Measurement invariance testing of the PHQ-9 in a multi-ethnic population in Europe: the HELIUS study

BMC Psychiatry. 2017 Oct 24;17(1):349. doi: 10.1186/s12888-017-1506-9.


Background: In Western European countries, the prevalence of depressive symptoms is higher among ethnic minority groups, compared to the host population. We explored whether these inequalities reflect variance in the way depressive symptoms are measured, by investigating whether items of the PHQ-9 measure the same underlying construct in six ethnic groups in the Netherlands.

Methods: A total of 23,182 men and women aged 18-70 of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish or Moroccan origin were included in the HELIUS study and had answered to at least one of the PHQ-9 items. We conducted multiple group confirmatory factor analyses (MGCFA), with increasingly stringent model constraints (i.e. assessing Configural, Metric, Strong and Strict measurement invariance (MI)), and regression analysis, to confirm comparability of PHQ-9 items across ethnic groups.

Results: A one-factor model, where all nine items reflect a single underlying construct, showed acceptable model fit and was used for MI testing. In each subsequent step, change in goodness-of-fit measures did not exceed 0.015 (RMSEA) or 0.01 (CFI). Moreover, strict invariance models showed good or acceptable model fit (Men: RMSEA = 0.050; CFI = 0.985; Women: RMSEA = 0.058; CFI = 0.979), indicating between-group equality of item clusters, factor loadings, item thresholds and residual variances. Finally, regression analysis did not indicate potential ethnicity-related differential item functioning (DIF) of the PHQ-9.

Conclusions: This study provides evidence of measurement invariance of the PHQ-9 regarding ethnicity, implying that the observed inequalities in depressive symptoms cannot be attributed to DIF.

Keywords: Confirmatory factor analysis; Depressive symptoms; Differential item functioning; HELIUS study; Measurement invariance; PHQ-9.

Publication types

  • Evaluation Study

MeSH terms

  • Adult
  • Aged
  • Depression / epidemiology*
  • Depression / psychology
  • Ethnicity / psychology
  • Ethnicity / statistics & numerical data*
  • Factor Analysis, Statistical
  • Female
  • Humans
  • Male
  • Middle Aged
  • Minority Groups / psychology
  • Minority Groups / statistics & numerical data*
  • Netherlands / epidemiology
  • Patient Health Questionnaire / standards*
  • Prevalence
  • Socioeconomic Factors