Validity of the Hospital Anxiety and Depression Scale and Patient Health Questionnaire-9 to screen for depression in patients with coronary artery disease
Introduction
Depression is disproportionately common in patients with coronary artery disease (CAD): 17% to 27% evidence major depression [1], [2], [3], [4], [5], [6], [7], [8], [9], [10] and 20% to 45% report subthreshold depressive symptoms [4], [9], [10], [11], [12], [13], [14]. Depression in patients with CAD is associated with poor health-related quality of life [15], [16], [17], [18], [19], [20], [21], [22], [23], [24] and elevated risk of morbidity and mortality [2], [3], [4], [9], [11], [25], [26]. Both major and minor depressive disorders respond well to treatment with anti-depressants and/or psychotherapy [27], emphasising the imperative to diagnose and treat, yet depression is frequently undetected and untreated in clinical practice [28]. Several well-established self-report instruments for screening depression are available; however, the validity and reliability of these instruments are typically determined in depressed patients without a comorbid somatic illness such as CAD. Symptoms such as insomnia and loss of energy may be a result of a recent cardiac event rather than a consequence of depression.
Previous research has indicated that self-report questionnaires such as the Hospital Anxiety and Depression Scale (HADS) [29] and Patient Health Questionnaire (PHQ-9) [30] can identify cardiac patients with depression [31], [32], [33]. McManus et al. [32] used the Diagnostic Interview Schedule [34] as a criterion standard and found that for detecting major depression in CAD outpatients, there were no statistical differences between the operating characteristics of the Centre for Epidemiological Studies Depression Scale [35], PHQ-9, a two-item version of the PHQ [36], and a simple two-item depression instrument. Strik et al. [31] reported that relative to the Structured Clinical Interview for DSM-IV (SCID) [37], the Beck Depression Inventory [38], Symptom Checklist-90 [39], HADS and Hamilton Depression Rating Scale [40] had acceptable properties for detecting major and minor depression in 206 patients 1 month after acute myocardial infarction (AMI), but these authors did not statistically compare the operating characteristics of the respective scales. To our knowledge, no previous study has comparatively evaluated both the PHQ-9 and the HADS against a diagnostic referent standard with recently hospitalized cardiac patients.
Given that the PHQ-9 appears to be the instrument of choice for screening depression in North America while the HADS is more commonly used in Europe and Britain, a comparison of the relative validity of these measures is useful. Furthermore, the PHQ-9 and HADS differ in important ways such as the exclusion of somatic symptoms in the latter. Some evidence suggests that self-report measures that include somatic items result in a twofold increase in depression prevalence rates when used to assess depression in medically ill samples [41]. Given that diagnostic interviews for depression include somatic items, comparison of a diagnostic referent standard with the HADS is important. To further investigate this issue, the specificity and sensitivity of the HADS and PHQ-9 in detecting depression in patients with CAD were compared using the Mini International Neuropsychiatric Interview version 5 (MINI) [42], [43] as the standard diagnostic tool. The MINI is a validated tool used to diagnose minor and major depression according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) [44] and is similar to the SCID [37] in operation and principle.
The aims of this study were to (1) investigate internal consistency and intercorrelations of the HADS and PHQ-9; (2) analyse the operating characteristics of the HADS and PHQ-9 according to an independent criterion standard for depressive disorders; (3) determine whether either screening instrument is superior for detecting DSM-IV depressive disorders; and (4) determine optimum cut-off scores for discriminating between patients with and without depressive disorders.
Section snippets
Participants
Participants were recruited between May 2005 and March 2006 from the Geelong Hospital, a major hospital in regional Victoria, Australia. All English-speaking, consenting patients who resided permanently in Australia and were hospitalized for percutaneous transluminal coronary angioplasty (PTCA), AMI or coronary artery bypass graft surgery (CABG) during this time were eligible for participation. There were no other exclusion criteria. According to discharge diagnoses, 528 patients were treated
Sample characteristics
One hundred and ninety-three of the recruited patients (84.3%) completed both the structured clinical interview and the self-report questionnaires. Twenty-eight participants did not return their questionnaires for an unknown reason, 3 withdrew due to physical illness and 4 withdrew due to depression. The sample was predominantly male (n=156; 80.8%), married (n=146; 75.6%) and retired (n=117; 60.6%), with a mean of 11.12 years of formal education (S.D.=2.91; range 5–22). Mean age was 64.14 years
Discussion
The main aim of this study was to determine sensitivity and specificity of two self-report depression screening instruments relative to a referent diagnostic standard in recently hospitalized patients with CAD. The results demonstrated excellent internal consistencies for both instruments. The substantial intercorrelations between the PHQ-9 and HADS showed the extent to which the scales measure the same construct. Criterion validity for the PHQ-9 and HADS was good, and both instruments can be
Conclusions
Despite these limitations, our results showed that both the HADS and PHQ-9 have acceptable properties for screening major and subthreshold depression in patients with CAD 3 months following cardiac hospitalization. To our knowledge, this is the first study to compare both self-report measures against a diagnostic referent standard with recently hospitalized cardiac patients. The HADS and PHQ-9 were statistically equivalent for detecting either the comprehensive or diagnostic group; however, the
Acknowledgments
The authors wish to acknowledge Jeromy Anglim for his statistical advice as well as the University of Melbourne for their financial contribution towards this project.
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