Psychosomatics 43:386-393, October 2002
© 2002 The Academy of Psychosomatic Medicine
Validity of the Beck Depression Inventory, Hospital Anxiety and Depression Scale, SCL-90, and Hamilton Depression Rating Scale as Screening Instruments for Depression in Stroke Patients
Ivo Aben, M.D.,
Frans Verhey, M.D., Ph.D.,
Richel Lousberg, Ph.D.,
Jan Lodder, M.D., Ph.D., and
Adriaan Honig, M.D., Ph.D., M.R.C.Psych.
Received June 22, 2001; revision received Feb. 8, 2002; accepted Feb. 13, 2002. From the Departments of Psychiatry and Neurology, University Hospital Maastricht. Address reprint requests to Dr. Honig, Department of Psychiatry, University Hospital Maastricht, P.O. Box 5800, 6202 AZ Maastricht, the Netherlands.
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ABSTRACT
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Most instruments used to assess poststroke depression have never been specifically validated in stroke patients. This study evaluated the depression screening abilities of three questionnaires and one observer-rated scale in 202 consecutive patients 1 month after they experienced their first-ever ischemic stroke. At their respective optimum cutoff values, the sensitivity of the self-rated scales varied between 80% and 90%, while the specificity was about 60%. For the observer-rated scale (Hamilton Depression Rating Scale), sensitivity was 78.1%, and specificity was 74.6%. The instruments clearly performed better in men than in women. Despite this difference, it was concluded that all scales were acceptable screening instruments for poststroke depression.
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INTRODUCTION
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Most scales used to assess poststroke depression have never been properly validated in stroke patients,1,2 which diminishes the force of conclusions based on research data generated with these scales. At least two different aspects of stroke patients potentially disturb the psychometric properties of depression rating scales. First, stroke patients are mainly elderly patients who frequently have cognitive impairments, which potentially decreases the reliability of their responses to questions.3 Second, as a direct consequence of stroke, patients may suffer from symptoms such as insomnia and loss of appetite, which may lead to an increase in false-positive depression scores.4,5
We studied the validity of four scales (three self-rated and one observer-rated) as screening or diagnostic instruments for depression in clinical stroke patients. The scales were the Beck Depression Inventory, the Hospital Anxiety and Depression Scale, the SCL-90, and the Hamilton Depression Rating Scale. Sensitivity, specificity, and predictive values were determined at different cutoff points; DSM-IV6 diagnoses of major and minor depressive disorder were used as the gold standard. The internal consistency of the self-rated scales was also studied.
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METHOD
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Two hundred two consecutive patients with a diagnosis of first hemispheric infarction were included in the study, which was performed by the Department of Neurology and the Department of Psychiatry and Neuropsychology, University Hospital of Maastricht, in Maastricht, the Netherlands, the only hospital in the vicinity. Patient data were entered into a prospective stroke registry, which has been described in detail elsewhere.7 Patients with comorbid intracerebral disease (e.g., a brain tumor or Parkinson's disease) or a major psychiatric disorder other than an affective disorder (e.g., schizophrenia, dementia, or a present psychotic episode) were excluded from this study. Additionally, patients who were unable to communicate reliably (e.g., because of severe aphasia or cognitive dysfunction) were excluded on the basis of combined clinical judgment and results on the Mini-Mental State Examination (MMSE)8 and Frenchay Aphasia Screening Test.9 All participants provided written informed consent. The study was approved by the Medical Ethics Committee of the University Hospital of Maastricht.
All patients were assessed 1 month after their first-ever stroke. First, the MMSE and Frenchay Aphasia Screening Test were administered to measure global cognitive functioning. The level of disability and handicap was rated by using the Barthel Index10 and Rankin score,11 respectively. Data concerning level of education, living situation, and marital status were collected on inquiry.
Next, all patients were interviewed with both the depression section of the Structured Clinical Interview for DSM-IV (SCID)12 and the Hamilton depression scale.13 Patients were diagnosed as having major depression if they had at least one core symptom (i.e., depressed mood or loss of interest) and at least four other symptoms of depression that had lasted at least 2 weeks. A diagnosis of "minor depression" was made if patients had at least one core symptom and at least two but less than five symptoms in total, as defined in DSM-IV.6 The Hamilton depression scale is a clinical rating scale that quantitatively measures the severity of depressive symptoms. All interviews were administered by the same clinician (I.A.), who was trained to use these instruments.
All eligible patients were asked to fill out three questionnaires at home after the interview. The Beck Depression Inventory14,15 is a 21-item questionnaire commonly used in research on poststroke depression.2 The Hospital Anxiety and Depression Scale,16,17 specifically developed for use in patients with somatic comorbidity, consists of 7-item subscales for both depression and anxiety. The SCL-9018,19 is a self-rated scale that consists of eight psychiatric symptom domains, including a 16-item depression subscale. In this study, all 90 items were administered. The SCL-90 has been used in stroke patients both as a measure of distress20 and as a screening instrument for depression in myocardial infarct patients.21 The delay between the interview and questionnaire completion was registered.
A score of at least 10 on the Beck Depression Inventory is the generally accepted threshold for the indication of possible depression. In the original publication on the Hospital Anxiety and Depression Scale,16 a cutoff score of at least 8 was recommended for both subscales. The Hospital Anxiety and Depression Scale total score (both subscales together) has also been used as a general measure of distress.16,17 In the case of the SCL-90 depression subscale, on the basis of score distributions from a large sample of normal individuals, a threshold score of at least 23 for men and 28 for women has been established.21
To assess the optimum cutoff points, receiver operating characteristic curves were obtained for all scales.22 The "area under the curve" was calculated as a measure of the overall accuracy of the scale. Additionally, the positive predictive value and the negative predictive value were calculated for different cutoff scores in the central range of the scales.
To determine whether the scores of the three self-rated questionnaires were biased by errors, internal consistency, as measured by Cronbach's alpha, was computed for both the whole study group and a subset of patients with MMSE scores of 23 or lower.
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RESULTS
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All 202 patients included in the study had a stroke between Sept. 1, 1997, and Sept. 1, 1999. During this period, a total of 462 patients were diagnosed as having a primary hemispheric cerebral infarction. One hundred ninety-six (42.4%) of them had to be excluded, mainly because of severe comorbidity (including aphasia and dementia). Sixty-four (24.1%) eligible patients refused participation. The major characteristics of the study population are summarized in Table 1.
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TABLE 1. Demographic and Clinical Characteristics of Patients Admitted After Experiencing Their First-Ever Ischemic Stroke
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Thirty-two patients (15.8%) met DSM-IV criteria for major depressive disorder, and 19 (9.4%) met criteria for minor depressive disorder for an overall prevalence of 25.2%. Twenty-four (47.1%) of these patients were women. There was a significant difference in Hamilton depression scale scores among patients with major depression (mean=17.6 [SD=7.5]), minor depression (mean=14.9 [SD=4.8]), and no depression (mean=7.7 [SD=5.0]) (F=51.9, df=2, 199, p<0.001).
As could be expected, a substantial number of patients had difficulties in filling out the self-rated scales. Each scale was considered to be completed if at least 75% of the items were filled out properly. By this definition, 26 patients (12.9%) did not complete any of the scales. Patients who reported experiencing difficulties filling out the questionnaires were encouraged to complete at least the SCL-90. Therefore, the response was slightly higher for this scale (N=176) than for the Hospital Anxiety and Depression Scale (N=171) and the Beck Depression Inventory (N=166). Only valid responses were used for the subsequent analysis of the sensitivity, specificity, and predictive values of each scale.
The median delay between the interview and completion of the self-rating scales was 5 days; all but 13 patients returned their questionnaires within 3 weeks after the interview. However, because of logistic problems, 20 patients were interviewed 1 day to 3 weeks after they had filled out the questionnaires.
The internal consistency of all self-rated scales turned out to be good, with values of Cronbach's alpha exceeding 0.80 for the depression subscale of the Hospital Anxiety and Depression Scale (0.85), the Beck Depression Inventory (0.83), and the SCL-90 depression subscale (0.88). Analysis of a subset of 43 patients with low scores on the MMSE ( 23) showed slightly lower alpha values (0.71, 0.79, and 0.77, respectively). Moreover, nonresponse was significantly higher in this subgroup ( 2=5.9, df=1, p=0.02).
Receiver operating characteristic curves are displayed in Figure 1. In screening for major depression, the areas under the curve of the SCL-90 depression subscale, Hospital Anxiety and Depression Scale depression subscale, and Hamilton depression scale were almost equal, ranging from 0.81 to 0.83. The area under the curve of the Beck Depression Inventory was only slightly lower (0.78). The anxiety subscale of the Hospital Anxiety and Depression Scale and the total Hospital Anxiety and Depression Scale were also entered into the receiver operating characteristic analyses (Figure 2). This revealed an area under the curve of 0.78 for the Hospital Anxiety and Depression Scale anxiety subscale and 0.83 for the total Hospital Anxiety and Depression Scale (Table 2).
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FIGURE 1. Receiver Operating Characteristic Curves for Instruments Used to Screen for Major Depression in Patients Who Experienced Their First-Ever Strokea
aNumbers represent cutoff values (i.e., the highest score for which depression is considered absent and the lowest score indicating possible depression). SCL-90-D=depression subscale of the SCL-90; BDI=Beck Depression Inventory; HADS-D=depression subscale of the Hospital Anxiety and Depression Scale; HAM-D=Hamilton Depression Rating Scale.
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FIGURE 2. Receiver Operating Characteristic Curves for the Depression Subscale, Anxiety Subscale, and Total Hospital Anxiety and Depression Scale in Screening for Major Depressiona
aNumbers represent cutoff values (i.e., the highest score for which depression is considered absent and the lowest score indicating possible depression).
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TABLE 2. Screening Abilities at Optimum Cutoff Values for Major Depression Alone and for Both Major and Minor Depression
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The optimum cutoff point (with the highest sum of sensitivity and specificity) for the SCL-90 depression subscale was a score of 25 (sensitivity: 88.5, specificity: 60.7); for the Beck Depression Inventory, it was a score of 10 (sensitivity: 80.0, specificity: 61.4); and for the Hospital Anxiety and Depression Scale depression subscale it was a score of 8 (sensitivity: 73.1, specificity: 81.6). Use of the total Hospital Anxiety and Depression Scale resulted in a sensitivity of no less than 91.7 (specificity: 65.3) at its optimum threshold score of 11 (Table 2).
For the Hamilton depression scale, the cutoff value with the highest sum of sensitivity and specificity was a score of 17 (sensitivity: 62.5, specificity: 91.7). However, detailed inspection of the receiver operating characteristic curve of the Hamilton depression scale showed that, especially in the central range, the smoothness of the curve was somewhat less than perfect. The sums of sensitivity and specificity at cutoff scores of 12 and 17 were almost equal, whereas the values in between clearly gave poorer results. Relative to a cutoff score of 17, use of a cutoff score of 12 improved sensitivity 15.6% to 78.1, whereas the specificity decreased by 17.1% to 74.6.
Screening for both major and minor depression did not change the overall accuracy of the instruments, as reflected by the receiver operating characteristic curves. The optimum cutoff values for the Beck Depression Inventory, SCL-90 depression subscale, and total Hospital Anxiety and Depression Scale also remained the same, while for the Hamilton depression scale, 12 became the best cutoff value. For the Hospital Anxiety and Depression Scale depression subscale, however, the optimum cutoff score decreased by one point to 7. The sensitivity and specificity did not change substantially compared to screening for major depression only (Table 2).
Separate receiver operating characteristic analyses for men and women revealed a clear gender effect on the validity of the scales (Figure 3). Especially for the self-rating scales, the areas under the curve were higher in male than in female respondents (SCL-90 depression subscale: 0.89 versus 0.69, respectively; Beck Depression Inventory: 0.86 versus 0.69; Hospital Anxiety and Depression Scale depression subscale: 0.87 versus 0.77; total Hospital Anxiety and Depression Scale: 0.94 versus 0.72; Hamilton depression scale: 0.87 versus 0.80). Optimum cutoff levels also varied between men and women, but this did not substantially improve screening performance.
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FIGURE 3. Receiver Operating Characteristic Curves for Instruments Used to Screen for Major Depression in Patients Who Experienced Their First-Ever Stroke, by Gendera
aSCL-90-D=depression subscale of the SCL-90; BDI=Beck Depression Inventory; HADS-D=depression subscale of the Hospital Anxiety and Depression Scale; HAM-D=Hamilton Depression Rating Scale.
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DISCUSSION
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Our main finding was that all scales were acceptable screening instruments for poststroke depression but that their performance was clearly worse in women than men. This is best represented by the area under the curve differences (receiver operating characteristic analysis), which reached levels as high as 34% (Beck Depression Inventory) and 40% (SCL-90 depression subscale) of the maximum possible variation. At optimum cutoff levels, this almost exclusively concerned false-positive cases.
A possible explanation for this sex difference lies in the fact that women tend to report more aspecific complaints of distress than men.23 This was confirmed by logistic regression analysis. The significant effect of female sex on a false-positive screening test (odds ratio=2.63; p=0.005) largely disappeared when the total SCL-90 score was entered into the logistic model as a measure of distress (odds ratio=2.58; p=0.07). In addition, total SCL-90 score proved to be a strong, independent predictor of a false-positive test result (odds ratio=1.11; p<0.0001).
Severity of handicaps (i.e., Rankin score) was also found to have contributed to the sex difference. When entered into the model, it further decreased the independent effect of sex (odds ratio=1.75; p=0.32), while it was independently related to the accuracy of the screening test itself (odds ratio=1.86; p=0.04). No effect was found for age or global cognitive functioning (i.e., MMSE score).
Use of the previously recommended and generally accepted cutoff levels for the Beck Depression Inventory (score  10) and Hospital Anxiety and Depression Scale depression subscale (score 8) turned out to be optimal. Defining separate thresholds for men and women did not improve their performance meaningfully. This finding does not support earlier reports on the screening performance of depression rating scales in stroke patients, which indicated that the original cutoff values for the Hospital Anxiety and Depression Scale or Beck Depression Inventory are suboptimal in this patient population.24–26
Overall, the total Hospital Anxiety and Depression Scale was just as accurate as the Hospital Anxiety and Depression Scale depression subscale, and combined high sensitivity (91.7) with acceptable specificity (65.3) at its optimum cutoff level of 11. Even the anxiety subscale alone performed satisfactorily. Indeed, the correlation between the depression and anxiety subscales of the Hospital Anxiety and Depression Scale was high (r=0.67, p<0.001), which illustrates the frequent coincidence of symptoms of anxiety and depression in stroke patients. Moreover, the total Hospital Anxiety and Depression Scale may be even more accurate in detecting cases of poststroke depression than the depression subscale alone.
The previously used cutoff value of the SCL-90 depression subscale combined a relatively low threshold for men (score of 23) with a higher level for women (score of 28). However, our results indicate that using separate cutoff values for men and women is not clearly superior to using a score of 25 as one uniform threshold (sensitivity: 88.5, specificity: 60.7).
The Hamilton depression scale had nearly equal sums of sensitivity and specificity at cutoff levels of 12 and 17 for both men and women. This can be explained by the lack of smoothness of the receiver operating characteristic curves because of the limited study group size. It seems, therefore, quite arbitrary to use separate cutoff values for men and women. On the basis of our data, it seems most sensible to set the threshold at 12 (sensitivity: 78.1, specificity: 74.6) if the Hamilton depression scale is used for screening purposes. For diagnostic purposes, a score 17 (sensitivity: 62.5, specificity: 91.7) would be most favorable because of the higher specificity (increasing the overall diagnostic accuracy).
Screening for both major and minor depression did not meaningfully decrease sensitivity nor improve specificity (5%). Optimum thresholds for the SCL-90 depression subscale, Beck Depression Inventory, total Hospital Anxiety and Depression Scale, and Hamilton depression scale were the same as in screening for major depression alone. For the Hospital Anxiety and Depression Scale depression subscale, it was lowered by one point to a score of 7.
Last, the internal consistency of all three self-rated scales was high and only slightly decreased in a subset of patients with low MMSE scores (23). In this subgroup, nonresponse was clearly higher. Moreover, we cannot exclude that relatives may have helped the patients to complete the scales. This suggests that, overall, stroke patients are able to fill out these scales reliably, but problems arise in more cognitively impaired patients.
The generalizability of the present findings mainly depends on both the prevalence rate of poststroke depression in our sample and the main patient characteristics. In our sample, 25.2% of the patients were diagnosed as suffering from poststroke depression 1 month after the stroke. This is similar to the prevalence of 20%–30% found in large epidemiologic studies.27–31 The age, gender ratio, and demographic characteristics of our sample are representative for a general stroke population.32,33 Therefore, our findings can be generalized to other samples of stroke patients, with the exception of severely cognitively damaged patients.
We determined whether misdiagnoses were more likely to occur with increasing delay between the diagnostic interview and completion of the self-rated scales (which were completed at home afterwards). However, logistic regression analysis showed no significant relationship. Also, misdiagnoses were not significantly more frequent among those 20 patients who filled out the self-rated scales before the diagnostic interview.
Another potential source of bias lies in the administration of the SCID and Hamilton depression scale by the same interviewer during one session. This may have increased the agreement between the two instruments. However, this effect was kept minimal by strictly applying the standard user manuals of both instruments and by strictly separating questions concerning the different instruments. The inconsistent findings of the SCID and the Hamilton depression scale can be explained by the fact that the SCID concerns a depressive episode lasting at least 2 weeks in the last month, whereas we used the Hamilton depression scale to rate symptoms during the last week only.
Our results indicate that none of the self-rated scales we studied is suitable to diagnose poststroke depression in clinical settings or to distinguish between depressed and nondepressed subjects in research settings because of the high misdiagnosis rate (20% with the Hospital Anxiety and Depression Scale depression subscale to almost 40% with the Beck Depression Inventory). However, the Hamilton depression scale turned out to be diagnostically accurate in 87.1% of cases at its optimum "diagnostic" cutoff point (score 17). Leentjens et al.34 found a similar accuracy of the Hamilton depression scale in patients with idiopathic Parkinson's disease.
With no substantial difference in screening performance between the four rating scales, both the total Hospital Anxiety and Depression Scale and Beck Depression Inventory could be preferred in screening for poststroke depression, since they need the least time to administer. Although the observer-based Hamilton depression scale has similar predictive validity, it requires trained staff to be administered and may, therefore, be less desirable for screening in day-to-day practice. The relatively high accuracy and specificity of the Hamilton depression scale make this instrument more suitable for diagnostic and dichotomization purposes.
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ACKNOWLEDGMENTS
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The authors thank Dr. Anita Boreas for registering all stroke patients during the inclusion period.
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Academy of Psychosomatic Medicine.
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