Document Type : Original Article
Department of Diabetes, Obesity and Metabolism, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
Department of Medical Ethics and Law, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
Department of Biostatistics and Epidemiology, School of Public Health, Babol University of Medical Sciences, Babol, Iran
Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
Department of Biostatistics, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
Background: The most common mental disorders in infertile patients are depression and anxiety. The four-item
Patient Health Questionnaire-4 (PHQ-4) is a widely used tool that consists of the PHQ-2 depression and Generalized
Anxiety Disorder-2 (GAD-2) scales. Given that PHQ-4 has not been validated in infertile patients, this study aimed to
examine its reliability and validity in this population.
Materials and Methods: Participants in this cross-sectional study consisted of 539 infertile patients from a referral
fertility centre in Tehran, Iran. The PHQ-4, Hospital Anxiety and Depression Scale (HADS), World Health Organisation-
Five Well-Being Index (WHO-5), Penn State Worry Questionnaire (PSWQ) and demographic/infertility questionnaires
were administered to all participants. Factor structure and internal consistency of PHQ-4 were evaluated
via confirmatory factor analysis (CFA) and Cronbach’s alpha, respectively. The convergent validity of this scale was
examined by its relationship with HADS, WHO-5 and PSWQ.
Results: CFA results provided support for a two-factor model of PHQ-4. Internal consistency of the PHQ-4 and its subscales
both were elevated with Cronbach’s alpha coefficients of 0.767 (PHQ-4), 0.780 (PHQ-2) and 0.814 (GAD-2). Inter-item
correlations were between 0.386 and 0.639, and corrected item-total correlations were between 0.576 and 0.687. PHQ-4,
PHQ-2 and GAD-2 showed positive correlations with measures of HADS-anxiety, HADS-depression, and PSWQ and negative
correlations with WHO-5, which confirmed convergent validity. Among demographic/fertility variables, we observed
that gender, infertility duration, and failure in previous treatment were correlated with PHQ-4 and its subscales scores.
Conclusion: The PHQ-4 is a reliable and valid ultra-brief screening instrument for measuring both anxiety and depressive
symptoms in infertile patients.