{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T14:19:27Z","timestamp":1787062767686,"version":"build-2736575974"},"reference-count":44,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2022,4,25]],"date-time":"2022-04-25T00:00:00Z","timestamp":1650844800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>The Post-Hurricane Distress Scale (PHDS) was developed to assess mental health risk in the aftermath of hurricanes. We derive both disorder-specific cutoff values and a single nonspecific cutoff for the PHDS for field use by disaster relief and mental health workers. Data from 672 adult residents of Puerto Rico, sampled 3 to 12 months after Hurricane Maria, were collected. Participants completed a five-tool questionnaire packet: PHDS, Kessler K6, Patient Health Questionnaire 9, Generalized Anxiety Disorder 7, and Post-Traumatic Stress Disorder Checklist for DSM V (PCL-5). ROC curves, AUC values, sensitivities, specificities, Youden\u2019s index, and LR+ ratios are reported. The recommended single cutoff value for the PHDS is 41, whereby a respondent with a PHDS score of 41 or above is deemed high-risk for a mental health disorder. The single field use PHDS cutoff demonstrated high specificity (0.80), an LR + ratio (2.84), and a sensitivity of 0.56. The mean ROC values of PHDS for Kessler K6, Patient Health Questionnaire 9, Generalized Anxiety Disorder 7, and PCL-5 were all above 0.74. The derived cutoff for the PHDS allows efficient assessment of respondents\u2019 and\/or a community\u2019s risk status for mental health disorders in the aftermath of hurricanes and natural disasters.<\/jats:p>","DOI":"10.3390\/ijerph19095204","type":"journal-article","created":{"date-parts":[[2022,4,25]],"date-time":"2022-04-25T21:16:28Z","timestamp":1650921388000},"page":"5204","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Post-Hurricane Distress Scale (PHDS): Determination of General and Disorder-Specific Cutoff Scores"],"prefix":"10.3390","volume":"19","author":[{"given":"Yonatan","family":"Carl","sequence":"first","affiliation":[{"name":"San Juan Bautista School of Medicine, Caguas 00726, Puerto Rico"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2912-9767","authenticated-orcid":false,"given":"Andy","family":"Vega","sequence":"additional","affiliation":[{"name":"Medical College of Wisconsin, Milwaukee, WI 53226, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gina","family":"Cardona-Acevedo","sequence":"additional","affiliation":[{"name":"Universidad Central del Caribe, Bayam\u00f3n 00960, Puerto Rico"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marina","family":"Stukova","sequence":"additional","affiliation":[{"name":"University of Miami, Coral Gables, FL 33146, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Melissa","family":"Matos-Rivera","sequence":"additional","affiliation":[{"name":"San Juan Bautista School of Medicine, Caguas 00726, Puerto Rico"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anamaris","family":"Torres-Sanchez","sequence":"additional","affiliation":[{"name":"San Juan Bautista School of Medicine, Caguas 00726, Puerto Rico"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Melissa","family":"Mili\u00e1n-Rodr\u00edguez","sequence":"additional","affiliation":[{"name":"San Juan Bautista School of Medicine, Caguas 00726, Puerto Rico"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brian","family":"Torres-Mercado","sequence":"additional","affiliation":[{"name":"San Juan Bautista School of Medicine, Caguas 00726, Puerto Rico"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Grisel","family":"Burgos","sequence":"additional","affiliation":[{"name":"San Juan Bautista School of Medicine, Caguas 00726, Puerto Rico"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Raymond L.","family":"Tremblay","sequence":"additional","affiliation":[{"name":"San Juan Bautista School of Medicine, Caguas 00726, Puerto Rico"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2022,4,25]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"135","DOI":"10.1016\/j.jad.2010.06.018","article-title":"Psychiatric disorders and functional impairment among disaster victims after exposure to a natural disaster: A population based study","volume":"128","author":"Hussain","year":"2011","journal-title":"J. Affect. Disord."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"261","DOI":"10.4103\/0253-7176.162915","article-title":"Disaster Management: Mental Health Perspective","volume":"37","author":"Math","year":"2015","journal-title":"Indian J. Psychol. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1521\/psyc.65.3.207.20173","article-title":"60,000 disaster victims speak: Part I. An empirical review of the empirical literature, 1981\u20132001","volume":"65","author":"Norris","year":"2002","journal-title":"Psychiatry"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"78","DOI":"10.1093\/epirev\/mxi003","article-title":"The epidemiology of post-traumatic stress disorder after disasters","volume":"27","author":"Galea","year":"2005","journal-title":"Epidemiol. Rev."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"865","DOI":"10.1017\/S0033291715002378","article-title":"Personality diatheses and Hurricane Sandy: Effects on post-disaster depression","volume":"46","author":"Kotov","year":"2016","journal-title":"Psychol. Med."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Chan, C.S., and Rhodes, J.E. (2014). Measuring exposure in Hurricane Katrina: A meta-analysis and an integrative data analysis. PLoS ONE, 9.","DOI":"10.1371\/journal.pone.0092899"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"959","DOI":"10.1017\/S0033291702006074","article-title":"Short screening scales to monitor population prevalences and trends in non-specific psychological distress","volume":"32","author":"Kessler","year":"2002","journal-title":"Psychol. Med."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"441","DOI":"10.1080\/09540260802397487","article-title":"Mental health and the psychosocial consequences of natural disasters in Asia","volume":"20","author":"Udomratn","year":"2008","journal-title":"Int. Rev. Psychiatry"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"716","DOI":"10.1192\/bjp.2018.210","article-title":"Psychological distress and psychiatric disorder after natural disasters: Systematic review and meta-analysis","volume":"213","author":"Beaglehole","year":"2018","journal-title":"Br. J. Psychiatry"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Fullerton, C.S., Ursano, R.J., Liu, X., McKibben, J.B., Wang, L., and Reissman, D.B. (2015). Depressive Symptom Severity and Community Collective Efficacy following the 2004 Florida Hurricanes. PLoS ONE, 10.","DOI":"10.1371\/journal.pone.0130863"},{"key":"ref_11","unstructured":"Robert, L.S.J., and Kroenke, K. (2022, February 21). Patient Health Questionnaire Screeners. Available online: https:\/\/www.phqscreeners.com\/select-screener\/31."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"82","DOI":"10.1017\/dmp.2019.12","article-title":"Post-Hurricane Distress Scale (PHDS): A Novel Tool for First Responders and Disaster Researchers","volume":"13","author":"Carl","year":"2019","journal-title":"Disaster Med. Public Health Prep."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1002\/jts.20030","article-title":"Traumatic Exposure Severity Scale (TESS): A measure of exposure to major disasters","volume":"18","author":"Elal","year":"2005","journal-title":"J. Trauma. Stress"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"169","DOI":"10.1146\/annurev-publhealth-032013-182435","article-title":"Mental Health Consequences of Disasters","volume":"35","author":"Goldmann","year":"2013","journal-title":"Annu. Rev. Public Health"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"753","DOI":"10.1002\/jts.21872","article-title":"Immediate and longer-term stressors and the mental health of Hurricane Ike survivors","volume":"26","author":"Lowe","year":"2013","journal-title":"J. Trauma. Stress"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1017\/S2045796011000758","article-title":"The importance of secondary trauma exposure for post-disaster mental disorder","volume":"21","author":"Kessler","year":"2012","journal-title":"Epidemiol. Psychiatr. Sci."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"34","DOI":"10.1176\/appi.ajp.2007.07030502","article-title":"Disruption of existing mental health treatments and failure to initiate new treatment after Hurricane Katrina","volume":"165","author":"Wang","year":"2008","journal-title":"Am. J. Psychiatry"},{"key":"ref_18","first-page":"14","article-title":"Post-traumatic stress disorder and acute stress disorder I: Their nature and assessment considerations","volume":"2","author":"Cahill","year":"2005","journal-title":"Psychiatry"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"161","DOI":"10.1146\/annurev.clinpsy.2.022305.095305","article-title":"Posttraumatic stress disorder: Etiology, epidemiology, and treatment outcome","volume":"2","author":"Keane","year":"2006","journal-title":"Annu. Rev. Clin. Psychol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1017\/dmp.2019.22","article-title":"The Correlation of English Language Proficiency and Indices of Stress and Anxiety in Migrants from Puerto Rico after Hurricane Maria: A Preliminary Study","volume":"14","author":"Carl","year":"2020","journal-title":"Disaster Med. Public Health Prep."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"359","DOI":"10.1016\/S0924-9338(99)80703-2","article-title":"Suicide attempts and job insecurity: A complex association","volume":"13","author":"Chastang","year":"1998","journal-title":"Eur. Psychiatry"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"928","DOI":"10.1097\/MLR.0b013e31826c8613","article-title":"Economic differences in direct and indirect costs between people with epilepsy and without epilepsy","volume":"50","author":"Libby","year":"2012","journal-title":"Med. Care"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"429","DOI":"10.1016\/j.jiph.2015.11.007","article-title":"Hygiene and mental health among middle school students in India and 11 other countries","volume":"9","author":"Ranasinghe","year":"2016","journal-title":"J. Infect. Public Health"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"509","DOI":"10.1111\/j.1524-4733.2007.00292.x","article-title":"Literature review of methods to translate health-related quality of life questionnaires for use in multinational clinical trials","volume":"11","author":"Acquadro","year":"2008","journal-title":"Value Health"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1092","DOI":"10.1001\/archinte.166.10.1092","article-title":"A brief measure for assessing generalized anxiety disorder: The GAD-7","volume":"166","author":"Spitzer","year":"2006","journal-title":"Arch. Intern. Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"88","DOI":"10.1002\/mpr.1349","article-title":"Validity study of the K6 scale as a measure of moderate mental distress based on mental health treatment need and utilization","volume":"21","author":"Prochaska","year":"2012","journal-title":"Int. J. Methods Psychiatr. Res."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"606","DOI":"10.1046\/j.1525-1497.2001.016009606.x","article-title":"The PHQ-9: Validity of a brief depression severity measure","volume":"16","author":"Kroenke","year":"2001","journal-title":"J. Gen. Intern. Med."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"E191","DOI":"10.1503\/cmaj.110829","article-title":"Optimal cut-off score for diagnosing depression with the Patient Health Questionnaire (PHQ-9): A meta-analysis","volume":"184","author":"Manea","year":"2012","journal-title":"CMAJ"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"489","DOI":"10.1002\/jts.22059","article-title":"The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and Initial Psychometric Evaluation","volume":"28","author":"Blevins","year":"2015","journal-title":"J. Trauma. Stress"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"369","DOI":"10.1002\/jts.20349","article-title":"Spanish and English versions of the PTSD Checklist-Civilian version (PCL-C): Testing for differential item functioning","volume":"21","author":"Miles","year":"2008","journal-title":"J. Trauma. Stress"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"758","DOI":"10.1177\/1073191115599639","article-title":"Measurement Equivalence of the K6 Scale: The Effects of Race\/Ethnicity and Language","volume":"23","author":"Kim","year":"2016","journal-title":"Assessment"},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Munoz-Navarro, R., Cano-Vindel, A., Medrano, L.A., Schmitz, F., Ruiz-Rodriguez, P., Abellan-Maeso, C., Font-Payeras, M.A., and 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.","DOI":"10.1186\/s12888-017-1450-8"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"654","DOI":"10.1161\/CIRCULATIONAHA.105.594929","article-title":"Receiver-operating characteristic analysis for evaluating diagnostic tests and predictive models","volume":"115","author":"Zou","year":"2007","journal-title":"Circulation"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"335","DOI":"10.1016\/j.jclinepi.2013.09.009","article-title":"Missing data in a multi-item instrument were best handled by multiple imputation at the item score level","volume":"67","author":"Eekhout","year":"2014","journal-title":"J. Clin. Epidemiol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"458","DOI":"10.1002\/bimj.200410135","article-title":"Estimation of the Youden Index and its associated cutoff point","volume":"47","author":"Fluss","year":"2005","journal-title":"Biom. J."},{"key":"ref_36","first-page":"36","article-title":"OptimalCutpoints: An R Package for Selecting Optimal Cutpoints in Diagnostic Tests","volume":"61","year":"2014","journal-title":"J. Stat. Softw."},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Robin, X., Turck, N., Hainard, A., Tiberti, N., Lisacek, F., Sanchez, J.C., and Muller, M. (2011). pROC: An open-source package for R and S+ to analyze and compare ROC curves. BMC Bioinform., 12.","DOI":"10.1186\/1471-2105-12-77"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"419","DOI":"10.1002\/bimj.200710415","article-title":"Youden Index and optimal cut-point estimated from observations affected by a lower limit of detection","volume":"50","author":"Ruopp","year":"2008","journal-title":"Biom. J."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"615","DOI":"10.1007\/s10979-005-6832-7","article-title":"Comparing effect sizes in follow-up studies: ROC Area, Cohen\u2019s d, and r","volume":"29","author":"Rice","year":"2005","journal-title":"Law Hum. Behav."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"184","DOI":"10.1001\/archpsyc.60.2.184","article-title":"Screening for serious mental illness in the general population","volume":"60","author":"Kessler","year":"2003","journal-title":"Arch. Gen. Psychiatry"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"317","DOI":"10.7326\/0003-4819-146-5-200703060-00004","article-title":"Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection","volume":"146","author":"Kroenke","year":"2007","journal-title":"Ann. Intern. Med."},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Belk, R.A., Pilling, M., Rogers, K.D., Lovell, K., and Young, A. (2016). The theoretical and practical determination of clinical cut-offs for the British Sign Language versions of PHQ-9 and GAD-7. BMC Psychiatry, 16.","DOI":"10.1186\/s12888-016-1078-0"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"567","DOI":"10.1016\/j.genhosppsych.2015.06.012","article-title":"Screening and case finding for major depressive disorder using the Patient Health Questionnaire (PHQ-9): A meta-analysis","volume":"37","author":"Moriarty","year":"2015","journal-title":"Gen. Hosp. Psychiatry"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"24","DOI":"10.1016\/j.genhosppsych.2015.11.005","article-title":"Screening for anxiety disorders with the GAD-7 and GAD-2: A systematic review and diagnostic metaanalysis","volume":"39","author":"Plummer","year":"2016","journal-title":"Gen. Hosp. Psychiatry"}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/19\/9\/5204\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T23:00:41Z","timestamp":1760137241000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/19\/9\/5204"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,4,25]]},"references-count":44,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2022,5]]}},"alternative-id":["ijerph19095204"],"URL":"https:\/\/doi.org\/10.3390\/ijerph19095204","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,4,25]]}}}