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Prevalence estimates of major depressive disorder in 27 European countries from the European Health Interview Survey: accounting for imperfect diagnostic accuracy of the PHQ-8
  1. Felix Fischer1,
  2. Dario Zocholl2,
  3. Geraldine Rauch2,
  4. Brooke Levis3,4,
  5. Andrea Benedetti4,5,6,
  6. Brett Thombs3,4,6,7,8,9,
  7. Matthias Rose1,10,
  8. Polychronis Kostoulas11
  1. 1 Department of Psychosomatic Medicine, Center for Internal Medicine and Dermatology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
  2. 2 Institute of Biometry and Clinical Epidemiology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
  3. 3 Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Quèbec, Canada
  4. 4 Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Quèbec, Canada
  5. 5 Respiratory Epidemiology and Clinical Research Unit, McGill University Health Centre, Montréal, Québec, Canada
  6. 6 Department of Medicine, McGill University, Montréal, Québec, Canada
  7. 7 Department of Psychiatry, McGill University, Montréal, Québec, Canada
  8. 8 Department of Psychology, McGill University, Montréal, Québec, Canada
  9. 9 Biomedical Ethics Unit, McGill University, Montréal, Québec, Canada
  10. 10 Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
  11. 11 Faculty of Public Health, University of Thessaly, Karditsa, Greece
  1. Correspondence to Dr Felix Fischer, Department of Psychosomatic Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany; felix.fischer{at}


Background Cut-offs on self-report depression screening tools are designed to identify many more people than those who meet criteria for major depressive disorder. In a recent analysis of the European Health Interview Survey (EHIS), the percentage of participants with Patient Health Questionnaire-8 (PHQ-8) scores ≥10 was reported as major depression prevalence.

Objective We used a Bayesian framework to re-analyse EHIS PHQ-8 data, accounting for the imperfect diagnostic accuracy of the PHQ-8.

Methods The EHIS is a cross-sectional, population-based survey in 27 countries across Europe with 258 888 participants from the general population. We incorporated evidence from a comprehensive individual participant data meta-analysis on the accuracy of the PHQ-8 cut-off of ≥10. We evaluated the joint posterior distribution to estimate the major depression prevalence, prevalence differences between countries and compared with previous EHIS results.

Findings Overall, major depression prevalence was 2.1% (95% credible interval (CrI) 1.0% to 3.8%). Mean posterior prevalence estimates ranged from 0.6% (0.0% to 1.9%) in the Czech Republic to 4.2% (0.2% to 11.3%) in Iceland. Accounting for the imperfect diagnostic accuracy resulted in insufficient power to establish prevalence differences. 76.4% (38.0% to 96.0%) of observed positive tests were estimated to be false positives. Prevalence was lower than the 6.4% (95% CI 6.2% to 6.5%) estimated previously.

Conclusions Prevalence estimation needs to account for imperfect diagnostic accuracy.

Clinical implications Major depression prevalence in European countries is likely lower than previously reported on the basis of the EHIS survey.

  • adult psychiatry
  • depression & mood disorders

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  • Contributors FF and PK conceived the study. FF and DZ performed data analysis. FF, DZ, GR, BL, AB, BT, MR and PK contributed to study design and interpretation. FF drafted the manuscript. DZ, GR, BL, AB, BT, MR and PK provided critical reviews and approved the final manuscript. FF as the guarantor of the study accepts full responsibility for the work and the conduct of the study, had access to the data, and controlled the decision to publish.

  • Funding BL was supported by a Fonds de recherche du Québec—Santé (FRQS) Postdoctoral Training Fellowship, AB by a FRQS researcher salary award and BT by a Tier 1 Canada Research Chair, all outside of the present work.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.