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.