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Depression as Measured by PHQ-9 Versus Clinical Diagnosis as an Independent Predictor of Long-Term Mortality in a Prospective Cohort of Medical Inpatients

Martin-Subero, Marta MD; Kroenke, Kurt MD, PhD; Diez-Quevedo, Crisanto MD, PhD; Rangil, Teresa PhD; de Antonio, Marta MD, PhD; Morillas, Rosa Maria MD, PhD; Lorán, Maria Eulalia MD; Mateu, Cristina PsyD; Lupon, Josep MD, PhD; Planas, Ramon MD, PhD; Navarro, Ruth MD

doi: 10.1097/PSY.0000000000000390
Original Articles

Background Depression has been associated with higher rates of mortality in medical patients. The aim of the study was to evaluate the impact of depression in medical inpatients on the rate of mortality during a prolonged follow-up period.

Method This is a prospective follow-up study of a cohort of medical inpatients assessed during 1997–1998 in medical and surgical units at a tertiary university hospital in Spain and followed-up for a period ranging between 16.5 and 18 years. Eight hundred three patients were included; 420 (52.3%) were male, and the mean (SD) age was 41.7 (13.8) years. Main outcome was death for any cause during follow-up. The original full Patient Health Questionnaire (PHQ) was administered at baseline as self-report from which the PHQ-9 was derived. Depressive disorders were assessed using PHQ-9 and a structured clinical interview (Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition).

Results Depressive disorders as defined by PHQ-9 were detected in 206 patients (25.7%), 122 (15.2%) of them fulfilling criteria for major depression. During follow-up, 152 patients (18.9%) died. A PHQ score indicating the presence of major depressive disorder predicted increased mortality (hazard ratio [HR], 2.44; 95% CI, 1.39–4.29), even after adjusting for important demographic and clinical variables. Similarly, the PHQ-9 score as a continuous measure of depression severity predicted increased mortality (HR, 1.06; 95% CI, 1.02–1.10). Results were similar for clinical interview diagnoses of major depression (HR, 2.07; 95% CI, 1.04–4.09).

Conclusions Medical inpatients with a PHQ depressive disorder had a nearly 2-fold higher risk of long-term mortality, even after adjustment for several confounders. Depression severity as represented by the PHQ-9 score was also a risk factor.

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From the Department of Psychiatry and Legal Medicine (Martin-Subero, Diez-Quevedo, Lorán), Universitat Autonoma de Barcelona, Badalona, Spain; Psychiatric Unit, Germans Trias i Pujol University Hospital (Martin-Subero, Diez-Quevedo, Rangil, Lorán, Mateu), Badalona, Spain; FIDMAG Germanes Hospitalaries Research Foundation (Martin-Subero), Barcelona, Spain; Carlos III Health Institute (Martin-Subero), Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain; Department of Medicine (Kroenke), Indiana University, Indianapolis, Indiana; Regenstrief Institute and VA HSR&D Center for Health Information and Communication (Kroenke), Indianapolis, Indiana; Heart Failure Unit, Department of Cardiology (de Antonio, Lupon), Germans Trias i Pujol University Hospital, Badalona, Spain; Carlos III Health Institute (Morillas, Planas), Centro de Investigación Biomédica en Red de Hepatologia (CIBEREHD), Madrid (Spain); Liver Unit, Department of Gastroenterology (Morillas, Planas), Germans Trias i Pujol University Hospital, Badalona, Spain; Department of Medicine (Lupon, Planas), Universitat Autonoma de Barcelona, Badalona, Spain; and Department of Clinical Documentation (Navarro), Germans Trias i Pujol University Hospital, Badalona, Spain.

Supplemental Content

Address correspondence and reprint requests to: Crisanto Diez-Quevedo, MD, PhD, Psychiatric Unit, Germans Trias i Pujol University Hospital, Ctra de Canyet s/n; 08916 Badalona (Barcelona), Spain. E-mail:

Ethical approval: The study was approved by the Germans Trias i Pujol hospital Research Ethics Committee (FIS project 97/1184). All participants gave written informed consent before taking part in the study.

Preliminary data from this paper were presented as a poster at the XVIII Spanish National Congress of Psychiatry, held in Santiago de Compostela, Spain, on September 24–26, 2015.

Received for publication November 28, 2015; revision received May 22, 2016.

Copyright © 2017 by American Psychosomatic Society
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