PHQ, HADS deemed acceptable for poststroke depression screening in Singapore

Both the Patient Healthcare Questionnaire (PHQ) and the Hospital Anxiety and Depression Scale (HADS) are useful for identifying stroke survivors with depression in Singaporean inpatient rehabilitation care settings, as shown in a study.

The study included 138 adults (mean age 62.8 years, 68.8 percent male, 86.2 percent Chinese) who were not delirious by clinical judgement and were not aphasic. These participants were screened for poststroke depression during inpatient rehabilitation and completed the English versions of the HADS and both the two- and nine-item versions of the PHQ independently or with assistance from trained allied health professionals.

All the screening tools yielded consistent results for identifying participants with poststroke depression, showing good convergent validity (rs, 0.55–0.89) and discriminative power (area under curve, 0.849–0.887). [Biopsychosoc Med 2025;19:18]

The optimal cutoff scores were ≥7 for the HADS depression (HADS-D) and anxiety (HADS-A) subscales and ≥10 for the total score. At these cutoffs, the sensitivity ranged from 55.56 percent to 66.67 percent, the specificity ranged from 85.83 percent to 95 percent, the positive predictive value (PPV) ranged from 41.38 percent to 62.5 percent, and the negative predictive value (NPV) ranged from 93.44 percent to 94.74 percent.

For PHQ-2, the optimal cutoff score was ≥2, with a sensitivity of 77.78 percent, specificity of 74.17 percent, PPV of 31.11 percent, and NPV of 95.7 percent. PHQ-9 at the optimal cutoff score of ≥8 had a sensitivity of 77.78 percent, specificity of 90 percent, PPV of 53.85 percent, and NPV of 96.43 percent.

The validation of HADS and PHQ makes the screening of poststroke depression in the local rehabilitation setting more efficient, according to researchers. These instruments can be administered quickly and accurately without the need for a trained medical health professional, they added.

Combining HADS and PHQ

Additional analyses indicated that the use of both PHQ and HADS in specific combinations further improved diagnostic performance. For example, screening positive on either PHQ-9 or HADS-A was associated with superior screening performance, with 83.33 percent sensitivity, 88.33 specificity, 51.72 percent PPV, and 97.25 percent NPV.

“We recommend administering both PHQ and HADS [together] and identifying patients who screen positive on these screening tools for further clinical diagnostic evaluation,” the researchers said.

“Clinical experience has proven this to be beneficial as the PHQ is limited by the omission of anxiety symptoms and potential overlap with somatic symptoms directly related to the stroke, while the HADS is limited by its focus on only psychological symptoms and its short symptom duration requirement that falls short of full diagnostic criteria for mood disorders,” they added.

The researchers stated that for patients who screen negative on either the PHQ-9 or HADS-A, poststroke depression can be effectively ruled out, given the high NPV of 97.3 percent.

“However, as the PPV for this screening combination is low at 51.7 percent, a more detailed diagnostic interview should be performed as there may be other poststroke sequelae that mimic poststroke depression such as apathy,” they said.

The researchers also acknowledged that while the current study successfully validated the HADS and PHQ for detecting the presence of mood disorders after a stroke, additional research is needed to determine the accuracy of the screening tools for detecting specific mood disorders (ie, minor depression, major depression, or adjustment disorders) and other important neuropsychiatric sequelae after stroke, such as anxiety and cognitive impairment.