Psychometric properties of Mongolian versions of the PHQ-9 and GAD-7 in young adults
DOI:
https://doi.org/10.31117/neuroscirn.v9i2.441Keywords:
Depression, Anxiety, Mental health assessment, Validation, Cultural adaptation, PHQ-9, GAD-7, MongoliaAbstract
The Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) are standardized self-report tools for screening depressive and anxiety disorders, respectively. While they have been validated in various cultural contexts, their psychometric properties have not been thoroughly evaluated in Mongolia. This study aimed to validate the PHQ-9 and GAD-7 among young adults in Mongolia, ensuring their reliability and efficacy in assessing mental health. A cross-sectional study was conducted with 1,391 young adults (aged 17-29 years). Tests for internal consistency, test-retest reliability, and validity were performed, including exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Convergent validity and cut-off scores were assessed using the Hospital Anxiety and Depression Scale (HADS). Results: Both the PHQ-9 and GAD-7 demonstrated excellent internal consistency (Cronbach’s alpha=0.913 and 0.895, respectively) and good test-retest reliability over time (ICC=0.637 for PHQ-9; ICC=0.782 for GAD-7). Factor analyses confirmed their unidimensional structures, explaining 59.1% and 61.5% of variance, respectively. Unidimensional models showed acceptable goodness-of-fit indices, with RMSEA values of 0.051 for PHQ-9 and 0.047 for GAD-7, indicating a close-to-good fit for both models. Strong correlations were observed between PHQ-9 and GAD-7 scores with HADS scores (p<0.001), indicating good convergent validity. Observed cut-off scores yielded high sensitivity and specificity in this sample population. The final Mongolian versions of the questionnaires exhibited robust psychometric properties. The PHQ-9 and GAD-7 were validated as reliable instruments for screening depression and anxiety among medical students in Mongolia. These findings improve the capacity for early identification and intervention in mental health among this population. However, further research should address limitations related to gender representation and the need for assessment in diverse settings.
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References
Anthoine, E., Moret, L., Regnault, A., Sébille, V., & Hardouin, J.-B. (2014). Sample size used to validate a scale: A review of publications on newly-developed patient reported outcomes measures. Health and Quality of Life Outcomes, 12(1), 2. https://doi.org/10.1186/s12955-014-0176-2
Arroll, B., Goodyear-Smith, F., Crengle, S., Gunn, J., Kerse, N., Fishman, T., Falloon, K., & Hatcher, S. (2010). Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. The Annals of Family Medicine, 8(4), 348–353. https://doi.org/10.1370/afm.1139
Asher, M., Asnaani, A., & Aderka, I. M. (2017). Gender differences in social anxiety disorder: A review. Clinical Psychology Review, 56, 1–12. https://doi.org/10.1016/j.cpr.2017.05.004
Baker, A. M., Holbrook, J. T., Yohannes, A. M., Eakin, M. N., Sugar, E. A., Henderson, R. J., Casper, A. S., Kaminsky, D. A., Rea, A. L., Mathews, A. M., Que, L. G., Ramsdell, J. W., Gerald, L. B., Wise, R. A., Hanania, N. A., Hanania, N., Sockrider, M., Bertrand, L., Atik, M., . . . Rivera, K. (2018). Test performance characteristics of the AIR, GAD-7, and HADS-anxiety screening questionnaires for anxiety in chronic obstructive pulmonary disease. Annals of the American Thoracic Society, 15(8), 926–934. https://doi.org/10.1513/AnnalsATS.201708-631OC
Bandelow, B., Boerner, R. J., Kasper, S., Linden, M., Wittchen, H.-U., & Möller, H.-J. (2013). The diagnosis and treatment of generalized anxiety disorder. Deutsches Ärzteblatt International, 110(17), 300–309. https://doi.org/10.3238/arztebl.2013.0300
Bat-Erdene, E., Tumurbaatar, E., Tumur-Ochir, G., Jamiyandorj, O., Jadamba, T., Yamamoto, E., Hamajima, N., Oka, T., & Lkhagvasuren, B. (2023). Validation of the abbreviated version of the World Health Organization Quality of Life in Mongolia: a population-based cross-sectional study among adults in Ulaanbaatar. Nagoya Journal of Medical Science, 85(1), 79–92. https://doi.org/10.18999/nagjms.85.1.79
Baxter, A. J., Scott, K. M., Vos, T., & Whiteford, H. A. (2013). Global prevalence of anxiety disorders: a systematic review and meta-regression. Psychological Medicine, 43(5), 897–910. https://doi.org/10.1017/S003329171200147X
Beard, C., & Björgvinsson, T. (2014). Beyond generalized anxiety disorder: Psychometric properties of the GAD-7 in a heterogeneous psychiatric sample. Journal of Anxiety Disorders, 28(6), 547–552. https://doi.org/10.1016/j.janxdis.2014.06.002
Beard, C., Hsu, K. J., Rifkin, L. S., Busch, A. B., & Björgvinsson, T. (2016). Validation of the PHQ-9 in a psychiatric sample. Journal of Affective Disorders, 193, 267–273. https://doi.org/10.1016/j.jad.2015.12.075
Beaton, D. E., Bombardier, C., Guillemin, F., & Ferraz, M. B. (2000). Guidelines for the process of cross-cultural adaptation of self-report measures: Spine, 25(24), 3186–3191. https://doi.org/10.1097/00007632-200012150-00014
Lépine, J.-P., & Briley, M. (2011). The increasing burden of depression. Neuropsychiatric Disease and Treatment, 7(Suppl 1), 3–7. https://doi.org/10.2147/NDT.S19617
Bromet, E., Andrade, L. H., Hwang, I., Sampson, N. A., Alonso, J., De Girolamo, G., De Graaf, R., Demyttenaere, K., Hu, C., Iwata, N., Karam, A. N., Kaur, J., Kostyuchenko, S., Lépine, J.-P., Levinson, D., Matschinger, H., Mora, M. E. M., Browne, M. O., Posada-Villa, J., … Kessler, R. C. (2011). Cross-national epidemiology of DSM-IV major depressive episode. BMC Medicine, 9(1), 90. https://doi.org/10.1186/1741-7015-9-90
Byrd-Bredbenner, C., Eck, K., & Quick, V. (2021). GAD-7, GAD-2, and GAD-mini: Psychometric properties and norms of university students in the United States. General Hospital Psychiatry, 69, 61–66. https://doi.org/10.1016/j.genhosppsych.2021.01.002
Cameron, I. M., Crawford, J. R., Lawton, K., & Reid, I. C. (2008). Psychometric comparison of PHQ-9 and HADS for measuring depression severity in primary care. British Journal of General Practice, 58(546), 32–36. https://doi.org/10.3399/bjgp08X263794
Carroll, H. A., Hook, K., Perez, O. F. R., Denckla, C., Vince, C. C., Ghebrehiwet, S., Ando, K., Touma, M., Borba, C. P. C., Fricchione, G. L., & Henderson, D. C. (2020). Establishing reliability and validity for mental health screening instruments in resource-constrained settings: systematic review of the PHQ-9 and key recommendations. Psychiatry Research, 291, 113236. https://doi.org/10.1016/j.psychres.2020.113236
Cattell, R. B. (1966). The scree test for the number of factors. Multivariate Behavioral Research, 1(2), 245–276. https://doi.org/10.1207/s15327906mbr0102_10
Depressive disorder (Depression). (n.d.). Retrieved December 19, 2024, from https://www.who.int/news-room/fact-sheets/detail/depression
Dhira, T. A., Rahman, M. A., Sarker, A. R., & Mehareen, J. (2021). Validity and reliability of the Generalized Anxiety Disorder-7 (GAD-7) among university students of Bangladesh. PLoS ONE, 16(12), e0261590. https://doi.org/10.1371/journal.pone.0261590
Esser, P., Hartung, T. J., Friedrich, M., Johansen, C., Wittchen, H., Faller, H., Koch, U., Härter, M., Keller, M., Schulz, H., Wegscheider, K., Weis, J., & Mehnert, A. (2018). The Generalized Anxiety Disorder Screener (GAD‐7) and the anxiety module of the Hospital and Depression Scale (HADS‐A) as screening tools for generalized anxiety disorder among cancer patients. Psycho-Oncology, 27(6), 1509–1516. https://doi.org/10.1002/pon.4681
Gelaye, B., Williams, M. A., Lemma, S., Deyessa, N., Bahretibeb, Y., Shibre, T., Wondimagegn, D., Lemenhe, A., Fann, J. R., Vander Stoep, A., & Andrew Zhou, X.-H. (2013). Validity of the patient health questionnaire-9 for depression screening and diagnosis in East Africa. Psychiatry Research, 210(2), 653–661. https://doi.org/10.1016/j.psychres.2013.07.015
Goldman, L. S., Nielsen, N. H., & Champion, H. C. (1999). Awareness, diagnosis, and treatment of depression. Journal of General Internal Medicine, 14(9), 569–580. https://doi.org/10.1046/j.1525-1497.1999.03478.x
Gong, Y., Zhou, H., Zhang, Y., Zhu, X., Wang, X., Shen, B., Xian, J., & Ding, Y. (2021). Validation of the 7-item Generalized Anxiety Disorder scale (GAD-7) as a screening tool for anxiety among pregnant Chinese women. Journal of Affective Disorders, 282, 98–103. https://doi.org/10.1016/j.jad.2020.12.129
González-Blanch, C., Medrano, L. A., Muñoz-Navarro, R., Ruíz-Rodríguez, P., Moriana, J. A., Limonero, J. T., Schmitz, F., & Cano-Vindel, A. (2018). Factor structure and measurement invariance across various demographic groups and over time for the PHQ-9 in primary care patients in Spain. PLoS ONE, 13(2), e0193356. https://doi.org/10.1371/journal.pone.0193356
Gopalkrishnan, N. (2018). Cultural diversity and mental health: Considerations for policy and practice. Frontiers in Public Health, 6, 179. https://doi.org/10.3389/fpubh.2018.00179
Granillo, M. T. (2012). Structure and function of the patient health questionnaire-9 among latina and non-latina white female college students. Journal of the Society for Social Work and Research, 3(2), 80–93. https://doi.org/10.5243/jsswr.2012.6
Grapp, M., Bugaj, T. J., Terhoeven, V., Friederich, H.-C., & Maatouk, I. (2025). Screening for anxiety in patients with cancer: Diagnostic accuracy of GAD-7 items considering lowered GAD-7 cut-offs. PLoS ONE, 20(1), e0316853. https://doi.org/10.1371/journal.pone.0316853
Hansson, M., Chotai, J., Nordstöm, A., & Bodlund, O. (2009). Comparison of two self-rating scales to detect depression: HADS and PHQ-9. British Journal of General Practice, 59(566), e283–e288. https://doi.org/10.3399/bjgp09X454070
Hirschfeld, R. M. A., Montgomery, S. A., Keller, M. B., Kasper, S., Schatzberg, A. F., Moller, H.-J., Healy, D., Baldwin, D., Humble, M., Versiani, M., Montenegro, R., & Bourgeois, M. (2000). Social functioning in depression: A review. The Journal of Clinical Psychiatry, 61(4), 268–275. https://doi.org/10.4088/JCP.v61n0405
Johnson, S. U., Ulvenes, P. G., Øktedalen, T., & Hoffart, A. (2019). Psychometric properties of the general anxiety disorder 7-item (GAD-7) scale in a heterogeneous psychiatric sample. Frontiers in Psychology, 10, 1713. https://doi.org/10.3389/fpsyg.2019.01713
Keum, B. T., Miller, M. J., & Inkelas, K. K. (2018). Testing the factor structure and measurement invariance of the PHQ-9 across racially diverse U.S. college students. Psychological Assessment, 30(8), 1096–1106. https://doi.org/10.1037/pas0000550
Konkan, R., Şenormanci, Ö., Güçlü, O., Aydin, E., & Sungur, M. Z. (2013). Yaygın anksiyete bozukluğu-7 (YAB-7) testi Türkçe uyarlaması, geçerlik ve güvenirliği [Validity and reliability study for the Turkish adaptation of the Generalized Anxiety Disorder-7 (GAD-7) scale]. Nöro Psikiyatri Arşivi, 50(1), 53–58. https://doi.org/10.4274/npa.y6308
Koo, T. K., & Li, M. Y. (2016). A guideline of selecting and reporting intraclass correlation coefficients for reliability research. Journal of Chiropractic Medicine, 15(2), 155–163. https://doi.org/10.1016/j.jcm.2016.02.012
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
Levis, B., Bhandari, P. M., Neupane, D., Fan, S., Sun, Y., He, C., Wu, Y., Krishnan, A., Negeri, Z., Imran, M., Rice, D. B., Riehm, K. E., Azar, M., Levis, A. W., Boruff, J., Cuijpers, P., Gilbody, S., Ioannidis, J. P. A., Kloda, L. A., … Benedetti, A. (2024). Data-driven cutoff selection for the patient health questionnaire-9 depression screening tool. JAMA Network Open, 7(11), e2429630. https://doi.org/10.1001/jamanetworkopen.2024.29630
Lkhagvasuren, B., Hiramoto, T., Bat-Erdene, E., Tumurbaatar, E., Tumur-Ochir, G., Amartuvshin, T., Dashtseren, M., Lai, E., Viswanath, V., Oka, T., & Jadamba, T. (2024). Anxiety, depression, and brain overwork in the general population of Mongolia. Scientific Reports, 14(1), 2484. https://doi.org/10.1038/s41598-024-52779-w
Löwe, B., Decker, O., Müller, S., Brähler, E., Schellberg, D., Herzog, W., & Herzberg, P. Y. (2008). Validation and standardization of the generalized anxiety disorder screener (GAD-7) in the general population. Medical Care, 46(3), 266–274. https://doi.org/10.1097/MLR.0b013e318160d093
Manea, L., Gilbody, S., & McMillan, D. (2012). Optimal cut-off score for diagnosing depression with the Patient Health Questionnaire (PHQ-9): a meta-analysis. Canadian Medical Association Journal, 184(3), E191–E196. https://doi.org/10.1503/cmaj.110829
Moriarty, A. S., Gilbody, S., McMillan, D., & Manea, L. (2015). Screening and case finding for major depressive disorder using the Patient Health Questionnaire (PHQ-9): a meta-analysis. General Hospital Psychiatry, 37(6), 567–576. https://doi.org/10.1016/j.genhosppsych.2015.06.012
Moussavi, S., Chatterji, S., Verdes, E., Tandon, A., Patel, V., & Ustun, B. (2007). Depression, chronic diseases, and decrements in health: Results from the World Health Surveys. The Lancet, 370(9590), 851–858. https://doi.org/10.1016/S0140-6736(07)61415-9
Muñoz-Navarro, R., Cano-Vindel, A., Medrano, L. A., Schmitz, F., Ruiz-Rodríguez, P., Abellán-Maeso, C., Font-Payeras, M. A., & Hermosilla-Pasamar, A. M. (2017). Utility of the PHQ-9 to identify major depressive disorder in adult patients in Spanish primary care centres. BMC Psychiatry, 17(1), 291. https://doi.org/10.1186/s12888-017-1450-8
Petersen, J. J., Paulitsch, M. A., Hartig, J., Mergenthal, K., Gerlach, F. M., & Gensichen, J. (2015). Factor structure and measurement invariance of the Patient Health Questionnaire-9 for female and male primary care patients with major depression in Germany. Journal of Affective Disorders, 170, 138–142. https://doi.org/10.1016/j.jad.2014.08.053
Plummer, F., Manea, L., Trepel, D., & McMillan, D. (2016). Screening for anxiety disorders with the GAD-7 and GAD-2: A systematic review and diagnostic metaanalysis. General Hospital Psychiatry, 39, 24–31. https://doi.org/10.1016/j.genhosppsych.2015.11.005
Sawaya, H., Atoui, M., Hamadeh, A., Zeinoun, P., & Nahas, Z. (2016). Adaptation and initial validation of the patient health questionnaire – 9 (PHQ-9) and the generalized anxiety disorder – 7 questionnaire (GAD-7) in an arabic speaking lebanese psychiatric outpatient sample. Psychiatry Research, 239, 245–252. https://doi.org/10.1016/j.psychres.2016.03.030
Schober, P., Boer, C., & Schwarte, L. A. (2018). Correlation Coefficients: Appropriate Use and Interpretation. Anesthesia & Analgesia, 126(5), 1763–1768. https://doi.org/10.1213/ANE.0000000000002864
Schueller, S. M., Kwasny, M. J., Dear, B. F., Titov, N., & Mohr, D. C. (2015). Cut points on the Patient Health Questionnaire (PHQ-9) that predict response to cognitive–behavioral treatments for depression. General Hospital Psychiatry, 37(5), 470–475. https://doi.org/10.1016/j.genhosppsych.2015.05.009
Snijkers, J. T. W., Van Den Oever, W., Weerts, Z. Z. R. M., Vork, L., Mujagic, Z., Leue, C., Hesselink, M. A. M., Kruimel, J. W., Muris, J. W. M., Bogie, R. M. M., Masclee, A. A. M., Jonkers, D. M. A. E., & Keszthelyi, D. (2021). Examining the optimal cutoff values of HADS, PHQ‐9 and GAD‐7 as screening instruments for depression and anxiety in irritable bowel syndrome. Neurogastroenterology & Motility, 33(12), e14161. https://doi.org/10.1111/nmo.14161
Sousa, T. V., Viveiros, V., Chai, M. V., Vicente, F. L., Jesus, G., Carnot, M. J., Gordo, A. C., & Ferreira, P. L. (2015). Reliability and validity of the portuguese version of the generalized anxiety disorder (GAD-7) scale. Health and Quality of Life Outcomes, 13(1), 50. https://doi.org/10.1186/s12955-015-0244-2
Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092. https://doi.org/10.1001/archinte.166.10.1092
Tibubos, A. N., Otten, D., Zöller, D., Binder, H., Wild, P. S., Fleischer, T., Johar, H., Atasoy, S., Schulze, L., Ladwig, K.-H., Schomerus, G., Linkohr, B., Grabe, H. J., Kruse, J., Schmidt, C.-O., Münzel, T., König, J., Brähler, E., & Beutel, M. E. (2021). Bidimensional structure and measurement equivalence of the Patient Health Questionnaire-9: sex-sensitive assessment of depressive symptoms in three representative German cohort studies. BMC Psychiatry, 21(1), 238. https://doi.org/10.1186/s12888-021-03234-x
Tong, X., An, D., McGonigal, A., Park, S.-P., & Zhou, D. (2016). Validation of the Generalized Anxiety Disorder-7 (GAD-7) among Chinese people with epilepsy. Epilepsy Research, 120, 31–36. https://doi.org/10.1016/j.eplepsyres.2015.11.019
Tumurbaatar, E., Hiramoto, T., Tumur-Ochir, G., Bat-Erdene, E., Erdenebaatar, C., Amartuvshin, T., Dashtseren, M., Lkhagvasuren, B., Boldbaatar, D., & Jadamba, T. (2023). Psychometric properties of the mongolian version of the pittsburgh sleep quality index. Neuroscience Research Notes, 6(3). https://doi.org/10.31117/neuroscirn.v6i3.190
Tumurbaatar, E., Hiramoto, T., Tumur-Ochir, G., Jargalsaikhan, O., Erkhembayar, R., Jadamba, T., & Lkhagvasuren, B. (2021). Translation, reliability, and structural validity of the Hospital Anxiety and Depression Scale (HADS) in the general population of Mongolia. Neuroscience Research Notes, 4(3Suppl), 30–39. https://doi.org/10.31117/neuroscirn.v4i3Suppl.101
Van Der Kooy, K., Van Hout, H., Marwijk, H., Marten, H., Stehouwer, C., & Beekman, A. (2007). Depression and the risk for cardiovascular diseases: Systematic review and meta analysis. International Journal of Geriatric Psychiatry, 22(7), 613–626. https://doi.org/10.1002/gps.1723
Wang, P. S., Simon, G., & Kessler, R. C. (2003). The economic burden of depression and the cost‐effectiveness of treatment. International Journal of Methods in Psychiatric Research, 12(1), 22–33. https://doi.org/10.1002/mpr.139
Wang, W., Bian, Q., Zhao, Y., Li, X., Wang, W., Du, J., Zhang, G., Zhou, Q., & Zhao, M. (2014). Reliability and validity of the Chinese version of the Patient Health Questionnaire (PHQ-9) in the general population. General Hospital Psychiatry, 36(5), 539–544. https://doi.org/10.1016/j.genhosppsych.2014.05.021
White, A. E., & Karr, J. E. (2023). Psychometric properties of the GAD-7 among college students: reliability, validity, factor structure, and measurement invariance. Translational Issues in Psychological Science. https://doi.org/10.1037/tps0000382
World Health Organization. (2025). Suicide worldwide in 2021: global health estimates. World Health Organization. https://iris.who.int/bitstreams/769d0a45-b50a-4b17-ba40-259bef44d9dd/download
Zhang, Y.-L., Liang, W., Chen, Z.-M., Zhang, H.-M., Zhang, J.-H., Weng, X.-Q., Yang, S.-C., Zhang, L., Shen, L.-J., & Zhang, Y.-L. (2013). Validity and reliability of Patient Health Questionnaire-9 and Patient Health Questionnaire-2 to screen for depression among college students in China: Depression screening among college students. Asia-Pacific Psychiatry, 5(4), 268–275. https://doi.org/10.1111/appy.12103
Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67(6), 361–370. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x
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Copyright (c) 2026 Oyunsuren Jargalsaikhan, Enkhnaran Tumurbaatar, Tergelsaran Olzvoi, Enkh-Uchral Perenleisambuu, Enkhzaya Batkhuyag, Dolgorsuren Dorj, Battuvshin Lkhagvasuren, Gantsetseg Tumur-Ochir
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