Psychosomatics 48:16-21, January-February
doi: 10.1176/appi.psy.48.1.16
© 2007 Academy of Psychosomatic Medicine
A Practical Screening Tool for Anxiety and Depression in Patients With Chronic Breathing Disorders
Mark E. Kunik, M.D., M.P.H.,
Pierre N. Azzam, M.D.,
Julianne Souchek, Ph.D.,
Jeffrey A. Cully, Ph.D.,
Nelda P. Wray, M.D., M.P.H.,
Laura L. Krishnan, M.S.,
Harlan A. Nelson, M.S., and
Melinda A. Stanley, Ph.D.
From the Houston Center for Quality of Care and Utilization Studies, Health Services Research and Development Service, the Michael E. DeBakey Veterans Affairs Medical Center; the Menninger Dept. of Psychiatry and Behavioral Sciences, Dept. of Medicine, Baylor College of Medicine; and the Veteran Affairs South Central Mental Illness Research, Education, and Clinical Center. Send correspondence and reprint requests to Mark E. Kunik, M.D., M.P.H., Houston Center for Quality of Care and Utilization Studies, Michael E DeBakey VAMC (152), 2002 Holcombe, Houston, TX 77030. e-mail: mkunik{at}bcm.tmc.edu
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ABSTRACT
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Obstructive lung diseases are associated with high rates of depression and anxiety, yet many patients are never screened or treated. This study evaluated the five-question Depression and Anxiety modules of the Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Questionnaire as a telephone screen in 1,632 patients with chronic breathing disorders at a Veterans Affairs Medical Center in Houston, TX. Subsequent testing of 828 patients with the Beck Depression Inventory–II and the Beck Anxiety Inventory showed that the sensitivity and specificity, respectively, of the Depression and Anxiety modules of the PRIME-MD Patient Questionnaire screening were 94.6% and 49.5% (Depression); 93.7% and 32.2% (Anxiety); and 97.7%, and 36.0% (combined screen), with an overall accuracy of 80.7%. In such populations, these two modules of the PRIME-MD Patient Questionnaire may be a useful screening tool.
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INTRODUCTION
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The role of primary-care physicians in maintaining psychiatric health remains poorly defined, particularly as it relates to the detection and treatment of depression and anxiety. Patients with depression and anxiety present to primary-care physicians as often as they present to mental health facilities,1 yet many are never adequately screened or treated for these conditions.2–4 Even the most advanced pharmaceutical and evidence-based approaches to mental illness prove powerless in the face of an inability to detect that mental illness.
Although significant depression and anxiety are observed in the general population of primary-care patients, the prevalence of these symptoms is far greater among chronically ill persons.5–12 Patients with obstructive lung diseases have high rates of psychiatric comorbidity:7,13,14 from 22% to 42% of patients with chronic obstructive pulmonary disease (COPD) endorse symptoms of depression, and between 34% and 50% report significant anxiety.6,15 In a recent study of veterans with COPD, which used the Primary Care Evaluation of Mental Disorders and the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, to diagnose depression and anxiety in patients treated during the previous year, just 43% of patients with depression and 29% of patients with anxiety disorder had been previously diagnosed by their primary-care physicians.5
The lack of mental health screening among patients with COPD is particularly alarming, given the adverse impact of depression and anxiety on their quality of life. Depression and anxiety are associated with higher levels of physical, emotional, and psychosocial disability among patients with COPD.16,17 The increased prevalence, poor track record of detection, and negative impact of depression and anxiety in patients with COPD collectively substantiate the need for psychiatric screening in the primary-care setting.
One promising screening tool, the Primary Care Evaluation of Mental Disorders (PRIME-MD), was designed to evaluate for several psychiatric conditions in the primary-care setting.2,18 The original version of the PRIME-MD includes a patient-administered Patient Questionnaire (PQ) that contained a two-question Depression module and a three-question Anxiety module in addition to a caretaker-administered Clinical Evaluation Guide. The validity of the two-part instrument was tested for use in the primary-care setting in a trial involving 1,000 patients.18
In an attempt to shorten administration time, a later version of the PRIME-MD provided a shorter Patient Health Questionnaire (PHQ) that the patient could self-administer. The PHQ contains the five screening questions (two for depression and three for anxiety) that made up the Depression and Anxiety modules of the original PQ, plus other questions. Screening with the PHQ has produced results comparable to the physician-administered component in this setting.19 The patient- and caretaker-perceived efficiency, ease, and value of the PRIME-MD have also been established.19
Although the PRIME-MD has been validated in obstetrics-gynecology,20 otorhinolaryngology,21 and general medicine,18,19,22,23 it has never been evaluated among patients with chronic breathing disorders.5 Multiple investigations have underscored its validity as administered by telephone and personal computer.22,23 This study examines the validity of the two-question Depression module and the three-question Anxiety module of the PRIME-MD PQ for telephone screening for depression and anxiety in patients with chronic breathing disorders.
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METHOD
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This study is part of a randomized, controlled trial to evaluate potential treatments for psychopathology in persons with COPD. Participants gave informed consent, as approved by the Baylor College of Medicine Institutional Review Board.
Recruitment and Screening
All persons treated for a chronic breathing disorder at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, TX, in 2002–2003 were targeted for recruitment.5 The sample was drawn from patients with one or more of the following diagnoses: bronchitis, emphysema, asthma, bronchiectasis, chronic airway obstruction, and respiratory condition not otherwise specified. The patient list was randomized using SAS (Version 9.1; SAS Institute, Inc., Cary, NC), and selected patients were contacted by telephone for prescreening. Individuals who acknowledged a breathing disorder were then screened with the PRIME-MD PQ Depression and Anxiety modules as follows: PRIME-MD Depression Screen—In the past month, have you been bothered a lot by: 1. Little interest or pleasure in doing things? 2. Feeling down, depressed, or hopeless? PRIME-MD Anxiety Screen—In the past month, have you been bothered a lot by: 1. "Nerves," or feeling anxious or on edge? 2. Worrying about a lot of different things? During the last month: 3. Have you had an anxiety attack (suddenly feeling fear or panic)?
A positive screen for depression or anxiety was defined as a positive response to one or more questions from the respective PQ component. All patients who screened positive for depression and/or anxiety and 100 randomly selected patients who screened negative for both conditions were asked to participate in an in-person evaluation using the Beck Depression Inventory–II (BDI) and Beck Anxiety Inventory (BAI).
Evaluation of Depression and Anxiety
The BDI and BAI are 21-item self-report instruments used to assess the severity of symptoms of depression and anxiety, respectively.24 Both instruments are widely accepted as highly reliable and valid tools for many patient populations.24,25 Clinical depression was defined by a score of  14 on the BDI, a cutoff that differentiates clinically symptomatic and community samples of adults.26 A BAI cutoff score of 16 was selected, given that scores of this magnitude represent moderate-to-severe anxiety27 and that a cut-point at this level adequately balances specificity (0.67) and sensitivity (0.62) for identifying anxiety among older adult psychiatric patients.28 A BDI–II cutoff of 14 corresponds with an empirically-derived cutoff for the BDI that differentiated community and clinically symptomatic samples of adults (cutoff: 14.3)26 and is one standard deviation (SD) above the BDI–II mean for male primary-care patients (5.8; SD: 6.9).29 No sensitivity or specificity data exist for this BDI cut-point in older adults with chronic medical illnesses.
Data Analysis
Using the results from the BDI and BAI as indicators of depression and anxiety, respectively, we calculated the sensitivity, specificity, predictive value–positive (PVP), predictive value–negative (PVN), and overall accuracy of the five PQ screening questions. These measures were calculated for every possible cut-point for each screen, in addition to a combined depression and anxiety screen. The test value for the combined screen is the number of questions answered positively on both components, ranging from 0 to 5. For the combined screen, a true positive was defined as a BDI score 14 and/or a BAI score 16.
The area under the receiver operating characteristic (ROC) curve was computed for the PQ Depression and Anxiety screens and represents the probability that the test correctly discriminates between a pair of responses, one positive and one negative. If the area under the curve (AUC) equals 0.5, the test is no better than chance, whereas an AUC close to 1 indicates good discrimination. Using the logistic procedure from SAS 9.1 to compute these statistics, we tested whether the AUC for the PRIME-MD was greater than 0.5 for each screen.
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RESULTS
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Study Population
A search of Veterans Affairs (VA) outpatient and inpatient files revealed 21,796 patients with chronic breathing disorder diagnoses in 2002–2003. Of these patients, 7,656 were randomly chosen and contacted; and with 137 self-referred patients, there were 7,793 calls. Of the 1,981 patients reached by telephone, 1,632 acknowledged a breathing problem and were then screened with the depression and anxiety modules of the PQ. Of these 1,632 patients, 1,351 (82.8%) screened positive for depression and/or anxiety, and 281 (17.2%) screened negative for both conditions. Of the 1,632 patients, 829 came in and completed the BDI and/or BAI (828 completed both). A majority of patients were men (777; 93.8%) versus 51 (6.2%) women. Mean age was 63.3 (SD: 11.8). A breakdown by race/ethnic group showed that 542 (65.5%) were white, 214 (25.8%) were African American), 54 (6.5%) were Hispanic, 10 (1.2%) were Native American), 2 (0.24%) were other, and 6 (0.72%) had missing data.
Outcomes of Screening With the PQ Depression and Anxiety Modules
Overall, of the 828 patients screened with the five questions of the PQ who completed both the BDI and BAI, 732 (88.4%) screened positive for depression, anxiety, or both. Of the 732 patients who screened positive by the two modules of the PQ and completed the BAI/BDI, 586 (80.1%) were found to have depression, anxiety, or both. Of the 281 who screened negative for both anxiety and depression by the two modules of the PQ, 100 were invited to complete the BAI/BDI. Of the 96 (34.1% of those who screened negative) who completed the BAI/BDI, 82 (85.4%) were negative for both anxiety and depression. Table 1 outlines the validity measures for depression, anxiety, and combined screening, with relative predictive measures for the two PQ screens at various cut-points.
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TABLE 1. Statistical Measures of Validity for the PRIME-MD Depression, Anxiety, and Combined Screens at Various Cut-Points
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Validity of PQ Depression Screen
Of the 828 telephone-screened participants who completed the BDI, 79.1% (N=655) screened positive and 20.9% (N=173) screened negative for depression by the PQ Depression module. With our screening criteria, the sensitivity and specificity of the PQ for detection of depression were 94.6% and 49.5%, respectively. The AUC for the ROC curve was estimated at 0.79 (Figure 1), which is significantly greater than 0.50 (p<0.001).
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FIGURE 1. Receiver Operating Curves (ROC) for PRIME-MD Depression Screen (Mild Depression, According to the Beck Depression Inventory)
AUC: area under curve.
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Validity of PQ Anxiety Screen
Of the 829 telephone-screened participants who subsequently completed the BAI, 82.8% (N=686) screened positive and 17.2% (N=143) screened negative for anxiety by the PQ. At the screening cutoff used in this study, the sensitivity and specificity of the PQ Anxiety module for the detection of anxiety were 93.7% and 32.2%, respectively. The estimated AUC for the ROC curve was estimated at 0.74 (Figure 2), which is significantly greater than 0.50 (p<0.001).
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FIGURE 2. Receiver Operating Curves (ROC) for the PRIME-MD Anxiety Screen (Moderate Anxiety, According to the Beck Anxiety Inventory)
AUC: area under curve.
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Validity of PQ Combined Screens
Of the 828 participants who were screened and subsequently completed the BDI and BAI, 88.4% (N=732) screened positive for anxiety and/or depression and 11.6% (N=96) screened negative by the two modules of the PQ. Under this screening paradigm, equating one or more positive responses on the five PQ questions with a positive screen, the sensitivity for the detection of anxiety and/or depression was 97.7%; and the specificity was 36.0%. A comparison of all screening outcomes reveals an overall accuracy of 80.7% for the combined screen. The AUC was estimated at 0.85 (Figure 3), which is significantly greater than 0.50 (p<0.001).
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FIGURE 3. Receiver Operating Curves (ROC) for PRIME-MD Combined Screens (Mild Depression on the BDI and/or Moderate Anxiety on the BAI)
BDI: Beck Depression Inventory; BAI: Beck Anxiety Inventory; AUC: area under curve.
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DISCUSSION
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The five questions of the Depression and Anxiety modules of the PQ, as used to screen for depression and anxiety in a sample of veterans with chronic breathing disorders, provided promising results. The depression, anxiety, and combined components were highly sensitive in detecting depression and anxiety in patients with chronic breathing disorders. Results from this investigation suggest relatively poor specificities for the screening when used at our selected screening cutoffs, with several false positives for depression and anxiety. However, given the high prevalence of anxiety and depression among patients with COPD and other chronic breathing disorders, it is important to note that the screening tests were still able to yield a reasonably good predictive value–positive.
Results of this investigation are made more compelling by its large sample size and inclusion of participants from an entire medical center population of patients with chronic breathing disorders at different levels of care.
Limitations of this study include its all-veteran sample and high proportion of men. Having an all-veteran sample might decrease the predictive value of the five-question modules because veterans have a higher rate of mental disorders than the general population. Conversely, having a high proportion of men should probably result in a lower predictive value than the modules would have in a sample with more women, given that women have a higher rate of anxiety disorders than men.
Other limitations include the lack of a standard interview by a mental health specialist and possible bias due to a large number of potential participants who did not respond. Regarding the former, an interview would have added even more strength to the results, in addition to the certainty of a firm diagnosis; however, the modules were intended only as a brief screening tool, not as a diagnostic instrument. Regarding the latter, a low response rate could create a bias, but it would probably give better agreement between the two modules and the BDI/BAI. It is the borderline cases that cause disagreement.
Although this investigation examined the validity of the PQ Depression and Anxiety screens as administered by telephone, we believe these components will prove equally valid for in-office screening of patients with chronic breathing disorders. Multiple studies19,20 have documented the practicality, versatility, and ease of use of the PRIME-MD for screening patients with general-medical conditions. Particularly in large group practices, the PRIME-MD may be administered by case managers and office workers to facilitate rapid, standardized screening of patients.
We postulate that the goal of an effective screening instrument for depression and anxiety is to maximize recognition of patients with clinically significant symptoms. Although this may lead to the incorrect identification of some patients without clinically significant symptoms as being depressed or anxious, this cost is relatively low in patients with chronic breathing disorders. A more thorough psychological assessment and confirmation may be undertaken with relative ease. The ease of administration of the PQ screening questions for anxiety and depression should not be undervalued. Given the debility associated with depression and anxiety in patients with chronic breathing disorders, which includes increased healthcare costs, poorer outcomes, and impaired quality of life, failing to identify patients who actually meet criteria for these psychiatric disorders proves very costly, indeed.16,17 Therefore, for the purpose of screening for depression and anxiety among patients with chronic breathing disorders, the PQ telephone instrument is a highly promising tool.
An evaluation of properties of the PQ Depression screen revealed optimal validity at a one-question cutoff. Although a two-question cutoff yielded lower sensitivity for the Anxiety and combined screens, its overall accuracy was superior. For the purposes of recruitment, where the goal is to find as many potential subjects as possible, the higher sensitivity of the one-question cutoff is preferable; but in a clinical setting, using the two-question cutoff for the Anxiety and combined screens would yield more efficient results.
The U.S. Preventive Services Task Force recommends routine screening for psychiatric symptoms with sensitive instruments (i.e., sensitivity greater than 80%) but indicates that screening is merely a first step in the care of persons with mental health conditions.30 Positive screening should be followed with more standardized and comprehensive diagnostic evaluations. With more patients relying on their primary-care physicians for quality health care that incorporates support for mental health needs, a practical, valid, and easy-to-administer tool such as the Depression and Anxiety modules of the PQ may prove a crucial first step in providing the care they deserve to patients with chronic medical illnesses, including chronic breathing disorders.
Future research may extend the findings of this study by investigating the properties of screening with the PQ Depression and Anxiety modules in other populations with breathing disorders. The use of the two modules in primary-care screening for depression and anxiety among patients with COPD could also be evaluated in the future.
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ACKNOWLEDGMENTS
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This material is based on work supported by a grant from the VA, Veterans Health Administration, Health Services Research and Development Service (IIR 00-097) and in part by the Houston Center for Quality of Care and Utilization Studies, Health Services Research and Development Service, Office of Research and Development, and the South Central MIRECC, Dept. of Veterans Affairs. The study sponsors had no role in the design, conduct, analysis, interpretation, writing, or decision to publish this study.
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ABSTRACT
INTRODUCTION
