Psychosomatics 45:461-469, December 2004
© 2004 The Academy of Psychosomatic Medicine
Screening for Depression in the Medically Ill: A Comparison of Self-Report Measures, Clinician Judgment, and DSM-IV Diagnoses
Kay Wilhelm, M.D., F.R.A.N.Z.C.P.,
Beth Kotze, M.B., B.S., F.R.A.N.Z.C.P., F.R.A.C.M.A., M.H.A., M.Med.,
Merilyn Waterhouse, B.A., P.G.Dip.Psychology,
Dusan Hadzi-Pavlovic, B.Sc., M.Psychol., and
Gordon Parker, M.D., Ph.D., D.Sc., F.R.A.N.Z.C.P.
Received June 2, 2003; revision received Jan. 6, 2004; accepted Jan. 30, 2004. From St. Vincent's Hospital; the School of Psychiatry, University of New South Wales, Kensington, Sydney, Australia; and the Mood Disorders Unit, Black Dog Institute, Prince of Wales Hospital, Randwick, Sydney, Australia. Address reprint requests to Dr. Wilhelm, Consultation Liaison Psychiatry, Level 4 DeLacy Building, St. Vincent's Hospital, Victoria Street, Darlinghurst, Sydney, NSW, 2010, Australia; kwilhelm{at}stvincents.com.au (e-mail).
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ABSTRACT
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The performance of the self-report 10-item Depression in the Medically Ill scale was observed in 210 patients as part of clinical assessment by consultation-liaison psychiatry clinicians. Both the Depression in the Medically Ill scale and the Beck Depression Inventory for Primary Care were completed by the patient, and the clinicians made their judgment of the presence and severity of "clinical depression" and DSM-IV affective disorder diagnoses. Both the Depression in the Medically Ill scale and the Beck Depression Inventory for Primary Care detected 85% of patients with DSM-IV major depressive episode. The Depression in the Medically Ill scale was slightly superior to the Beck Depression Inventory for Primary Care in its relationship to clinicians' judgments of clinical depression caseness.
Key Words: Depression • Syndromes Secondary to General Medical Disorders • DSM • Diagnostic Criteria • Other Diagnostic Tools • Primary Care
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INTRODUCTION
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Depression is a major cause of psychological and physical morbidity, with considerable social and economic burden.1–3 Statistics from a recent Australian survey indicated that in the last month 6.6% of the population were likely to have a depressive disorder and that rates are higher in the presence of physical disease, most notably liver and lung disease.4 Depression complicates medical management by leading to higher rates of complications, longer length of stay, more cardiac deaths,5 a higher risk of suicide,6 and higher costs per illness episode.7
Although depression is said to occur in about one-third of medically ill patients, it is also generally amenable to treatment.2,3 However, assessment of depression in medically ill patients can be complex and challenging. Clinicians working with the medically ill are aware not only of the "normal" reactive depressive symptoms, demoralization, and grief that accompany illnesses8 but also of the potential interactions between physical illness and depression, including the overlap between symptoms of depression and those of medical illness (for example, tiredness, anorexia, insomnia) and the phenomena of depression arising as a prodrome to or as a consequence of the medical illness.9–11 Many serious medical illnesses are accompanied by some depressive symptoms, and some medical illnesses (including malignancy, painful syndromes, endocrine disorders, some viral disorders) and some medications are depressogenic.9–12 There is also a "vicious cycle" whereby depression is associated with worsening of the index medical illness, with greater morbidity in turn leading to increased severity of depression.3 While suicidal ideation is associated with some medical illnesses more than others, it occurs generally in medically ill patients who also fulfill the criteria for major depression and often diminishes or disappears with assertive treatment of the depressive disorder.12–14
Because of the factors just discussed, the common depression screening instruments may not be as useful in the assessment of medically ill patients. There is also a question of whether the DSM-IV diagnosis of major depressive episode has the same benchmark status among medically ill patients as in other population groups. Some symptoms that constitute criteria for major depressive episode do not discriminate between depressed and nondepressed people in the presence of a medical illness,15,16 although medically ill patients who meet the criteria only for minor depression (adapted from the criteria for major depression) have been shown to respond to pharmacological and psychotherapeutic interventions.17 However, despite attempts to create modify the criteria for major depressive episode in the presence of medical illness,14–16 studies still use clinical and structured interviews that are based on DSM criteria for case finding in medically ill populations.11,15,16
An alternative approach has been to attempt to distinguish symptoms and other cognitive features that are characteristic of depression in the medically ill. Clark et al.18 used the Beck Depression Inventory in groups with either a primary psychiatric or medical illness. He found that the inventory's somatic symptom items were nondiscriminatory but that certain cognitive symptom items (loss of interest, sense of failure, sense of punishment, and suicidal thoughts) were common to depressed people in both groups. Beck et al.19 subsequently developed a short version of the Beck Depression Inventory by excluding somatic items from the original instrument. Their aim was to identify people with DSM-IV major depressive episode among medically ill inpatients. The 7-item measure assesses mood "in the past 2 weeks" on a 4-point scale from 0 (item not experienced) to 3 (the most severe expression of item). It has been used in primary and secondary care settings as a case-finding instrument in screening primary care patients for major depression.6 Since then a simple self-report measure, the Depression in the Medically Ill scale, has been described.16 The development used a "bottom-up" approach, utilizing cognitive items thought to be relevant in the presence of medical illness rather than "stripping" items from other depression measures. The original 16-item scale, refined to a 10-item measure, is examined here. The self-report questionnaire taps several constructs characteristic of depressed state, with questions phrased to elicit state responses only, each of which is rated on a 4-point Likert-type scale, ranging from 0 (not true) to 3 (completely true) to match instructions for the Beck Depression Inventory.
We set out to observe the performance of the 10-item Depression in the Medically Ill scale in patients with a known medical illness referred to a consultation-liaison psychiatry service for assessment. The patients were either routine referrals for inpatient or outpatient assessment or were outpatients attending various hospital services (heart and lung transplant assessment clinics, renal dialysis service, cardiac rehabilitation service, diabetic outpatient clinics) with which our team had regular liaison links. We selected the Beck Depression Inventory for Primary Care as the comparison measure, based on the finding of an earlier study16 that it was superior to the Hospital Anxiety and Depression Scale20 depression subscale in its capacity to differentiate depressed and nondepressed hospitalized patients.
In this study we consider the 10-item Depression in the Medically Ill scale's 1) concurrent validity (extent to which a test yields the same results as other measures of the same construct) by comparing the rate of identification of "cases" of depression by the Depression in the Medically Ill scale with the rate of identification by an established self-report measure, the Beck Depression Inventory for Primary Care, and with DSM-IV diagnoses made at the assessment interview and 2) construct validity (extent to which a test measures the hypothetical trait or construct it is intended to measure) by comparing "caseness" according to the Depression in the Medically Ill scale with the impression of severity of depression made by clinicians at the end of their assessment.
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METHOD
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Subjects
The study was conducted over a period of 10 months during 2000–2001 at St. Vincent's Hospital in Sydney. During this time, all inpatients and outpatients were approached as part of their clinical assessment by members of the consultation-liaison psychiatry team (consultant psychiatrists, psychiatric registrars, and clinical psychologists), whether or not the referral was for assessment of depression. Patients were excluded if they were referred solely for assessment of suicidal ideation and deliberate self-harm (i.e., with no medical illness), if they had psychosis or cognitive impairment, or if they were unable to understand the purpose of the interview or give informed consent because of language difficulties.
Procedure
On the basis of medical notes, the assessing clinicians completed a form that categorized the patient's primary medical diagnosis as a neurological disorder (including cerebrovascular diseases and dementia), cardiopulmonary disease, malignancy, loss of mobility (including arthritis, fractures), endocrine disorders, infectious and inflammatory disorders, renal diseases, and "other" diseases. The assessing clinicians made an independent appraisal, based on their usual interview and the patient's responses, as to whether the patient was depressed. If the patient was judged to be depressed, the clinician rated the severity as "mildly," "moderately," "severely," or "profoundly" depressed. The clinician also made a diagnosis of a DSM-IV affective disorder (including major depressive episode, minor depressive disorder [at least two of the symptom criteria for major depressive episode], dysthymic disorder, and brief or chronic adjustment disorder with depressed mood). Where there was no DSM-IV affective disorder diagnosis, the primary DSM-IV nonaffective diagnosis was noted.
Patient self-report forms were completed prior to the clinician’s assessment after consent was obtained. If there were disabilities that affected a patient’s writing or visual acuity, one of us (M.W.) read the items to the patient and/or checked the appropriate boxes upon patient instruction.
We also devised a feedback form (Figure 1) that was used by the consultation-liaison psychiatry team to assimilate the various appraisals of depression for each patient into a concise format for informing the referring medical team. Treatment recommendations were made as part of the consultation-liaison service when they were clinically indicated, but the consultation-liaison clinician also provided the referring medical team with a feedback form for each patient who was referred. The form included the diagnosis made at the interview, the caseness estimations from the measures, and a brief comment. The recommendations varied from "no evidence of depression" to "the patient is distressed and may benefit from seeing your social worker" to "this patient is depressed but currently receiving treatment." Ethics approval was given through the St Vincent's Hospital Ethics Committee, and the patients were provided with an information sheet as part of a consent process.
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FIGURE 1. Form Completed to Provide Feedback to Referring Medical Team in a Study of Patients With a Known Medical Illness Referred to a Consultation-Liaison Psychiatry Service for Assessment
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Statistical Analyses
Confidence intervals for sensitivity and specificity were calculated by the method of Agresti and Coull (as described by Zhou et al.21). Testing for differences in sensitivity and specificity between the Beck Depression Inventory for Primary Care and the 10-item Depression in the Medically Ill scale was done with McNemar's test for paired data.21 A nonparametric procedure (two-tailed z test)22 was used to calculate and compare areas under the receiver operating characteristic curve (AUC).
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RESULTS
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Of the 260 patients identified, 213 consented and were included in the study. One patient was excluded because of missing data, leaving a cohort of 212 patients. Of these, 117 (55.2%) were female. The age range was 16–91 years, with a mean age of 55.0 (SD=17.7) years for men and 50.6 (SD=18.0) years for women. The primary medical diagnoses were neurological disorder (N=6, 2.8%), cardiopulmonary disease (N=54, 25.5%), malignancy (N=20, 9.4%), loss of mobility (N=26, 12.3%), endocrine disorder (N=29, 13.7%), infectious and inflammatory disorder (N=8, 3.8%), renal disease (N=26, 12.3%) and "other" diseases (N=43, 20.2%).
Depression was judged to be "at least possible" (i.e., rated from "possibly" to "definitely") by the clinicians in 88 (41.5%) of the patients seen, including 43.2% (N=41) of the men and 40.2% (N=47) of the women. For the 212 patients included in the study, the following DSM-IV diagnoses were made: major depressive episode in 25 (11.8%), minor depressive disorder in 24 (11.3%), dysthymic disorder in six (2.8%), brief adjustment disorder with depressed mood in 26 (12.3%), and chronic adjustment disorder with depressed mood in five (2.4%). In two patients (0.9%), another primary DSM-IV diagnosis was made (generalized anxiety disorder or anorexia nervosa). For the 88 patients in whom depression was judged to be at least possible, the clinicians' rating of depression severity was "mild" for 50 patients (56.8%) and "moderate" for 35 patients (39.8%); three patients (3.4%) were rated as "severely" depressed.
Comparison of Performance of Self-Report Measures
We first determined rates of "caseness" generated by the two self-report measures using the cutoff scores recommended for the two measures ( 9 for the 10-item Depression in the Medically Ill scale and 4 for the Beck Depression Inventory for Primary Care). We compared these rates with the rate of a major depressive episode diagnosis alone and the rate of a DSM-IV affective disorder diagnosis (major depressive episode, minor depressive disorder, or dysthymic disorder) made by the clinicians (Table 1). Sensitivity was around 90% for both measures for the DSM-IV affective disorder diagnoses. Specificity ranged from 62% to 72% for the Beck Depression Inventory for Primary Care and from 66% to 77% for the 10-item Depression in the Medically Ill scale. For both measures, specificity was higher for the more inclusive category of DSM-IV affective disorder diagnoses than for major depressive episode diagnoses alone. The only significant difference reported was for the Depression in the Medically Ill scale's higher specificity in relation to the clinicians' judgment of patients' depression status.
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TABLE 1. Sensitivity and Specificity of the Beck Depression Inventory for Primary Care and the 10-Item Depression in the Medically Ill Scale in Detecting Depression
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We then determined AUCs for both self-report measures for each of the methods of affective disorder diagnosis to determine whether the two tests differed in diagnostic performance. The AUCs for the 10-item Depression in the Medically Ill scale were larger than those for the Beck Depression Inventory for Primary Care for the broader affective disorder diagnostic groupings, but these differences were not significant (Table 2). The only significant difference between measures was for clinicians' judgment of patients' depression status.
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TABLE 2. Area Under the Receiver Operating Characteristic Curve (AUC) for Performance of the Beck Depression Inventory for Primary Care and the 10-Item Depression in the Medically Ill Scale in Detecting Depression
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We then compared rates of different levels of severity of depression based on clinicians' judgment with the "caseness" rates generated by using the two self-report measures (see Table 3). Sixty-seven (76%) of the 88 patients rated as depressed according to the 10-item Depression in the Medically Ill scale and 64 (66%) of the 97 patients rated as depressed according to the Beck Depression Inventory for Primary Care were judged by clinicians to be mildly or moderately depressed. All three of the patients judged by clinicians to be severely depressed were identified by both the 10-item Depression in the Medically Ill scale and the Beck Depression Inventory for Primary Care.
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TABLE 3. Consultation-Liaison Psychiatry Clinicians' Judgment of the Severity of Depression in Medically Ill Patients Grouped by Scores on the Beck Depression Inventory for Primary Care and the 10-Item Depression in the Medically Ill Scale
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Performance of the 10-Item Depression in the Medically Ill Scale Items
We then sought to observe the performance of individual items on the 10-item Depression in the Medically Ill scale. Table 4 reports rates of positive responses ("somewhat true" to "completely true") to each item on the 10-item Depression in the Medically Ill scale and the Beck Depression Inventory for Primary Care for patients with major depressive episode, a DSM-IV affective disorder, and other DSM-IV diagnoses (including adjustment disorder, generalized anxiety disorder, eating disorders). All of the patients with a DSM-IV affective disorder diagnosis (major depressive episode, minor depressive disorder, or dysthymic disorder) affirmed the item about "stewing over things," compared to 76% of those with other DSM-IV disorders. All of the items were more likely to be affirmed by those with DSM-IV depression diagnoses than by those with other disorders.
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TABLE 4. Rate of Positive Responses on the 10-Item Depression in the Medically Ill Scale Items and the Beck Depression Inventory for Primary Care Items for Medically Ill Patients Grouped by DSM-IV Diagnostic Group
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The 10-item Depression in the Medically Ill scale does not (by design) include an item related to suicidal ideation. However, we investigated how those who had affirmed the suicidal ideation item on the Beck Depression Inventory for Primary Care performed on individual items on the 10-item Depression in the Medically Ill scale. For the 55 patients who reported suicidal ideation, the most highly rated individual items of the Depression in the Medically Ill scale were "feeling depressed," "stewing," and "being self-critical." Of the 55 patients with suicidal ideation, 46 (84%) were classified as having possible depression according to the 10-item Depression in the Medically Ill scale.
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DISCUSSION
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Despite the number of instruments available, there is still a need for an instrument to diagnose depression with high sensitivity in the medically ill.12 The Beck Depression Inventory for Primary Care and the 10-item Depression in the Medically Ill scale both concentrate on cognitive items but base the items on different symptoms. Despite the emphasis on cognitive symptoms, both measures identified most patients with major depressive episode. Both have a low threshold for definition of caseness, and both identified patients with adjustment disorders, reflecting their use in detecting possible cases rather than making definitive diagnoses. In a medically ill population, the detection of possible cases may well be a better index of performance than the simple identification of patients with major depressive episode alone. The AUC data indicate that the 10-item Depression in the Medically Ill scale appears to be slightly better at identifying a broader spectrum of mood disorders, and our impression was that the instrument was well accepted by the clinicians and patients alike.
Assessment for detection of depression is a common reason for referrals to consultation-liaison psychiatry teams in the general hospital setting. Overall, in our study, the clinicians' judgments of the presence and severity of depression were consistent with notions of clinical caseness built on formal DSM-IV categories. The clinician's judgment of whether the patient was depressed was based on the clinical interview, and we anticipated that in the general hospital context "clinical depression" would not necessarily coincide with "DSM-IV major depressive episode," as the clinician would consider the effects of medical illness, the presence of observable psychomotor change, and factors related to medications prescribed to individual patients, all of which are important in the medical setting. We acknowledge the shortcoming that for each patient, the same clinician made both the clinical judgment and the diagnostic assessment, but we considered that this feature reflected usual clinical practice, in which the assessing clinician simultaneously makes a diagnosis and assesses the clinical significance in the presence of a medical illness.
We have noted the paradox involved in using the DSM-IV affective disorders (particularly major depressive episode) as the standard for making a depressive diagnosis in medically ill patients, even though these categories are not necessarily the benchmark for patients with a medical illness. However, the findings indicate that the clinicians had a working model of clinical depression that was in keeping with current diagnostic patterns. Silverstone15 circumvented this problem by substituting four nonsomatic assessment items (fearfulness or depressed appearance; social withdrawal or decreased talkativeness; brooding, self-pity, or pessimism; and inability to be cheered up) for certain somatic items (appetite or weight loss, sleep disturbance, loss of energy or fatigue, poor concentration). We used the standard DSM-IV major depressive episode items, as we assumed this procedure reflected usual practice. Despite this belief, we found that the caseness criteria based on the cognitive items of the 10-item Depression in the Medically Ill scale and the Beck Depression Inventory for Primary Care more closely reflected cases of major depressive episode and DSM-IV affective disorders than cases of adjustment disorder. These findings suggest that there is a construct related to a more "biological" depression that is being identified, even without attending to the vegetative symptoms that are thought to be distracting in medically ill patients.
On the 10-item Depression in the Medically Ill scale, the three items most often affirmed by those with major depressive episode were "feeling depressed," "stewing over things," and "being self-critical." The item "stewing over things" is similar to Silverstone's "brooding" item, which he recommended as an additional symptom criterion for major depressive episode in the medically ill.15 The three items with the next highest rates of affirmation ("feeling vulnerable," "more distant," and "hopeless and/or helpless") seem meaningful in terms of being likely cognitions in patients with medical illness. The finding for "stewing" is noteworthy, because this apparently important factor would be overlooked if clinicians followed previous suggestions that simply asking whether a medically ill patient is depressed is sufficient.18,23 However, it is important not to burden those who are already suffering from a medical condition. Both the 10-item Depression in the Medically Ill scale and the Beck Depression Inventory for Primary Care are short, simple instruments that meet the requirement to avoid additional burden. The 10-item Depression in the Medically Ill scale, however, has the advantage of tapping into patients' concerns that are not generally identified in routine medical assessment.
An earlier paper investigating core symptoms of depression in medical and psychiatric patients found that cognitive items (including sense of failure, loss of interest, indecision, dissatisfaction, a sense of punishment), along with suicidal ideation, discriminated depression severity better than did vegetative symptoms, which also had the disadvantage of being confounded with medical illness.18 The Depression in the Medically Ill scale items have a less "plaintive" overlay and may well prove more acceptable to depressed medically ill people, who, in our experience, are often wary of completing a depression scale lest it make them feel worse. A previous report16 had noted higher rates of affirming loss of "core and essence" among medically ill patients. In the current study, this item was the least frequently affirmed item among patients with major depressive episode but was nevertheless affirmed by nearly three-quarters of the study group. In our study group, we had the impression that some patients had difficulty understanding the concept of "core and essence."
The 10-item Depression in the Medically Ill scale does not raise the issue of suicidal ideation, as it was observed that patients who completed a screening instrument found the issue of suicide off-putting and that all suicidal patients scored above the threshold for depression on the 10-item Depression in the Medically Ill scale in the developmental studies.16 We also believe that suicide risk assessment should be a regular part of the clinical interview of depressed patients and should not be accomplished by relying on a screening instrument. In our study, the suicidal ideation item was the least likely of the Beck Depression Inventory for Primary Care items to be affirmed. This finding supports the case for asking about suicidal ideation as part of the clinical interview.
Others have proposed the need for a screening instrument that would alert medical teams to the possibility of depression in the patients they treat and encourage them to then probe further. This technique has been used with the 12-item General Health Questionnaire and the Composite International Diagnostic Interview in previous research,24 but we elected to incorporate "usual" clinical referral and assessments as part of the process to determine how useful the "usual" screening is in routine consultation-liaison practice. The researchers in the previous study found that rates of psychiatric morbidity, especially of depression and generalized anxiety disorder, were high in general hospital patients but that these conditions were underrecognized by hospital medical staff.24 They noted several factors that affected recognition, including the type and severity of the medical illness, the precipitating events related to hospital admission, the rate of depression, and the lower tolerance of medical treatment by patients with psychiatric morbidity. Besides identifying patients with depressive disorders, the 10-item Depression in the Medically Ill scale identified a group of people who were distressed and generally had a diagnosis of adjustment disorder, characteristics that seem likely to be found in people seen in a general hospital setting.
Finally, the members of our consultation-liaison team found the 10-item Depression in the Medically Ill scale easy to introduce, particularly because it lacked contentious items such as questions about suicidal ideation, hopelessness, and emptiness in life. Such questions can be difficult to address for a person who is medically ill and possibly facing death, and some patients have reported to us that they feel more depressed when asked these types of questions. It therefore seems better to use other questions in a screening tool, provided those questions can still identify depressed patients. We believe the 10-item Depression in the Medically Ill scale performs that task. It is important that any self-report measures for the medically ill should be relevant and simple, as such patients are often tired and many have poor concentration.
Figure 1 shows the form we developed to provide feedback about individual assessments to the referring teams. The information and the individualized recommendations were found to be useful, and use of the form helped maintain interest in the study for the referring teams.
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CONCLUSIONS
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Both the 10-item Depression in the Medically Ill scale and the Beck Depression Inventory for Primary Care proved to be satisfactory for screening for depression in medically ill patients. Both instruments identified patients with major depressive episode, as well as other DSM-IV diagnoses reflecting distress in the context of a medical illness. The 10-item Depression in the Medically Ill scale was comparable to the Beck Depression Inventory for Primary Care in overall performance and performed better in some respects. Three 10-item Depression in the Medically Ill scale items—"stewing," "feeling depressed," and "being self-critical"—were highly indicative of major depressive episode. The 10-item Depression in the Medically Ill scale was well accepted and appears appropriate for use as a screening tool to detect most cases of clinically relevant depression in medically ill patients.
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ACKNOWLEDGMENTS
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The study was supported by program grant 222708 from the National Health and Medical Research Council and a grant from the St. Vincent's Hospital Clinic Foundation. The authors thank the patients for participating in the study, the staff of the consultation-liaison team at St. Vincent's Hospital (Justine Chubb, Mandy MacDonald, Beaver Hudson, Dr. Peter Vaux, Dr. Kathy Smith, and Dr. Karen Arnold) for conducting the interviews, Kay Parker for data analysis, and Andrea Millar and Adam Finch for preparation of the manuscript.
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Utility of Observer-Rated and Self-Report Instruments for Detecting Major Depression in Women After Cardiac Surgery: A Pilot Study
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ABSTRACT
INTRODUCTION
