Measures of depression and depressive symptoms: The Beck Depression Inventory (BDI), Center for Epidemiological Studies-Depression Scale (CES-D), Geriatric Depression Scale (GDS), Hospital Anxiety and Depression Scale (HADS), and Primary Care Evaluation of Mental Disorders-Mood Module (PRIME-MD)

Authors


BECK DEPRESSION INVENTORY (BDI)

General Description

Purpose

To measure depression symptoms and severity in persons age 13 and older.

Content

Based on clinical observations and patient description, the BDI contains items that reflect the cognitive, affective, somatic, and vegetative symptoms of depression (1,2).

Developer/contact information

Aaron T. Beck, PhD, Center for Cognitive Therapy, Philadelphia, PA.

Versions

The revised BDI (BDI-IA) (3), replaced the original version (2). The BDI-IA is similar to the original, except timeframe extends “over the past week, including today” and some items were reworded to avoid double negative statements. The BDI-II contains substantial revision of the original and revised BDI so that the assessment of symptoms corresponds to the DSM-IV criteria (4). BDI-II timeframe extends for 2 weeks to correspond with the DSM-IV criteria for major depressive disorder.

BDI FastScreen for Medical Patients (formerly known as BDI-Primary Care [BDI-PC]) contains 7 cognitive and affective items from the BDI-II to assess depression in individuals with biomedical or substance abuse problems (5). The BDI FastScreen excludes the somatic items from BDI-II. The timeframe on the BDI FastScreen is the same as BDI-II.

The BDI has been translated into several languages, including Spanish, Chinese, Dutch, Finnish, French (Canadian), German, Korean, Polish, Swedish, and Turkish (6).

Number of items in scale

There are 21 items in the BDI-IA and BDI-II; and 7-items in the BDI FastScreen.

Subscales

None typically reported. The BDI-IA manual discusses the cognitive-affective (Items 1–13) and the somatic-performance (Items 14–21) subscales that discriminate between psychiatric, medical, and normal samples (2). Factors analysis of the BDI-II revealed two intercorrelated factors, somatic-affective and cognitive dimensions (3).

Populations

Developmental/target

BDI-IA: developed and validated using psychiatric and normal populations. Beck and colleagues (3) studied outpatient samples that included persons with severe psychiatric diagnoses, depressive disorders, substance abuse, and college students. BDI-II validated using college students, adult psychiatric outpatients, and adolescent psychiatric outpatients (4).

BDI-FastScreen validated using general medical inpatients referred for psychiatric consultation and outpatients seen by family practice, pediatrics, and internal medicine (5).

Other uses

Since being revised in 1972, the BDI has been widely accepted and used in psychology and psychiatry for assessing the intensity of depression in psychiatric and normal populations. Studies have been conducted in a variety of settings using medical populations (e.g., Parkinson's disease, human immunodeficiency virus, oncology), persons with disabilities, (e.g., arthritis, spinal cord injury, amputation), veterans, students, older adults, adolescents, and many populations with psychiatric diagnoses (e.g., eating disorders, addictions, anxiety disorders).

WHO ICF Components

Participation restriction.

Administration

Method

Paper and pencil self-report in group or individual format; self or oral administration.

Training

Minimal training required for paraprofessionals or professionals to administer. A clinician needs to interpret the revised BDI score by paying particular attention to items endorsing self harm or feelings of helplessness, such as suicide ideation (item 9) and pessimism/hopelessness (item 2).

Time to administer/complete

Self-administration: 5-10 minutes; Oral administration: 15 minutes.

Equipment needed

Pencil or pen to indicate response.

Cost/availability

Contact The Psychological Corporation to purchase the BDI, BDI-II, or the BDI FastScreen for Medical Patients manuals and instrument. Computer software is available from Psychological Corporation for on-screen administration, for use with paper and pencil administration, or for input of data from a desktop scanner. The computer program may be used to administer a single questionnaire or to integrate the results of sequential administrations. The Psychological Corporation, 555 Academic Court, San Antonio, TX 78204; Website: www.psychcorp.com. Items may be seen in McDowell and Newell (7).

Scoring

Responses

Scale

4-point scale indicates degree of severity; items are rated from 0 (not at all) to 3 (extreme form of each symptom).

Score range

BDI: 0–63; BDI-II: 0–63; BDI FastScreen: 0–21.

Interpretation of scores

No arbitrary cut-off score for all purposes to classify different degrees of depression.The following guidelines have been suggested to interpret the revised BDI (the BDI-IA) (3). With the normal population, a BDI-IA score of ≥15 may indicate possible depression and warrants an additional clinical evaluation as confirmation. Minimal range 0–9; Mild depression 10–16; Moderate depression 17–29; Severe depression 30–63.

The following guidelines have been suggested to interpret the BDI-II (4), Minimal range 0–13; Mild depression 14–19; Moderate depression 20–28; Severe depression 29–63.

The following guidelines have been suggested to interpret the BDI FastScreen for Medical Patients (5). Minimal 0–3; Mild depression 4–8; Moderate depression 9–12; Severe depression 13–21.

Method of scoring

Sum the severity ratings of each depression item. Use the highest response when an item has more than one severity rating. Special instructions: BDI-IA: If examinee is consciously trying to lose weight, then Item 19 is not added to total score. BDI-II: For diagnostic purposes, Item 16 (sleep patterns changes) and Item 18 (appetite changes) contain 7-point ratings to note increases or decreases in behavior.

Time to score

5 minutes.

Training to score

Minimal training, 5–10 minutes.

Training to interpret

Minimal training to interpret, yet due to the suicide risk with depression, a health professional should interpret the BDI-IA to provide appropriate referrals and possibly psychotherapeutic interventions for at-risk individuals.

Norms available

Means and standard deviations appear in the manuals for samples used to validate the instrument.

Psychometric Information

Reliability

Internal consistency

Beck and Steer (3) report that Cronbach's coefficient alphas for the revised BDI's normative-psychiatric samples range from 0.79 to 0.90. These coefficients are consistent with estimates of coefficient alpha reported in a psychiatric sample (0.86) and in a non-psychiatric sample (0.81; 8). The BDI-II has higher internal consistency than the BDI-IA: Cronbach's alpha reported as 0.92 for outpatients and 0.93 for college students. Coefficient alphas for BDI FastSceen ranged from 0.85 to 0.89.

Test-retest

Beck et al's (8) review of BDI-IA studies reported correlations between pre- and posttests, for varying time intervals, that ranged from 0.48 to 0.86 for psychiatric patients and from 0.60 to 0.90 for non-psychiatric patients. For college students, test-retest correlations ranged from 0.64 to 0.90; BDI-II test-retest (administered 1-week apart) correlation was 0.93.

Validity

Content

According to the manual (3), BDI-IA items reflect 6 of 9 DSM-II criteria well. The BDI-II revision improved content validity by rewording and adding items to assess DSM-IV criteria for depression.

Construct

As theorized, the BDI-IA and BDI-II are positively correlated with hopelessness construct in normative samples. In a factor analysis of the BDI responses of patients and non-patients, Beck and colleagues (8) found that 3 factors (cognitive-affective, performance, and somatic) were consistently identified across diagnostic groups. Factor analysis of the BDI-II yielded 2 factors (somatic-affective and cognitive factors) (4).

Criterion

Beck and colleagues (8) reported a mean correlation of 0.72 between BDI-IA and clinical depression ratings in psychiatric patients and 0.60 in a nonpsychiatric sample. In normative samples, correlations between BDI-IA and Hamilton Rating Scale for Depression (HRSD) ranged from 0.40 in single episode major depression to 0.87 in alcoholics. The BDI-IA was significantly related to the depression subscale of the Symptom Checklist-90-Revised (0.76); BDI-II and HRSD were positively correlated (0.71) (4).

Sensitivity/responsiveness to change

The BDI is less likely to overestimate changes due to psychotherapy or pharmacologic interventions than the HRSD.

Comments and Critique

The BDI has been criticized for having items that are confounded by the physical sequelae associated with physical disability, such as arthritis; items related to physical appearance, fatigue, ability to work, weight loss, and physical complaints (9). The cost of the test materials may be prohibitive since less expensive public domain assessments are readily available. The manual suggests using the BDI cautiously as a screening tool for clinical depression.

References

1. (Original) Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561–71.

2. Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive therapy of depression. New York: Guilford Press; 1979.

3. Beck AT, Steer RA. Manual for the Beck Depression Inventory, 1993 edition. San Antonio (TX): The Psychological Corporation; 1987.

4. Beck AT, Steer RA, Brown GK. Beck Depression Inventory-Second Edition Manual. San Antonio (TX): The Psychological Corporation; 1996.

5. Beck AT, Steer RA, Brown GK. BDI-FastScreen for Medical Patients Manual. San Antonio (TX): The Psychological Corporation; 2000.

6. Naughton MJ, Wiklund I. A critical review of dimension-specific measures of health-related quality of life in cross-cultural research. Qual Life Res 1993;2:397–432.

7. McDowell I, Newell CI. Measuring health: a guide to rating scales and questionnaires. New York: Oxford University Press; 1996.

8. Beck AT, Steer RA, Garbin M. Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clin Psychol Rev 1988;8:77–100.

9. Callahan LF, Kaplan MR, Pincus T. The Beck Depression Inventory, Center for Epidemiological Studies Depression Scale (CES-D), and General Well-Being Schedule Depression subscale in rheumatoid arthritis. Arthritis Care Res 1991;4:3–11.

Additional References

Beck AT, Guth D, Steer RA, Ball R. Screening for major depression disorders in medical inpatients with the Beck Depression Inventory for primary care. Behav Res Ther 1997;35:785–91.

Beck AT, Steer RA, Ball R, Ranieri WF. Comparison of the Beck Depression Inventories-1A and -II in psychiatric outpatients. J Pers Assess 1996;67:588–97.

Steer RA, Cavalieri TA, Leonard DM, Beck AT. Use of the Beck Depression Inventory for Primary Care to screen for major depression disorders. Gen Hosp Psychiatry 1999;21:106–11.

Steer RA, Rissmiller DJ, Beck AT. Use of the Beck Depression Inventory-II with depressed geriatric inpatients. Behav Res Ther 2000;38:311–8.

Tanaka-Matsumi J, Kameoka VA. Reliabilities and concurrent validities of popular self-report measures of depression, anxiety, and social desirability. J Consult Clin Psychol 1986;54:328–33.

CENTER FOR EPIDEMIOLOGICAL STUDIES-DEPRESSION SCALE (CES-D)

General Description

Purpose

To measure current level of depressive symptomatology in a general population. The CES-D was developed for research purposes and is used as a screening tool to identity persons at risk for clinical depression (1).

Content

Items assess perceived mood and level of functioning during the past week. Four factors are represented: depressed affect, positive affect, somatic problems and retarded activity, and interpersonal relationship problems. Items do not assess the diagnostic criteria of appetite, anhedonia, psychomotor agitation or retardation, guilt, or suicidality.

Developer/contact information

Lenore Sawyer Radloff, National Institute of Mental Health, Rockville, MD.

Versions

Translated into Spanish, Chinese, Dutch, Korean, Russian, German, and French. The original 20-item version has been shortened to a 10-item version for older adults (2) and to 5-item version (3). There is also a modified version available for children (Center for Epidemiological Studies-Depression Scale [CES-] for Children [CES-DC] (4).

Number of items in scale

There are 20 items.

Subscales

A total score is obtained, no subscales.

Populations

Developmental/target

Epidemiology studies using a general population.

Other uses

Widely used and validated in many populations including rheumatoid arthritis, fibromyalgia, and other medical cohorts (stroke, multiple sclerosis, oncology); adolescents; women; African Americans; primary care; the elderly; persons of Korean, Puerto Rican, Spanish, and Chinese decent; American Indians; and in clinical and psychiatric populations. Reliability and validity available for African American, Asian American, French, Greek, Hispanic, Japanese, and Yugoslavian populations (5).

WHO ICF Components

Participation restriction.

Administration

Method

Easily self-administered or administered by interviewer. Can be administered in-person, written, or interview format, by telephone interview, or by mail.

Training

Minimal.

Time to administer/complete

Approximately 10 minutes.

Equipment needed

When self-administered, need a pencil or pen to complete.

Cost/availability

The CES-D is available in original article by Radloff (1) and is available from the National Institutes of Health, Epidemiology Branch, 5600 Fishers Lane, Rockville, MD 20857; available at www.chcr.brown.edu/pcoc/cesdscale.pdf and www.psychiatry.uchc.edu/screening/CES-D/. There is no cost to use the CES-D.

Scoring

Responses

Scale

4-point scale, where 0 = rarely or none of the time (less than 1 day), 1 = some or a little of the time (1–2 days), 2 = occasionally or a moderate amount of time (3–4 days), 3 = most or all the time (5–7 days).

Score range

The range is 0–60.

Interpretation of scores

A higher score reflects greater symptoms of depression, weighted by frequency of occurrence in past week. CES-D ≥16 is typically employed as a cut-off for clinical depression and usually warrants a referral for a more thorough evaluation.

Turk and Okifuji (6) recommend a cut-off score of 19 for detecting depressive disorder in chronic pain patients. Blalock et al (7) identified 4 arthritis-related items and suggested a modified scoring approach. Callahan et al (8) discussed additional scoring issues in rheumatic disease.

Method of scoring

Easily hand scored. Items are summed to obtain a total score, using the 0 (rarely or none of the time) to 3 (most or all the time) scores for individual items. Four items (4,8,12,16) are worded in a positive direction to reduce a tendency towards response bias; these items are reverse scored.

Time to score

Less than 10 minutes. Can be scored during administration.

Training to score

Minimal training time to score, ≤10 minutes.

Training to interpret

≤10 minutes.

Norms available

Reference scores available at Sayette and Johnson (9), Eaton and Kessler (10), Murrell et al (11), Golding et al (12), and Vera et al (13).

Psychometric Information

Reliability

Internal consistency

High internal consistency. Coefficient alphas range from 0.85 in the general population to 0.90 in a psychiatric patient population.

Test-retest

The CES-D measures “current” level of symptomatology and is expected to vary over time. In the original sample, test-retest correlations were in the moderate range falling between 0.45 and 0.70, as expected if the scale is sensitive to current depressive state; stronger test-retest correlations were identified with shorter administration time intervals.

Validity

Content

Items were selected from longer previously used and validated scales considered to be representative of clinical symptoms of depression.

Criterion

The CES-D adequately correlates with other valid self-report depressions scales to provide concurrent validity. In the original sample, CES-D correlations with depression measures (e.g., Lubin, Bradburn Negative Affect) ranged from 0.51 to 0.61; moderate correlation (0.49) was found between CES-D and clinical interview ratings of depression. Using a cut-off of 16, CES-D scores were found to discriminate strongly between psychiatric inpatients and general population samples (70% with scores ≥16 versus 21%). CES-D scores and depression severity ratings by a nurse clinician were moderately correlated (0.56); CES-D was negatively correlated (−0.20) with Bradburn Positive Affect and low correlations (0.19–0.26) were found between CES-D scores and medications, disability days, social functioning, and aggression. CES-D scores were moderately correlated with self-esteem (0.58) and state anxiety (0.44) and highly correlated (0.71) with trait anxiety (14).

Sensitivity/responsiveness to change

Sensitive to change since the test-retest changes have been found before and after treatment, as well as before and after a stressful life event.

Comments and Critique

The CES-D has been extensively used and studied, and is considered a reliable valid instrument; widely recognized research tool. It can be used to measure change in affective state and is an excellent choice to measure depression symptoms in research studies. It can be used in diverse settings and has been validated in numerous populations, allowing comparisons across studies.

Researchers have used shorter versions to examine alternate CES-D cutoffs and simplified scoring system (yes/no) (15). It is not intended as a diagnostic tool (16), to discriminate among depression subtypes (major depressive disorder versus dysthymic disorder; bipolar versus unipolar), or to distinguish between a primary or secondary depression (17). The CES-D is appropriate as a screening tool to identify depressive disorders in clinical and research settings and as the initial element of a two-pronged depression screening procedure in the general community, medical community, or primary care. The CES-D provides a rough indicator of clinical depression and is modestly related to depressive disorders.

The high correlation between CES-D and trait anxiety indicates that CES-D measures depression as well as anxiety, a conceptually related construct. Based on the validity studies, the CES-D may not be specific for depression, but may be a measure of general distress.

A CES-D cut-off score of 16 seems appropriate in most populations, especially when the goal is to identify individuals at high risk for major depressive disorder, accepting some false positives. Slightly lowering the CES-D cut-off may be necessary to identify persons with dysthymic disorder or minor depressive disorder.

References

1. (Original) Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1977;1:385–401.

2. Irwin M, Artin KH, Oxman M. Screening for depression in the older adult: criterion validity of the 10-item Center for Epidemiological Studies Depression Scale (CES-D). Arch Intern Med 1999;159:1701–4.

3. Shrout PE, Yager TJ. Reliability and validity of screening scales: effect of reducing scale length. J Clin Epidemiol 1989;42:69–78.

4. Fendrich M, Weissman M, Warner V. Screening for depressive disorder in children and adolescents: validating the Center for Epidemiologic Studies Depression Scale for Children. Am J Epidemiol 1990;131:538–51.

5. Naughton MJ, Wiklund I. A critical review of dimension-specific measures of health-related quality of life in cross-cultural research. Qual Life Res 1993;2:397–432.

6. Turk DC, Okifuji A. Detecting depression in chronic pain patients: adequacy of self-reports. Behav Res Ther 1994;32:9–16.

7. Blalock SJ, DeVellis RF, Brown GK, Wallston KA. Validity of the Center for Epidemiological Studies Depression Scale in arthritis populations. Arthritis Rheum 1989;32:991–7.

8. Callahan LF, Kaplan MR, Pincus T. The Beck Depression Inventory, Center for Epidemiological Studies Depression Scale (CES-D), and General Well-Being Schedule Depression Subscale in rheumatoid arthritis. Arthritis Care Res 1991;4:3–11.

9. Sayetta R, Johnson D. Basic data on depressive symptomatology, United States, 1974–75. Washington (DC): United States Government Printing Office, Public Health Services 1980. (DHEW [PHS] 80-1666).

10. Eaton WW, Kessler LG. Rates of symptoms of depression in a national sample. Am J Epidemiol 1981;114:528–38.

11. Murrell SA, Himmelfarb S, Wright K. Prevalence of depression and its correlates in older adults. Am J Epidemiol 1983;117:173–85.

12. Golding JM, Aneshensel CS, Hough RL. Responses to depression scale items among Mexican-Americans and non-Hispanic whites. J Clin Psychol 1991;47:61–75.

13. Vera M, Alegria M, Freeman D, Robles RR, Rios R, Rios CF. Depressive symptoms among Puerto Ricans: island poor compared with residents of the New York City area. Am J Epidemiol 1991;134:502–10.

14. Orme JG, Reis J, Herz EJ. Factorial and discriminant validity of the Center for Epidemiological Studies Depression (CES-D) Scale. J Clin Psychol 1986;42:28–33.

15. Kohout FJ, Berkman LF, Evans DA, Cornoni-Huntley J. Two shorter forms of the CES-D depression symptoms index. J Aging Health 1993;5:179–93.

16. Radloff LS, Teri L. Use of the Center for Epidemiological Studies-Depression Scale with older adults. Clin Gerontol 1986;5:119–136.

17. Radloff LS, Locke BZ. The community mental health assessment survey and the CES-D Scale. In: Weismann MM, Meyers JK, Ross CG, editors. Community survey of psychiatric disorder. New Brunswick, (NJ): Rutgers University Press; 1985. p. 177–89.

Additional References

DeForge BR, Sobal J. Self-report depression scales in the elderly: the relationship between the CES-D and the Zung. Int J Psychiatry Med 1988;18:325–8.

Gerety MB, Williams JW Jr, Mulrow CD, Cornell JE, Kadri AA, Rosenberg J, et al. Performance of case-finding tools for depression in the nursing home: influence of clinical and functional characteristics and selection of optimal threshold scores. J Am Geriatr Soc 1994;42:1103–9.

Roberts RE. Reliability of the CES-D Scale in different ethnic contexts. Psychiatry Res 1980;2:125–43.

GERIATRIC DEPRESSION SCALE (GDS)

General Description

Purpose

Developed as a self-rating, screening tool to measure depressive symptoms in older adults. Designed to identify depression in the elderly by distinguishing symptoms of depression and dementia.

Content

Items represent characteristics of depression in the elderly in the affective (e.g., sadness, apathy, crying) and cognitive domains (e.g., thoughts of hopelessness, helplessness, guilt, worthlessness). The GDS contains no somatic concerns common in elderly (i.e., disturbances in energy level, appetite, sleep, sexual interest).

Developer/contact information

Jerome Yesavage, MD, Stanford University, Director Aging Clinical Research Center. Stanford, CA.

Versions

Long version (30 items) (1,2). Short version (15 items) developed to decrease fatigue or lack of focus seen in the elderly (3). GDS has been adapted into Japanese, Portuguese, Italian, Spanish, Chinese, Korean, French, Swedish, and other languages. (See availability on website).

Number of items in scale

There are 30 items (long form); 15 items (short form).

Subscales

None.

Populations

Developmental/target

Normal community dwelling elderly and elders hospitalized for depression.

Other uses

Validity studied extensively. Stiles and McGarrahan (4) reported that the GDS has been used successfully in community samples, psychiatric and medical patients, nursing home residents (cognitively impaired and intact), geriatric samples, and young adults. The GDS has been used with medical patients, (i.e., stroke, rheumatology, and cancer), African Americans, Mexican Americans, and other non-whites.

WHO ICF Components

Participation restriction.

Administration

Method

Designed as paper and pencil, self-administered questionnaire. Oral assistance and/or interview can be utilized; however, it has been suggested that the same format be used for repeated administrations for patients or within subject groups because different administration formats can produce variable results. Oral administration may be advisable in some situations, particularly for individuals who have cognitive impairments.

Training

None.

Time to administer/complete

8–10 minutes.

Equipment needed

Pencil or pen to record responses.

Cost/availability

Available from the original Yesavage et al (2) article; English long and short versions, scoring instruction, and versions in many languages available at www.Stanford.edu/∼yesavage/GDS.html. There is no cost, it is in public domain.

Scoring

Responses

Scale

Yes or no.

Score range

The range is 0 (no depression) to 30 (severe depression) for long form, 0 (no depression) to 15 (severe depression) for short form.

Interpretation of scores

Higher GDS scores are indicative of more severe depression. Brink et al (1) suggested GDS scores 1–10 be considered normal, while GDS ≥11 indicative of possible depression. Using a cut-off score of 14 avoids false positives.

Method of scoring

Total score calculated by summing responses that endorse depression; Negatively endorsing items 1, 5, 7, 9, 15, 19, 21, 27, and 29 indicate depression, while positively endorsing the remaining 20 items indicates depression.

Time to score

Two minutes.

Training to score

Minimal, 5 minutes.

Training to interpret

Minimal, 5 minutes.

Norms available

None.

Psychometric Information

Reliability

Internal consistency

High: Cronbach's alpha was 0.94 and split-half reliability was 0.94.

Test-retest reliability

Correlation (r = 0.85) at 1- week retest suggested the GDS scores reflect stable individual differences.

Validity

Content

Items are based on characteristics of depression in the elderly. Brink and colleagues (1) selected 100 items that distinguished between elderly depressed and non-depressed individuals; 30 items were selected for GDS using an empirical selection procedure.

Criterion

High correlations have been noted between GDS and other depressive symptom measures. The GDS more consistently differentiates depressed from non-depressed seniors than other depression measures (4).

Construct

Yesavage and colleagues (2) validated the 30-item version using two depressive symptomatology measures, the Zung Self-rating Scale for Depression (SDS) and the Hamilton Rating Scale for Depression (HRSD), to compare their ability to classify normal subjects from mild and severe depression. The measures yielded similar results, with normal subjects scoring lower than persons endorsing mild depressive symptoms and those endorsing severe depressive symptoms, and persons with severe symptoms having the highest scores. When compared to a diagnostic classification variable, the GDS and HRSD yielded similar results, while the SDS appeared to discriminate less effectively. Correlation between the GDS and the SDS was 0.84; correlation between the GDS and the HRSD was 0.83.

Other studies have used depression measures (i.e., CES-D) to examine the GDS convergent validity. Stiles and McGarrahan (4) reported that most studies report correlations ranging from 0.58 to 0.89. Studies involving young subjects reported lower correlations (0.66–0.67).

Divergent

The correlations between the GDS and cognitive screening tests and Mini Mental State Examination and modified Blessed Test were low since intended to measure different constructs.

Sensitivity/responsiveness to change

Sensitivity of the GDS to change was compared to the SDS and HRSD; normal subjects were expected to receive the lowest GDS scores, and persons reporting with severe depressive symptoms to receive the highest scores. When SDS, HRSD, and GDS scores were compared, the 3 severity levels seen in GDS were also seen in criterion measures.

Comments and Critique

The GDS has a simple format that accurately and efficiently assesses depressive symptoms in the elderly, from the young old 65–74 to the oldest old age 85+. A gap remains regarding the validity of the GDS in persons age 85+. The GDS appears valid in younger samples, yet may not be the best choice of assessment with a younger sample. The GDS may also assess “general distress” rather than only depressive symptoms — several items are indicative of both cognitive and somatic symptoms of anxiety.

GDS Short Form and Long Form were highly correlated (0.84) with and sensitive to depressive symptoms in mild to moderate dementia. Debate in the literature concluded that the GDS was effective and reliable with individuals with mild dementia. Stiles and McGarrahan (4) recommend caution when using the GDS with cognitively impaired individuals, and also recommend not using the scale with severely cognitively impaired patients or individuals with compromised insight and accuracy of self-report.

Simple administration and robust psychometric properties have led to the GDS being translated into many languages and cultures, yet studies conducted in other countries/cultures suggest that depressive symptoms are expressed differently in other parts of the world, suggesting cautious use.

Stiles and McGarrahan (4) recommend the following: 1) use oral administration since it is appropriate for persons with the widest range of abilities, 2) use long form versus short form since it is more reliable and valid, 3) use cutoff scores of 11 for higher sensitivity and 14 for higher specificity for screening efficiency, and 4) use cautiously with cognitively impaired populations and with non-white populations (more data needed).

References

1. (Original) Brink TL, Yesavage JA, Lum O, Heersema PH, Adey M, Rose TL. Screening tests for geriatric depression. Clin Gerontol 1982;1:37–43.

2. Yesavage JA, Brink TL, Rose TL, Lum D, Huang V, Adey M, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1983;17:37–49.

3. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol 1986;5:165–73.

4. Stiles PG, McGarrahan JF. The Geriatric Depression Scale: a comprehensive review. J Clin Geropsychol 1998;4:89–110.

Additional References

Alden D, Austin C, Sturgeon R. A correlation between the Geriatric Depression Scale Long and Short Forms. J Gerontol 1989;44:124–5.

Harper RG, Kotik-Harper D, Kirby H. Psychometric assessment of depression in an elderly generally medical population. J Nerv Ment Dis 1990;178:113–9.

Katz PP, Yelin EH. Prevalence and correlates of depressive symptoms among persons with rheumatoid arthritis. J Rheumatol 1993;20:790-6.

Montorio I, Izal M. The Geriatric Depression Scale: a review of its development and utility. Int Psychogeriatr 1996;8:103–12.

Olin JT, Schneider LS, Eaton EM, Zemansky MF, Pollock VE. The Geriatric Depression Scale and the Beck Depression Inventory as screening instruments in an older adult outpatient population. Psychol Assess 1992;4:190–92.

Rule BG, Harvey HZ, Dobbs AR. Reliability of the Geriatric Depression Scale for younger adults. Clin Gerontol 1989;9:37–43.

Sheikh JI, Yesavage JA, Brooks JO, III, Freidman L, Gratzinger R, Hill RD, et al. Proposed factor structure of the Geriatric Depression Scale. Int Psychoger 1991;3:23–8.

HOSPITAL ANXIETY AND DEPRESSION SCALE (HADS)

General Description

Purpose

To assess anxiety and depressive symptoms in a general medical population (1,2).

Content

There are 7 depression items measuring cognitive and emotional aspects of depression, predominately anhedonia, intermingled with 7 anxiety items that focus on cognitive and emotional aspects of anxiety. Somatic items relating to emotional and physical disorders are excluded.

Developer/contact information

A. S. Zigmond and R. P. Snaith, St James' University Hospital at Leeds Leeds, UK.

Versions

Available in English, as well as all other languages of Western Europe and many of Eastern Europe, Scandinavia along with some African and Far East languages, including Arabic, Chinese, Danish, Dutch, Finish, French, German, Hebrew, Italian, Japanese, Norwegian, Portuguese, Spanish, Swedish, Thai, and Urdu.

Number of items in scale

There are 14 items.

Subscales

Anxiety subscale (HADS-A) and Depression subscale (HADS-D).

Populations

Developmental/target

General medical outpatients, ages 16–65.

Other uses

Used extensively, primarily with psychiatric and medical patients, as well as the general population, students, non-patients, and subjects with chronic medical conditions. Herrmann (3) tabulated HADS literature specifying study type, medical specialty, population, and originating country where validated.

WHO ICF components

Participation restriction.

Administration

Method

Paper and pencil self-administered questionnaire.

Training

None, designed as easy, short, and to be administered in clinic.

Time to administer/complete

5–10 minutes.

Equipment needed

Pencil or pen to endorse items.

Cost/availability

Copyrighted and available from: Nfer-Nelson, Darville House, 2 Oxford Road East, Windsor, Berkshire, SL4 IDF, UK. A test manual (2) accompanies the scale and describes administration, scoring procedures, and psychometrics. Available from the following Web sites: www.clinical-supervision.com/hads/htmwww.organon.se/deprimerad/allm/had/hadskala.htmwww.clinical-supervision.com/hads/htm, www.organon.se/deprimerad/allm/had/hadskala.htm, www.psychiatry.ox.ac.uk/cebmh/guidelines/depression/appendix1.html#had, www.sahs.utmb.edu/Psychology/Adultrehab/hospital_anxiety_and_depression_.htm. You can request a manual from author at no cost.

Scoring

Responses

Scale

The scale is a 4-point Likert Scale, ranging from 0 to 3.

Score range

Range 0–42 for the total score; 0–21 for HADS-A and HADS-D.

Interpretation of scores

Higher scores indicate greater severity. Zigmond and Snaith (1) recommended the following cutoff scores for the subscales: 0–7 considered non-case, 8–10 considered possible case, 11–21 considered probable case.

Method of scoring

Sum the ratings of 14 items to yield a total score; sum the rating on 7 items on each subscale to yield separate scores for anxiety and depression.

Time to score

1–2 minutes.

Training to score.%Minimal.

Training to interpret

Minimal.

Norms available

None.

Psychometric Information

Reliability

Internal consistency

Cronbach's coefficient alpha ranges from 0.78 to 0.93 for HADS-A and from 0.82 to 0.90 for HADS-D. Cronbach's alpha for the German version was 0.80 for HADS-A and 0.81 for HADS-D. Similar or slightly lower coefficient alphas were observed for other versions.

Test-retest

High test-retest correlations (r > 0.80) were found after ≤2 weeks and gradually decrease as time lapses (2–6 weeks 0.73–0.76, and >6 week 0.70).

Validity

Content

The HADS relies on anhedonia, not on somatic complaints, and is sensitive to mild distress. Construction of the HADS depression subscale minimizes effect of somatic disorders associated with depression.

Concurrent

Correlations with corresponding measures of the same theoretical construct (i.e., anxiety or depression) were adequate. Significantly higher correlations were found between HADS-D and observer ratings and self-assessments for depression than with observer and self-ratings of anxiety; similar finding identified with measures of anxiety and the HADS-A. Compared to commonly used depression and anxiety measures (BDI, State-Trait Anxiety Inventory, Symptom Checklist-90-Revised), correlations with the HADS-D and HADS-A ranged between 0.60 (good) to 0.80 (very good) (4).

Predictive

HADS has been found to relate to prospective measurements in renal transplant patients, baseline HADS predicted followup psychiatric morbidity using a clinical interview. In coronary patients, baseline HADS-D predicted quality of life ≥2 years later, and HADS-D predicted surgical outcomes in urology patients.

Discriminant

The correlation between HADS-A and HADS-D average 0.56 (range 0.49–0.74).

Sensitivity/responsiveness to change

Designed to identify probable “cases” of anxiety or depression. The HADS is not a diagnostic tool; it is a poor predictor of making a specific diagnosis (5). Average sensitivities and specificities are ≥0.80, similar to other self-rating screening tools (3,4). Bjelland et al's (2001) tabulation estimated HADS sensitivity and specificity at optimal cutoffs (4). Silverstone (5) and Goldberg (6) compared HADS depression subscale scores with standard clinical assessments in medical patients. Sensitivity estimates ranged from 56 to 100%, and specificity estimates ranged from 73 to 94%. Positive predictive values range from 19 to 70%. These estimates favorably compares to studies using BDI and CES-D.

HADS scores are responsive to pharmacologic and psychotherapeutic interventions (3).

Comments and Critique

HADS is a reliable, valid method for assessing emotional distress in medical populations. Despite its brevity, it screens for possible anxiety and depressive symptompatology similar to more comprehensive clinical measures. The HADS can be used in clinical and research settings, and may be particularly useful when studying the cognitive processes associated with depressive symptoms and anxiety, since it is free of physical symptoms, such as insomnia and weight loss. The HADS has good psychometric properties, making it a good choice to measure psychological distress, to differentiate symptoms of depression and anxiety, or to examine the impact of cognition on depression or anxiety (4).

References

1. (Original) Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983;67:361–70.

2. Snaith RP, Zigmond AS. The Hospital Anxiety and Depression Scale Manual. Windsor, Berkshire (UK): Nfer-Nelson; 1994.

3. Hermann C. International experiences with Hospital Anxiety and Depression Scale: a review of validation data and clinical results. J Psychosomatic Res 1997;42:17–41.

4. Bjelland I, Dahl AA, Haut TT, Neckelmann D. The validity of the Hospital Anxiety and Depression Scale: an updated literature review. J Psychosomatic Res 2002;52:69–77.

5. Silverstone PH. Poor efficacy of the Hospital and Anxiety Depression Scale in the diagnosis of major depressive disorder in both medical and psychiatric patients. J Psychosomatic Res 1994;38:441–50.

6. Goldberg D. Identifying psychiatric illness among general medical patients. BMJ 1985;29:161–2.

Additional References

Johnston M, Pollard B, Hennessey P. Construct validation of the Hospital Anxiety and Depression Scale with clinical populations. J Psychosomatic Res 2000;48:579–84. Lisspers J, Nygren A, Soderman E. Hospital Anxiety and

Depresion Scale (HAD): some psychometric data for a Swedish sample. Acta Psychiatr Scand 1997;96:281–6. Mykletun A, Stordal E, Dahl AA. Hospital Anxiety and Depression Scale: factor structure, item analysis and internal consistency in a

large population. Br J Psychol 2001;179:540–4. Snaith RP, Zigmond AS. The Hospital Anxiety and Depression Scale. BMJ (Clin Res Ed) 1986;292:344.

PRIMARY CARE EVALUATION OF MENTAL DISORDERS-MOOD MODULE (PRIME-MD)

General Description

Purpose

A 2-stage (screening and structured interview) diagnostic instrument designed for primary care physicians in general medical settings to identify persons with mental disorders (1). The Mood Module was developed to guide the clinician to a criterion-based diagnosis of depressive disorders based on the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R), now updated to DSM-IV.

Content

PRIME-MD consists of 2 components: a 27-item patient questionnaire (PQ) to be used as a screening tool, and a clinician evaluation guide (CEG) that serves as a structured interview to evaluate mental disorders in 5 diagnostic areas.

The Mood Module in the CEG can be administered independent of the PQ. Mood Module items directly reflect the DSM-III-R diagnostic criteria for a particular mood disorder and assess sleep disturbance, appetite, anhedonia, low self-esteem, depressed mood, concentration difficulties, suicide ideation, psychomotor agitation or retardation, and fatigue.

Developer/contact information

Robert L. Spitzer, MD, of the Biometrics Research Department, New York State Psychiatric Institute and Columbia University.

Versions

Spanish, Danish, and German versions. PRIME-MD has been shortened to maximize clinical usefulness. The 2 components of the original PRIME-MD were combined into a 3- and 4-page, self-administered version called PRIME-MD Patient Health Questionnaire (PHQ) (2). A 2-page version, the Brief PHQ, has also been developed. PHQ-9 is the depression module of PHQ.

Number of items in scale

The Mood Module consists of 17 questions pertaining to depressive symptoms. Thirteen items require the interviewer to elicit responses, 4 items require an interviewer response. 10 items pertaining to past 2 weeks assess for major depressive disorder (MDD), 1 item assesses for partial remission or reoccurrence of MDD, 2 items address symptoms over past 2 years to assess for dysthymic disorder (DD), 2 items assess symptoms of minor depressive disorder (MND), 1 item assesses the need to rule out bipolar disorder (BD), and 1 item assesses the need to rule out depressive disorder due to physical disorder, medication, or other drug.

Subscales

Mood module consists of 6 sections pertaining to the following diagnostic categories: MDD, DD, partial remission or reoccurrence of MDD, MND, rule out depressive disorder due physical disorder, medication, or other drug, or rule out bipolar disorder.

Populations

Developmental/target

Original sample consisted of 1,000 adults from 4 outpatient settings with 8 medical diagnoses, (i.e., arthritis, hypertension, diabetes, heart disease, and pulmonary disease). PRIME-MD was validated by a telephone re-interview of a subsample of 431 individuals using the Structured Clinical Interview for DSM-III-R (SCID).

Other uses

Validity data available for Spanish and German versions. Self-administered paper/pencil and computerized versions available. The PRIME-MD has been used in specialty clinics (rheumatology, neurology, plastic surgery, oncology, and endocrinology), with veteran populations, and in rural settings. The developers provide validity data for obstetrics-gynecology outpatients. Validity data are also available for urban American Indians in primary care, but studies of reservation populations are needed.

WHO ICF Components

Participation restriction.

Administration

Method

Brief, straightforward, and easy to administer. The PQ is a paper and pencil screening tool to determine if administration of the PRIME-MD mood module is indicated. The Mood Module is interviewer administered and can be administered without the PQ if clinical information indicates depressive disorders assessment.

Training

Minimal, although should be administered and scored by a professional who has familiarity with or interest in psychiatric diagnostic categories.

Time to administer/complete

Authors report mean completion time of CEG portion as 8.4 minutes; administration time of PRIME-MD mood module <10 minutes.

Equipment needed

None.

Cost/availability

PRIME-MD is a trademark of Pfizer, Inc. All versions are distributed free to healthcare providers by local Pfizer sales representatives, and may be photocopied ad libitum. Pfizer, Inc. provides a CD-Rom containing the PHQ and the Brief PHQ.

Scoring

Responses

Scale

Yes/No.

Score range

No score; diagnostic categories result.

Interpretation of scores

Three diagnostic categories in the PRIME-MD system include DSM-IV diagnoses of MDD, DD, and partial remission or reoccurrence of MDD. The Mood Module includes subthreshold diagnoses (i.e., MND) since psychiatric symptoms below DSM-IV diagnostic categories are associated with functional impairments and individuals may benefit from monitoring or treatment. Two rule out diagnoses are included (i.e., rule out depressive disorder due physical disorder, medication, or other drug and rule out bipolar disorder). More than 1 diagnosis can be made, such as MDD and DD.

Method of scoring

PRIME-MD questions require a yes or no response. The interview uses a self-explanatory decision tree to guide the interviewer in a systematic manner.

Time to score

Following tree structure, the PRIME-MD is scored during the interview, which takes <10 minutes.

Training to score

Minimal, allow time to understand the decision tree prior to administering.

Training to interpret

Minimal training is required for health professionals who can provide appropriate psychotherapeutic intervention and referrals to diagnosed individuals. Clinical supervision may be needed; interviewers may need to provide individuals meeting the criteria for depressive disorders with treatment approaches (pharmacologic and/or psychological), including referral options. Suicide risk associated with depression must be taken seriously and promptly addressed. Plans must exist to immediately deal with anyone who is an imminent danger to self or others.

Norms available

No.

Psychometric Information

Reliability

Interrater reliability

Agreement between primary care physicians (PCPs) and mental health professionals (MHPs) regarding reinterviewed patients was used to demonstrate interrater reliability (1). Kappa coefficients were used to represent agreement, correcting for agreement due to chance. Agreement for all psychiatric diagnoses was good (0.71) and was satisfactory for the mood module (0.61). Diagnostic prevalence rates for PCPs and the MHPs did not identify systematic over- or under-diagnosing.

Validity

Content

Items developed directly from DSM-III-R criteria, thereby a diagnostic tool.

Criterion

A SCID administered by MHPs was considered to be the “gold standard” measure to assess the validity of the PCPs' PRIME-MD evaluation (1). The sensitivity (proportion of cases given a diagnosis by MHPs who were correctly identified by the PCPs) was very good for any psychiatric disorder (83%). The Mood Module was found to be satisfactory (67%), ranging from 22% for MND to 57% MDD. The specificity (proportion of cases identified by MHPs not given the diagnosis correctly identified by the PCPs) was excellent across diagnostic modules (88%) and for the mood module (92%, ranging from 94% for MND to 98% for MDD), indicating that the PRIME-MD seldom resulted in diagnoses not confirmed using the SCID. Overall accuracy rate was excellent across modules (86%) and mood module (84%).

Sensitivity/responsiveness to change

Using SCID as the criterion measure, the PRIME-MD reflect changes identified during a standard clinical interview.

Comments and Critique

The PRIME-MD has streamlined the cumbersome psychiatric nomenclature for untrained health professionals. Even though based on DSM-III-R criteria, the mood module remains current since the updated DSM-IV depressive disorder criteria changed little from DSM-III-R criteria.

The PRIME-MD offers clinicians and researchers an easier method to diagnosing mental disorders and offers a less expensive and time-effective approach to diagnosing depressive disorders. Individuals seeking medical care ought to receive earlier identification and treatment, thereby reducing disability and unnecessary suffering.

The PRIME-MD has been reduced to administering 4 core items (sleep disturbance, anhedonia, low self-esteem, and decreased appetite) following the administration of the 2 depression screening items on the PQ. This approach is called the “S4 model” and has begun to emerge using rheumatology patients (3).

With the PRIME-MD methodology available in brief formats, many clinicians/researchers will be able to identify a version that suits their individual needs and settings .

Table  . Summary Table for Depression Measures*
Measure/scaleContentMeasure outputsNumber of itemsResponse formatMethod of administrationTime for administrationValidated populationsPsychometric properties
ReliabilityValidityResponsiveness
  • *

    BDI = Beck Depression Inventory; CES-D = Center for Epidemiological Studies-Depression Scale; GDS - Geriatric Depression Scale; HADS = Hospital Anxiety and Depression Scale; PRIME-MD = Primary Care Evaluation of Mental Disorders-Mood Module.

BDICognitive, affective, somatic, and vegetative itemsTotal score; cognitive-affective (13 items) and somatic-performance (8-items) subscales21 items0–3 rating scaleSelf5–10 minutesPsychiatric and normal populationsExcellentGoodAdequate
CES-DPositive affect, negative affect, activity level, and interpersonal itemsTotal score20 items4-point Likert scaleSelf<10 minutesGeneral population, including RA and fibromyalgiaExcellentExcellentGood
GDSAffective and cognitive symptoms common in elderlyTotal score30-long form 15-short formYes/NoSelf8–10 minutesElderly, hospitalized and in the communityExcellentGoodGood
HADSIntermingled depression and anxiety itemsDepression and anxiety subscales; 7 items each14 items4-point Likert scaleSelf5–10 minutesGeneral medical outpatientsGoodGoodGood
PRIME-MDItems correspond to the DSM-III-R diagnostic criteria of six mood disordersDiagnostic categories of major depressive disorder (MDD), dysthymic disorder, partial remission or occurrence of MDD, minor depressive disorder, rule-out depressive disorder due to physical disorder, medication, or other drug, and rule out bipolar disorder17 items in Mood ModuleYes/NoInterview<10 minutesEight medical diagnoses, including arthritisGoodGoodGood

Ancillary