validate the PHQ-4 in Arabic.\u003c/p\u003e \u003cp\u003eBesides participating in the cross-national body of work on this scale, we believe that providing a validated Arabic version of the PHQ-4 is critical for many reasons. Firstly, mental disorders are a leading cause of disability in the Arab region, which encompasses 5.54% of the global population [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Secondly, Arab individuals are less likely to have access to mental health services due to insufficient planning, inadequate community services, and ongoing military conflicts [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Out of 20 Arab countries, six lack mental health legislation, and two lack a mental health policy [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Thirdly, Arab countries produce only 1% of the global output of peer-reviewed mental health related publications [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. In Lebanon alone, research has shown that 17% of individuals met the criteria for a 12-month mental disorder, and 27% were classified as serious [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], and half of the respondents had a history of exposure to war-related traumatic events. The availability of a psychometrically validated ultra-brief scale such as the PHQ-4 in Arabic will assist clinicians in screening for anxiety and depression, provide a valuable follow-up tool to assess intervention efficacy, enhance augment mental health research in the Arab world, and contribute to a broader cross-cultural validation of the PHQ-4. Therefore, the aim of this study was to translate the PHQ-4 into Arabic and determine the psychometric properties of this translation, including internal reliability, sex invariance, composite reliability, and its correlation with measures of psychological distress and well-being. We hypothesize that our translation of the PHQ-4 will demonstrate a fit for a two-factor solution similar to the original scale [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], good internal consistency reliability, adequate convergent and concurrent validity, as well as cross-sex invariance.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and procedures\u003c/h2\u003e \u003cp\u003eAll data were collected via a Google Form link, between February and March 2023. After being trained by the research team, five university students were asked to collect data via the snowball sampling technique. Students were instructed to forward the link to acquaintances, who were asked to forward the link to other family members and friends. Inclusion criteria for participation included being of a resident and citizen of Lebanon of adult age. Exclusion criteria were those who refused to fill out the questionnaire. Internet protocol (IP) addresses were monitored to prevent duplicate survey responses. Participants provided digital informed consent before completing the survey instruments, which were presented in a pre-randomized order to control for order effects. The survey was anonymous and participation was voluntary and without remuneration. A total of 587 participants completed the survey (mean age of 34.48\u0026thinsp;\u0026plusmn;\u0026thinsp;15.06 years, 69.4% females, 42.7% married and 74.0% with a university level of education).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eTranslation Procedure\u003c/h2\u003e \u003cp\u003eAccording to Beaton\u0026rsquo;s guidelines [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], the forward-backward translation approach was employed for the scale. Initially, the English version was translated into Arabic by two Lebanese translators who were unaffiliated with the study. Subsequently, two Lebanese psychologists who were proficient in English, back-translated the Arabic version back into English. To ensure the accuracy of the translation, the original English version and the translated one were compared, and any inconsistencies were identified and corrected by a committee of experts comprising the research team and the translators [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Furthermore, an adaptation of the measure to the Arab context was conducted to ascertain any potential misunderstanding of the item wordings and the ease of item interpretation, ensuring the conceptual equivalence between the original and Arabic scale in both contexts [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Following translation and adaptation of the scale, a pilot study was conducted with 20 participants to confirm comprehension of all questions; no alterations were made after the pilot study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eMeasures\u003c/h2\u003e \u003cp\u003e \u003cem\u003ePatient Health Questionnaire (PHQ-4).\u003c/em\u003e The PHQ-4 is a concise 4-item questionnaire designed to assess anxiety and depressive symptoms experienced over the past two weeks [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. It comprises two subscales: anxiety (e.g. \u0026ldquo;\u003cem\u003eFeeling nervous, anxious or on edge\u003c/em\u003e\u0026rdquo;) and depression (e.g. \u0026ldquo;\u003cem\u003eLittle interest or pleasure in doing things\u003c/em\u003e\u0026rdquo;), each consisting of two items. Each item is rated on a 4-point Likert scale ranging from 0 (not at all) to 3 (nearly every day). To calculate the total PHQ-4 score, the scores from all four items are summed. The cut-off score for the PHQ-4\u0026rsquo;s subscales is greater than or equal to 3. A total PHQ-4 score of 6 or higher, or individual scores of 3 or higher on either the anxiety or depression subscales, suggest the presence of depression or an anxiety disorder.\u003c/p\u003e \u003cp\u003e \u003cem\u003eThe Depression Anxiety and Stress Scale-8 items (DASS-8)\u003c/em\u003e: This instrument has been developed and validated in Arabic by Ali et al. [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. It is composed of eight items and three dimensions: (1) stress (two items; e.g. \u0026ldquo;\u003cem\u003eI felt that I was using a lot of nervous energy\u0026rdquo;\u003c/em\u003e), (2) anxiety (three items; e.g. \u0026ldquo;\u003cem\u003eI felt scared without any good reason\u0026rdquo;\u003c/em\u003e), and (3) depression (three items; \u0026ldquo;\u003cem\u003eI was unable to become enthusiastic about anything\u0026rdquo;\u003c/em\u003e). Higher scores reflect higher level of symptom affirmation.\u003c/p\u003e \u003cp\u003e \u003cem\u003eWHO-5 Wellbeing Index.\u003c/em\u003e Validated in Lebanon [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], formed of 5 items scored on a 6-point Likert scale with anchors ranging from \u0026ldquo;at no time\u0026rdquo; to \u0026ldquo;all the time\u0026rdquo; (e.g. \u0026ldquo;\u003cem\u003eIn the last two weeks, I have felt cheerful in good spirits\u0026rdquo;\u003c/em\u003e). Items are summed on a scale from 0 to 25, with higher scores reflecting higher wellbeing [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eAnalytic Strategy\u003c/h2\u003e \u003cp\u003e \u003cb\u003eData treatment.\u003c/b\u003e There were no missing responses in the dataset. To examine the factor structure of the PHQ-4, we conducted a confirmatory factor analysis (CFA) using the data from the total sample via SPSS and AMOS (version 29) software. A minimum sample size of 80 participants was needed, based on 20 participants per item on the scale was deemed necessary to conduct the CFA [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Parameter estimates were obtained using the maximum likelihood method. Calculated fit indices were the normed model chi-square (\u003cem\u003eχ\u0026sup2;\u003c/em\u003e/\u003cem\u003edf\u003c/em\u003e), the Steiger-Lind root mean square error of approximation (RMSEA), standardized root mean square residual (SRMR), the Tucker\u0026ndash;Lewis index (TLI) and the comparative fit index (CFI). Values\u0026thinsp;\u0026le;\u0026thinsp;5 for \u003cem\u003eχ\u0026sup2;\u003c/em\u003e/\u003cem\u003edf\u003c/em\u003e, \u0026le; .08 for RMSEA, \u0026le; .05 for SRMR and \u0026ge;\u0026thinsp;.95 for CFI and TLI indicate good fit of the model to the data [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Multivariate normality was verified (Bollen-Stine \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.752). Convergent validity was confirmed via an average extracted variance (AVE) value\u0026thinsp;\u0026gt;\u0026thinsp;0.5.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSex invariance.\u003c/b\u003e To examine sex invariance of the PHQ-4 scores, we conducted multi-group CFA using the total sample [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Measurement invariance was assessed at the configural, metric and scalar levels [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. We accepted ΔCFI\u0026thinsp;\u0026le;\u0026thinsp;.010 and ΔRMSEA\u0026thinsp;\u0026le;\u0026thinsp;.015 or ΔSRMR\u0026thinsp;\u0026le;\u0026thinsp;.010 as evidence of invariance [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], Comparison between males and females was done using the \u003cem\u003eStudent t-test\u003c/em\u003e only if scalar or partial scalar invariance held.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFurther analyses.\u003c/b\u003e Composite reliability in both subsamples was assessed using McDonald\u0026rsquo;s omega (ω) and Cronbach\u0026rsquo;s alpha (α), with values greater than .70 reflecting adequate composite reliability [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. The normality of the PHQ-4 score was verified, since the skewness and kurtosis values for each item of the scale varied between \u0026minus;\u0026thinsp;1 and +\u0026thinsp;1 [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. To assess concurrent validity, Pearson\u0026rsquo;s correlation coefficient was used to correlate the PHQ-4 scores with DASS-8 and WHO-5. Correlation coefficients values\u0026thinsp;\u0026le;\u0026thinsp;.10 were considered weak, ~ .30 were considered moderate, and ~\u0026thinsp;.50 were considered strong correlations [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eFive hundred eighty-seven participants completed the survey, with a mean age of 34.48\u0026thinsp;\u0026plusmn;\u0026thinsp;15.06 years, 69.4% females, 42.7% married and 74.0% with a university level of education. Moreover, according to the PHQ-4 cut-off, 24.0% of the participants reported no depression, whereas 37.2%, 30.2% and 8.6% of the participants showed mild, moderate and severe psychological distress respectively.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eConfirmatory factor analysis\u003c/h2\u003e \u003cp\u003eCFA indicated that the fit of the two-factor model of the PHQ-4 scores was modest: \u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e/\u003cem\u003edf\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.13/1\u0026thinsp;=\u0026thinsp;.13, RMSEA\u0026thinsp;=\u0026thinsp;.001 (90% CI\u0026thinsp;\u0026lt;\u0026thinsp;.001, .078), SRMR\u0026thinsp;=\u0026thinsp;.002, CFI\u0026thinsp;=\u0026thinsp;1.005, TLI\u0026thinsp;=\u0026thinsp;1.000. The standardized estimates of factor loadings were all adequate (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Internal reliability was excellent (McDonald\u0026rsquo;s ω\u0026thinsp;=\u0026thinsp;.86; Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;.86). The AVE value was satisfactory at =\u0026thinsp;.65.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSex invariance\u003c/h2\u003e \u003cp\u003eThe indices suggested that configural, metric, and scalar invariance were supported across sex (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). No significant difference was found between males and females in terms of the PHQ-4 total scores (4.75\u0026thinsp;\u0026plusmn;\u0026thinsp;3.16 vs 4.67\u0026thinsp;\u0026plusmn;\u0026thinsp;3.00, \u003cem\u003et\u003c/em\u003e(590)\u0026thinsp;=\u0026thinsp;.30, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.762), PHQ-4 anxiety scores (2.31\u0026thinsp;\u0026plusmn;\u0026thinsp;1.66 vs 2.27\u0026thinsp;\u0026plusmn;\u0026thinsp;1.71, t(590)\u0026thinsp;=\u0026thinsp;.24, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.807), and PHQ-4 depression scores (2.44\u0026thinsp;\u0026plusmn;\u0026thinsp;1.68 vs 2.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.57, t(590)\u0026thinsp;=\u0026thinsp;.32, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.751).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eMeasurement invariance across sex in the total sample.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCFI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRMSEA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSRMR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModel Comparison\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eΔCFI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eΔRMSEA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eΔSRMR\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConfigural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetric\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.995\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eConfigural vs metric\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScalar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.991\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.053\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMetric vs scalar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eNote.\u003c/em\u003e CFI\u0026thinsp;=\u0026thinsp;Comparative fit index; RMSEA\u0026thinsp;=\u0026thinsp;Steiger-Lind root mean square error of approximation; SRMR\u0026thinsp;=\u0026thinsp;Standardized root mean square residual.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eConvergent and concurrent validity\u003c/h2\u003e \u003cp\u003eThe PHQ-4 total score and the PHQ-4 depression and anxiety scores were significantly and moderately-to-strongly associated with lower wellbeing and higher DASS total and subscales scores (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePearson correlation matrix\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1. PHQ-4 total\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4.69\u0026thinsp;\u0026plusmn;\u0026thinsp;3.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2. PHQ-4 anxiety\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.28\u0026thinsp;\u0026plusmn;\u0026thinsp;1.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.93***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3. PHQ-4 depression\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.41\u0026thinsp;\u0026plusmn;\u0026thinsp;1.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.92***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.71***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e4. DASS total\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e10.42\u0026thinsp;\u0026plusmn;\u0026thinsp;6.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.56***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.53***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.51***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e5. DASS depression\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.79\u0026thinsp;\u0026plusmn;\u0026thinsp;2.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.52***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.47***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.49***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.92***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6. DASS anxiety\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.52\u0026thinsp;\u0026plusmn;\u0026thinsp;2.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.50***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.48***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.43***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.91***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.76***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e7. DASS stress\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.11\u0026thinsp;\u0026plusmn;\u0026thinsp;1.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.46***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.44***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.41***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.80***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.65***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.59***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e8. Well-being\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e13.68\u0026thinsp;\u0026plusmn;\u0026thinsp;5.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.50***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.46***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.47***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.36***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.36***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.24***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.39***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003e***\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe findings from this study suggest that an ultra-brief 4-item measure can reliably and validly measure depression and anxiety in the general population. Overall, the results support the reliability and validity of the instrument, as well as its suitability for use in Arabic-speaking adults from the general population. It is important to note the PHQ-4 serves only serve as a screening tool, and individuals with elevated PHQ\u0026ndash;4 scores should undergo further assessment to determine whether they meet the full diagnostic criteria for either disorder or if intervention is warranted.\u003c/p\u003e \u003cp\u003eThough depression and anxiety often coexist [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e], assessment for both conditions seems necessary. Consistent with prior research conducted in various countries, such as Germany [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], Colombia [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], the United States [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], Spain [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e], and Iran [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e], our study reaffirmed the two-factor structure of the PHQ-4, indicating distinct subscales for anxiety and depression. Hence, our findings support the differentiation between the two scales, PHQ-2 and GAD-2, rather than relying solely on one of them or the total PHQ-4 score. However, these finding contrasts with a study conducted among a sample of Quechua speakers, which supported a one-dimensional model, where anxiety and depression items combined to form a single latent variable of emotional problems [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven the brevity of the PHQ-4, its reliability was notably high. In our study, internal reliability was excellent (McDonald's ω\u0026thinsp;=\u0026thinsp;.86; Cronbach's α\u0026thinsp;=\u0026thinsp;.86), slightly surpassing those reported in the German validation study for the PHQ-2 (α\u0026thinsp;=\u0026thinsp;0.75) and GAD-2 (α\u0026thinsp;=\u0026thinsp;0.82) [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], and to some extent similar to the values from previous studies conducted across various other populations [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. This suggests that the PHQ-4 is equally effective in measuring symptoms of depression and anxiety in the Arabic-speaking population as it is in other demographic groups.\u003c/p\u003e \u003cp\u003eAnother finding of our research is that the factor loadings of the Arabic PHQ-4 remained consistent across sex at the three levels (configural, metric, and scalar). Consequently, comparisons between sex groups showed no statistically significant variances in PHQ-4 total scores and two subscores within our sample. Put differently, individuals of both genders comprehend and interpret the significance of PHQ-4 items similarly. Consistent with our findings, studies conducted in Colombia [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], Germany [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], and Greece [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] have also provided evidence supporting the consistency of measurement across sexes.\u003c/p\u003e \u003cp\u003eOur findings also revealed that the PHQ-4 depression and anxiety scores were significantly and moderately-to-strongly associated with depression, anxiety and stress scores as measured using another brief scale, i.e. the DASS-8, thus confirming the convergent validity of the Arabic PHQ-4. Furthermore, the PHQ-4 total score and the PHQ-4 depression and anxiety scores were linked to lower levels of well-being, in line with a previous study [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. Indeed, the presence of both anxiety and depressive disorders has been shown to have negative impacts on various aspects of an individual's life, including perceived well-being, satisfaction in relationships [\u003cspan additionalcitationids=\"CR65\" citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e], poorer occupational outcomes [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e], and more loneliness [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. These negative impacts may be attributed to the common characteristics observed in individuals experiencing depressive and anxiety symptoms, such as fatigue, loss of energy, feeling slowed down or agitated, poor attention and concentration, slow thinking, distractibility, impaired memory, and indecisiveness [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e], all of which contribute to a diminished well-being.\u003c/p\u003e \u003cp\u003eOur study showed that, according to the PHQ-4 cut-off, 24.0% of the participants had no depression, while 37.2%, 30.2% and 8.6% of the participants exhibited mild, moderate and severe psychological distress respectively. These findings are consistent with a prior study indicating a depression prevalence of 34.44% in the Southeast Asian context [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e], as well as recent meta-analytic studies by Bueno-Notivol et al. [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e] and Salari et al. [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. Nevertheless, our results are higher than those reported in a German study, which suggested that 6.5% and 7.0% of participants had probable anxiety and depression, respectively [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLebanon has recently experienced a series of profound tragedies, including the COVID-19 pandemic and the devastating explosion at the Beirut port on August fourth, which stands as the world's most powerful non-nuclear explosion [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. Additionally, Lebanon is grappling with its worst economic crisis in modern history, characterized by the rapid devaluation of the national currency, one of the highest inflation rates globally, and severe shortages of essential resources such as electricity and fuel. All those factors are significantly impacting the well-being and contributing to an increase in psychological disorders among the Lebanese population. Consequently, interventions aimed at early detection and treatment may play a crucial role in reducing the persistence or severity of primary anxiety and depressive disorders and preventing the onset of secondary disorders.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eClinical Implications\u003c/h2\u003e \u003cp\u003eProviding a reliable and valid Arabic version of the PHQ-4 could help gather precise epidemiological information regarding anxiety and depression symptoms in Arab nations. This initiative could enhance awareness surrounding mental health (anxiety and depression) screening and diagnosis in Arab contexts, and guide the creation of culturally appropriate interventions grounded in evidence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eFirstly, the snowball sampling method was used, which may have introduced sampling bias and restricted the representation of the general population. Hence, future studies should aim to employ more diverse and representative sampling techniques to enhance the external validity of the findings. Secondly, using cross-sectional data precludes the ability to assess the predictive validity and test\u0026ndash;retest reliability of the PHQ-4. Additionally, despite the utilization of a substantial community sample of Lebanese participants in this study, access to the survey was restricted to individuals with internet connectivity, potentially leading to an incomplete representation of the entire adult general population. Finally, this study was conducted exclusively in Lebanon, thereby restricting the generalizability of our results to Arab-speaking individuals in other Arab and non-Arab countries.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe PHQ-4 proves to be a reliable, valid, and cost-effective tool for assessing symptoms related to depression and anxiety. Using reliable mental health screening instruments lessens the load on participants in extensive data gathering, facilitates swift estimation by researchers of the prevalence and intensity of mental health symptoms, assists in timely interventions and psychological support, and provides a sustainable method for monitoring and assessing mental health symptoms amidst economic crises and other humanitarian disasters. To evaluate the practical effectiveness of the Arabic PHQ-4 and to further enhance the data on its construct validity, future studies should assess the measure in diverse contexts and among specific populations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate:\u003c/strong\u003e Ethics approval for this study was obtained from the\u0026nbsp;ethics committee\u0026nbsp;of the School of Pharmacy at the Lebanese International University (2023RC-006-LIUSOP). When filling out the online form, each participant provided written informed consent, as did their parents or legal guardian(s) if they were study participants under the age of sixteen. Every step of the process was carried out in compliance with all applicable laws and rules (such as the Declaration of Helsinki).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication: \u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eAll data generated or analyzed during this study are not publicly available due the restrictions from the ethics committee, but are available upon a reasonable request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests: \u003c/strong\u003eThe authors have nothing to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding: \u003c/strong\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e FFR, SO and SH\u0026nbsp;designed the study; SO and AH drafted the manuscript; SH carried out the analysis and interpreted the results; DM, FS, and MD collected the data. JX, YY, CJ, and RM authors reviewed the paper for intellectual content; all authors reviewed the final manuscript and gave their consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e The authors would like to thank all participants.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eSteel Z, Marnane C, Iranpour C, Chey T, Jackson JW, Patel V, Silove D: \u003cstrong\u003eThe global prevalence of common mental disorders: a systematic review and meta-analysis 1980\u0026ndash;2013\u003c/strong\u003e. \u003cem\u003eInternational journal of epidemiology\u0026nbsp;\u003c/em\u003e2014, \u003cstrong\u003e43\u003c/strong\u003e(2):476-493.\u003c/li\u003e\n \u003cli\u003eManzoor S: \u003cstrong\u003ePrevalence of Anxiety and Depression in Medically Ill Patients Admitted In OPD of AIMS Muzaffarabad AJ\u0026amp;K: Prevalence of Anxiety and Depression\u003c/strong\u003e. \u003cem\u003ePakistan Journal of Health Sciences\u0026nbsp;\u003c/em\u003e2023, \u003cstrong\u003e4\u003c/strong\u003e(04):145-150.\u003c/li\u003e\n \u003cli\u003eKhadka R, Bista S, Bista S, Sapkota S, Baskota S: \u003cstrong\u003ePrevalence of Anxiety and Depression among College Students in Kathmandu, Nepal\u003c/strong\u003e. \u003cem\u003eOne Health Journal of Nepal\u0026nbsp;\u003c/em\u003e2022, \u003cstrong\u003e2\u003c/strong\u003e(1):36-39.\u003c/li\u003e\n \u003cli\u003eKhuwaja AK, Lalani S, Dhanani R, Azam IS, Rafique G, White F: \u003cstrong\u003eAnxiety and depression among outpatients with type 2 diabetes: A multi-centre study of prevalence and associated factors\u003c/strong\u003e. \u003cem\u003eDiabetology and metabolic syndrome\u0026nbsp;\u003c/em\u003e2010, \u003cstrong\u003e2\u003c/strong\u003e(1):72-72.\u003c/li\u003e\n \u003cli\u003eLim ICZY, Tam WWS, Chudzicka-Czupała A, McIntyre RS, Teopiz KM, Ho RC, Ho CSH: \u003cstrong\u003ePrevalence of depression, anxiety and post-traumatic stress in war- and conflict-afflicted areas: A meta-analysis\u003c/strong\u003e. \u003cem\u003eFrontiers in psychiatry\u0026nbsp;\u003c/em\u003e2022, \u003cstrong\u003e13\u003c/strong\u003e:978703-978703.\u003c/li\u003e\n \u003cli\u003eBalta G, Paparrigopoulos T: \u003cstrong\u003eComorbid anxiety and depression: Diagnostic issues and treatment management\u003c/strong\u003e. \u003cem\u003ePsychiatrikē\u0026nbsp;\u003c/em\u003e2010, \u003cstrong\u003e21\u003c/strong\u003e(2):107.\u003c/li\u003e\n \u003cli\u003eLamers F, van Oppen P, Comijs HC, Smit JH, Spinhoven P, van Balkom AJLM, Nolen WA, Zitman FG, Beekman ATF, Penninx BWJH: \u003cstrong\u003eComorbidity patterns of anxiety and depressive disorders in a large cohort study: the Netherlands Study of Depression and Anxiety (NESDA)\u003c/strong\u003e. \u003cem\u003eThe journal of clinical psychiatry\u0026nbsp;\u003c/em\u003e2011, \u003cstrong\u003e72\u003c/strong\u003e(3):341.\u003c/li\u003e\n \u003cli\u003eWittchen HU, Kessler RC, Pfister H, H\u0026ouml;fler M, Lieb R: \u003cstrong\u003eWhy do people with anxiety disorders become depressed? 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prevention\u0026nbsp;\u003c/em\u003e2021, \u003cstrong\u003e24\u003c/strong\u003e:200218.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Anxiety, Depression, Patient Health Questionnaire, Arabic, Psychometric properties, Validation","lastPublishedDoi":"10.21203/rs.3.rs-4200473/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4200473/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eAnxiety and depression are psychiatric disorders that often coexist and share some features. Developing a simple and cost-effective tool to assess anxiety and depression in the Arabic-speaking population, predominantly residing in low- and middle-income nations where research can be arduous, would be immensely beneficial. The study aimed to translate the four-item composite Patient Health Questionnaire – 4 (PHQ-4) into Arabic and evaluate its psychometric properties, including internal reliability, sex invariance, composite reliability, and correlation with measures of psychological distress.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e 587 Arabic-speaking adults were recruited between February and March 2023. An anonymous self-administered Google Forms link was distributed via social media networks. We utilized the FACTOR software to explore the factor structure of the Arabic PHQ-4.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eConfirmatory factor analysis (CFA) indicated that fit of the two-factor model of the PHQ-4 scores was modest (\u003cem\u003eχ\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e/\u003cem\u003edf\u003c/em\u003e= .13/1 = .13,\u0026nbsp;RMSEA = .001, SRMR = .002, CFI = 1.005, TLI = 1.000). Internal reliability was excellent (McDonald’s omega = .86; Cronbach’s alpha = .86). Indices suggested that configural, metric, and scalar invariance were supported across sex. No significant difference was found between males and females in terms of the PHQ-4 total scores, PHQ-4 anxiety scores, and PHQ-4 depression scores. The total score of the PHQ-4 and its depression and anxiety scores were significantly and moderately-to-strongly associated with lower wellbeing and higher Depression Anxiety and Stress Scale (DASS) total and subscales scores.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe PHQ-4 proves to be a reliable, valid, and cost-effective tool for assessing symptoms related to depression and anxiety. To evaluate the practical effectiveness of the Arabic PHQ-4 and to further enhance the data on its construct validity, future studies should assess the measure in diverse contexts and among specific populations.\u003c/p\u003e","manuscriptTitle":"Validation of the ultra-brief self-report Patient Health Questionnaire-4 (PHQ-4) to measure anxiety and depression in Arabic-speaking adults","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-05 17:21:47","doi":"10.21203/rs.3.rs-4200473/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-21T08:57:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-15T10:06:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"194880380143365745683412426979764794721","date":"2024-05-14T11:42:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-27T06:32:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-25T05:11:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1bd42639-af3b-4f1c-acc2-8b6856fddf22","date":"2024-04-14T04:02:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5cac2bc1-7779-4109-9373-944fc577f282","date":"2024-04-12T06:33:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-11T08:37:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-02T11:06:02+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-04-01T17:59:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-01T17:48:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2024-04-01T11:59:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a8beca5a-b9d4-406e-836c-792e0f7890a3","owner":[],"postedDate":"April 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-05T16:05:54+00:00","versionOfRecord":{"articleIdentity":"rs-4200473","link":"https://doi.org/10.1186/s12888-024-05978-8","journal":{"identity":"bmc-psychiatry","isVorOnly":false,"title":"BMC Psychiatry"},"publishedOn":"2024-07-30 15:58:02","publishedOnDateReadable":"July 30th, 2024"},"versionCreatedAt":"2024-04-05 17:21:47","video":"","vorDoi":"10.1186/s12888-024-05978-8","vorDoiUrl":"https://doi.org/10.1186/s12888-024-05978-8","workflowStages":[]},"version":"v1","identity":"rs-4200473","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4200473","identity":"rs-4200473","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}