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Sensitivity and Specificity of Observer and Self-Report Questionnaires in Major and Minor Depression Following Myocardial Infarction

Received January 16, 2001; revised April 25, 2001; accepted April 30, 2001. From Department of Psychiatry, Academic Hospital Maastricht/ Maastricht University, Department of Clinical Health Psychology, Tilburg University. Address correspondence and reprint requests to Dr. Adriaan Honig, MD PhD MRC Psych; Consultant psychiatrist and senior lecturer, corresponding author; Department of Psychiatry, Academic Hospital Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands; E-mail: adriaan.honig{at}spsy.azm.nl

ABSTRACT

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This study evaluated screening abilities of self-report questionnaires for depression in first myocardial infarction (MI) patients. One month post-MI, 206 patients with first MI were screened for major and minor depression using the 90-item Symptom Check List (SCL-90), the Beck Depression Inventory (BDI), the Hospital Anxiety and Depression Scale (HADS), and the 17-item Hamilton Depression Rating Scale (Ham-D). The Structured Clinical Interview for DSM-IV criteria was used as the gold standard. Sensitivity and specificity for different cutoff points, using relative operating characteristics curves, were assessed. The internal consistency for all scales was good. When screening for major and minor depression, the optimal cutoff scores are lower than those for screening major depression only. The SCL-90, BDI, HADS, and Ham-D proved to have acceptable abilities for screening post-MI major and minor depression.

Key Words: Depression • Treatment • Tests

INTRODUCTION

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Screening for depression in post-myocardial infarction (MI) patients is important as depression decreases cardiac prognosis after the MI.^1–3 Patients with MI or coronary artery disease (CAD) are often screened with self-report questionnaires and/or observer rating scales to detect symptoms of depression or even to diagnose depression.^4–7 However, the validity and reliability of most scales as screening instruments for depressive disorder have been established in depressed patients without somatic comorbidity.^8–11 These questionnaires may have a different sensitivity in identifying patients with depression after an acute MI, because some aspects of MI samples may disturb psychometric abilities of depression rating scales. Symptoms such as loss of energy, insomnia, and loss of interest may be a direct consequence of MI rather than related to depression, leading to an overrepresentation of somatic symptoms and to false-positive test results.¹²

The use of self-report questionnaires as screening instruments for depressive disorder or symptoms in patients with MI is only justified in case of a high concurrent validity of these questionnaires in relation to the DSM-IV criteria for major and minor depression. The Beck Depression Inventory (BDI) is a widely used questionaire and has high internal consistency and high convergent validity with depression rating scales based on data in non-MI patients.¹³ This explains the popularity of the BDI in research with MI patients. The 90-item Symptom Check List (SCL-90) has been proven to be a useful tool for identifying psychiatric symptoms in a primary care setting and research and is frequently used for case identification.¹⁴ The Hospital Anxiety and Depression Scale (HADS) has been proven to be a reliable and valid instrument for assessing anxiety and depression in medical patients.¹⁵ However, low validity of the HADS for detecting depressive and anxiety symptoms was found in patients with angina pectoris.¹⁵ Although these instruments are frequently used in research, to our knowledge their validity has not been evaluated in MI patients. Cutoff points of these scales are thereby primarily based on data from other than MI populations.

In this study the concurrent sensitivity and specificity of three self-report questionnaires frequently used in MI or CAD, the SCL-90,^8,16,17 the BDI,^1,9,18–20 the HADS,^21–23 and one observer rating scale, the 17-item Hamilton Depression Rating Scale, (Ham-D-17)^{6,7,11,20,22,21–23} were assessed. Validity was achieved in relation to DSM-IV criteria, assessed by the Structured Clinical Interview for DSM-IV (SCID-I),²⁴ a screening instrument for major and minor depression, in a consecutive cohort of patients following an acute first MI. In addition, Cronbach's alphas were computed as a measure of internal consistency.

METHODS

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Patients
Between May 1997 and September 1999, as part of a prospective study on risk factors for post-MI depression, 292 consecutive patients who had had a first acute MI were eligible for this study; 206 (71%) were willing to participate. There were 156 men and 50 women, all Caucasian (Table 1). The average age was 59 (SD = 10.6, range = 34–84) years for the men and 62.9 (SD = 10.7, range = 38–78) years for the women. This difference in age was statistically significant (P = 0.024). The mean maximum value of the enzyme aspartate aminotransferase (ASAT_max) score was 239 U/L (SD = 167) for men and 207 U/L (SD = 147) for women, which difference was not statistically significant (P = 0.22). The participating and nonparticipating group differed in age and gender; refusers were older (P = 0.03) and were more likely to be women (P = 0.03). This is comparable to other studies in which MI patients were screened for depression.^1,7

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TABLE 1. Baseline characteristics of the myocardial infarction patient sample

MI diagnoses were made by a cardiologist according to the following criteria: clinical picture and electrocardiographic signs typical for an acute MI and a maximum value of the enzyme aspartate aminotransferase (ASAT_max) of at least 80 U/L (twice the upper limit).²⁵ Exclusion criteria were recurrent MI or inability to fill out questionnaires.

The local ethics committee approved this study, and all patients gave written informed consent before inclusion.

Assessments
One month post-MI patients were interviewed by the first author (JS) using the depression section of the SCID-I²⁴ and the Ham-D-17.¹¹ Patients were diagnosed with major depression if they fulfilled at least one core criterion (depressed mood or loss of interest) and at least four additional criteria (total of five) with a duration of at least 2 weeks.²⁶ A diagnosis of minor depression was made in case of one to three instead of four additional criteria.²⁶ The outcome on the SCID interview was considered the gold standard in this study. The Ham-D-17 was used to measure severity of the depression.

In addition to the SCID and Ham-D-17, the SCL-90, BDI, and HADS were used as self-report questionnaires.^8,9,21 All patients included in this study were asked to fill out these questionnaires at home following the 1-month post-MI interview. If patients did not return the questionnaires within 2 weeks after the interview, they received a reminder phone call.

Data Analyses
To assess the optimal cutoff scores, relative operating characteristics (ROC) curves were obtained for all scales.²⁷ This ROC curve plots the sensitivity versus ‘1 minus specificity’ for every possible cutoff score. The optimal cutoff score is determined visually by assessing which score combines maximal sensitivity with optimal specificity.

The scale with the largest area under the curve (AUC) is better for distinguishing between depressed and nondepressed patients. In addition, positive predictive values (PPV) and negative predictive values (NPV) were measured for different cutoff scores in the central range of the scale scores. All analyses were performed with the STATA software package, release 5.²⁸

RESULTS

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Twenty-three patients met criteria for major depression (M = 13; F = 10), 16 for minor depression (M = 12; F = 4), corresponding to a 1-month post-MI depression prevalence of 18.9%. Of the 206 patients, 11 were diagnosed with a panic disorder (8 with depression), 3 with agoraphobia (1 with depression), 1 with a single phobia, and 4 with generalized anxiety disorder (in three cases concurrent with depression). The average score on the Ham-D-17 was 20.2 (SD = 4.7, range = 13–30) for the depressed women and 14.5 (SD = 6.5, range = 5–25) for the depressed men; the Ham-D score for the nondepressed men was 6.8 (SD = 4.0, range = 0–18) and 9.3 (SD = 3.8, range = 3–20) for the nondepressed women. One hundred ninety-nine patients (96.6%) returned the questionnaires; 6 patients (3%) refused and one patient (0.5%) was unable to fill out the questionnaires. The HADS was filled out by 179 patients because this questionnaire was added 2 months after the start of the study. The internal consistency of all self-report questionnaires was good, with Cronbach's alphas ranging from 0.81 (BDI), 0.82 (HADS depression subscale) and 0.83 (HADS anxiety subscale) to 0.86 (SCL-90, depression subscale) and 0.88 (total HADS).

The optimum cutoff score for detecting major and minor depression post-MI can be obtained visually from the ROC curve (Figure 1 and Table 2). For the SCL-90 depression subscale, this optimal cutoff score was 26/27 (sensitivity = 81.1%; specificity = 83.5%; PPV = 40%; NPV = 93.3%). For the BDI, the optimal cutoff score was 7/8 (sensitivity = 83.8%; specificity = 71.7%; PPV = 25.3%; NPV = 98.3%). For the HADS depression subscale, the optimal cutoff score was 3/4 (sensitivity = 75%; specificity = 77.6%; PPV = 32.1%; NPV = 98.4%). For the HADS anxiety subscale the optimal cutoff score was 5/6 (sensitivity = 96.9%; specificity = 68.7%; PPV = 40%; NPV = 95.8%). If we add both subscales of the HADS together, the optimal cutoff score was 11/12 (sensitivity = 78.1%; specificity = 85%; PPV = 45.2%; NPV = 99.3%). For the observer rating scale Ham-D-17, the optimal cutoff score was 11/12 (sensitivity = 76.3%; specificity = 86.0%; PPV = 40.7%; NPV = 99.3%). The AUCs varied from 0.84 (BDI) via 0.85 (HADS depression subscale) and 0.87 (SCL-90) to 0.88 (total HADS) and 0.90 (HADS anxiety subscale). The AUC of the Ham-D-17 was 0.89.

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FIGURE 1. ROC curves of the SCL-90 depression subscale, BDI, HADS, and Ham-D with the optimal cut-off values for screening major and minor depression after first myocardial infarctionNote: AUC = area under curve; BDI = Beck Depression Inventory; HADS = Hospital Anxiety and Depression Scale; Ham-D = Hamilton Rating Scale for Depression, 17 items; ROC = relative operating characteristics; SCL-90 = Symptom Check List, 90 items.

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TABLE 2. Screening abilities at optimal cutoff values of the SCL-90, depression subscale, BDI, HADS and Ham-D for major and minor depression 1 month after first myocardial infarction

For major depression only, the validity and optimum cutoff points change (Table 3). The optimum cutoff score for the SCL-90 was then 24/25 (sensitivity = 95.5%; specificity = 74%; PPV = 36.8%; NPV = 96.2%), for the BDI, 9/10 (sensitivity = 81.8%; specificity = 78.7%; PPV = 33.3%; NPV = 97.9%), for the HADS depression subscale, 3/4 (sensitivity = 85%; specificity = 74.8%; PPV = 32.1%; NPV = 98.4%), and 8/9 for the HADS anxiety subscale, (sensitivity = 85%; specificity = 88.1%; PPV = 48.6%; NPV = 97.4%). For the total HADS the optimum cutoff point is 12/13 (sensitivity = 90%; specificity = 84.3%; PPV = 45.2%; NPV = 99.3%). For the Ham-D the optimum cutoff point is 14/15 (sensitivity = 86.4%; specificity = 92.2%; PPV = 58.8%; NPV = 98.2%).

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TABLE 3. Screening abilities at optimal cutoff values of the SCL-90, depression subscale, BDI, HADS, and Ham-D for major depression 1 month after first myocardial infarction

DISCUSSION

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The goal of this study was to assess sensitivity and specificity of three self-report questionnaires and one observer rating scale as screening instruments for depression following first MI. The main finding of our study is that all scales have acceptable abilities to be used as screening instruments for post-MI depression. A limitation of this study is that women and older patients refused to participate in this study, which decreases generalization of the results.

All optimum cutoff scores for major and minor depression, observed in the ROC curves, were below the generally accepted cutoff scores of the SCL-90 depression subscale (M = 22/23, F = 27/28), HADS (7/8 for both subscales), BDI (9/10),^7–9,11,21 and Ham-D (17/18).¹¹ Relative to our findings, these generally accepted cutoff scores would result in a slight decrease in sensitivity and specificity of SCL-90 (75.3% and 81.1%, respectively); for the Ham-D and HADS depression subscale, it would lead to a higher sensitivity (98.8% and 95.2%, respectively) but lower specificity (55.3% and 34.3%, respectively). The generally used cutoff scores of 9/10 for the BDI and 7/8 for the HADS anxiety scale^9,21 would result in a slight decrease in sensitivity (81.1%) and specificity (67.6%) for the BDI and a decreased sensitivity (86.4%) but increased specificity (71.9%) for the HADS anxiety.

In cardiac patients, a lower cutoff score for the HADS depression subscale compared with the HADS anxiety subscale has been described.²¹ In addition, mean age in our study population (59 years for men and 62.9 years for women) was within the age group that scores highest on HADS anxiety.²¹ The validity of the total HADS increases if we add the depression and anxiety subscale together (sensitivity = 78.1%; specificity = 85%; PPV = 45.2%; NPV = 99.3%). An explanation for this increase of validity of the total HADS compared with the two subscales could be that depressive affect is typically characterized by a combination of high negative affect and low positive affect.²⁹ These affective mood states were also identified in coronary patients.³⁰ Visual inspection of the items of the HADS strongly suggests that the anxiety subscale is closely related to the negative mood dimension, while the depression scale is closely related to anhedonia or the relative absence of positive mood status. Hence, adding the HADS anxiety and depression subscales together may identify patients who are characterized by depressive affect in two-dimensional mood space.^29,30 Because of the increase in specificity and PPV, one might use the total HADS instead of both subscales, as most studies do.²¹

For screening purposes, a high sensitivity and NPV are more important than a high specificity and PPV. In our study, the HADS anxiety subscale had a sensitivity of almost 100% (96.9% and NPV = 95.8%) at the optimal cutoff 5/6 for screening major and minor depression. Our results show that sensitivity and NPV of the SCL-90, BDI, and Ham-D can be optimized by choosing lower cutoff scores (BDI = 3/4; SCL-90 = 17/18; Ham-D = 5/6). However, this induces an unacceptably low specificity in these scales (BDI = 23.1%; SCL-90 = 13.9%; Ham-D = 29.9%) (see ROC curves), thereby increasing the number of false positives. So, the HADS anxiety subscale is at least comparable to the BDI for screening purposes in post-first MI depression, having the highest AUC. Ham-D as an observer rating scale is equally valid as a screening instrument as the self-report questionnaires for major and minor depression post-MI.

For diagnostic purposes a high specificity and PPV are most important. The PPV of a test depends, in part, on prevalence of the disorder in the population. Due to the relatively low number of depressed patients compared with nondepressed patients in this study, the PPVs are much lower than the NPVs. For example, when using the HADS, one can be quite certain that a patient scoring below the cutoff does not have a depressive disorder. When a patient scores above the cutoff, the chance that this patient has a depressive disorder is equal to the chance of not having a depressive disorder. This would mean that half of the patients who are asked to participate in a lengthy interview do not fulfill criteria for depression. Therefore, dichotomizing samples based on the use of self-rating scales for diagnostic purposes remains hazardous.

The optimum cutoff scores for major depression are different and higher than those for both major and minor depression. The generally accepted cutoff scores for the BDI, HADS anxiety subscale, and total HADS are equal to that of the optimum cutoff scores for major depression. Apart from major depression, it is important to screen for minor depression, as minor depression also has an impact on morbidity and mortality post -MI.^1,18,31 Therefore lower cutoff scores might be preferable, although they lead to a larger number of false positives.

The possibility that patients may have filled out the questionnaires at home with the help of the spouse or someone else may be a limitation of this study, although the high internal consistency (mean Cronbach's = .84) suggests otherwise. Second, generalization of the outcome to patients with coronary artery disease (CAD) other than first MI should be cautioned. Also, predictive values may not reflect the performance of these same instruments when used in non-hospital settings.

In sum, all three self-report questionnaires (SCL-90, BDI, and HADS) proved to have acceptable abilities for screening major and minor depression in MI patients, although some optimum cutoff values differ from the general accepted values. Screening abilities of the observer rating scale (Ham-D) were comparable to those of the self-report questionnaires. Validity of the HADS is comparable to the BDI because of a high AUC at a cutoff value of 12/13. One has to use different cutoff scores post-MI for screening for major depression only compared with screening for both major and minor depression.

REFERENCES

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				P. J. Schmidt, K. L. Berlin, M. A. Danaceau, A. Neeren, N. A. Haq, C. A. Roca, and D. R. Rubinow The Effects of Pharmacologically Induced Hypogonadism on Mood in Healthy Men Arch Gen Psychiatry, October 1, 2004; 61(10): 997 - 1004. [Abstract] [Full Text] [PDF]

				G. Schrader, F. Cheok, A.-L. Hordacre, and N. Guiver Predictors of Depression Three Months After Cardiac Hospitalization Psychosom Med, July 1, 2004; 66(4): 514 - 520. [Abstract] [Full Text] [PDF]

				J. J. M. H. Strik, J. Denollet, R. Lousberg, and A. Honig Comparing symptoms of depression and anxiety as predictors of cardiac events and increased health care consumption after myocardial infarction J. Am. Coll. Cardiol., November 19, 2003; 42(10): 1801 - 1807. [Abstract] [Full Text] [PDF]

				P. M.J.C. Kuijpers, J. Denollet, R. Lousberg, H. J.J. Wellens, H. Crijns, and A. Honig Validity of the Hospital Anxiety and Depression Scale for Use With Patients With Noncardiac Chest Pain Psychosomatics, August 1, 2003; 44(4): 329 - 335. [Abstract] [Full Text] [PDF]

				I Aben, F Verhey, J Strik, R Lousberg, J Lodder, and A Honig A comparative study into the one year cumulative incidence of depression after stroke and myocardial infarction J. Neurol. Neurosurg. Psychiatry, May 1, 2003; 74(5): 581 - 585. [Abstract] [Full Text] [PDF]

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