Screening for anxiety and depression in dialysis patients: Comparison of the Hospital Anxiety and Depression Scale and the Beck Depression Inventory

https://doi.org/10.1016/j.jpsychores.2012.04.015Get rights and content

Abstract

Objective

Although anxiety and depression are frequent comorbid disorders in dialysis patients, they remain underrecognized and often untreated. The aim of the study was to evaluate the Hospital Anxiety and Depression Scale (HADS), the Beck Depression Inventory (BDI) and a truncated version of the BDI, the Cognitive Depression Index (CDI), as screening tools for anxiety and depression in dialysis patients.

Methods

A total of 109 participants (69.7% males), from four dialysis centers, completed the self-report symptom scales HADS and BDI. Depression and anxiety disorders were diagnosed with the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I). The sensitivity, specificity, positive and negative predictive value, overall agreement, kappa and receiver operating characteristic (ROC) curves were assessed.

Results

Depressive disorders were found in 22% of the patients based on the SCID-I, while anxiety disorders occurred in 17%. The optimal screening cut-off score for depression was ≥7 for the HADS depression subscale (HADS-D), ≥14 for the HADS-total, ≥11 for the CDI and ≥17 for the BDI. The optimal screening cut-off for anxiety was ≥6 for the HADS anxiety subscale (HADS-A) and ≥14 for the HADS-total. At cut-offs commonly used in clinical practice for depression screening (HADS-D: 8; BDI: 16), the BDI performed slightly better than HADS-D.

Conclusion

The BDI, CDI and HADS demonstrated acceptable performance as screening tools for depression, as did the HADS-A for anxiety, in our sample of dialysis patients. The recommended cut-off scores for each instrument were: ≥17 for BDI, ≥11 for CDI, ≥7 for HADS depression subscale, ≥6 for HADS anxiety subscale and ≥14 for HADS total. The CDI did not perform better than the BDI in our study. Lower cut-off for the HADS-A than recommended in medically ill patients may be considered when screening for anxiety in dialysis patients.

Introduction

Anxiety and depression are frequent comorbid disorders in dialysis patients and may adversely affect hospitalization [1], mortality [2], quality of life (QoL) [3], [4] and adherence to treatment [5]. However, symptoms of depression and anxiety are often not recognized in these patients and may therefore go untreated [6], [7]. Patients with anxiety [8] and depression [9] can be effectively treated with medication and psychotherapy; therefore, early detection is important to provide effective treatment and reduce the additional negative impact of these symptoms.

The gold standard for diagnosing psychiatric disorders is a structured clinical interview, such as the Structured Clinical Interview for DSM-IV Axis I diagnoses (SCID-I). However, structured clinical interviews require administration by trained health professionals, are time-consuming and difficult to apply in routine clinical practice. Reliable, valid and easily applicable screening instruments are needed to identify those with anxiety and depression. The Beck Depression Inventory (BDI), a self-report questionnaire, has been frequently used to assess depressive symptoms in dialysis patients [3], [10]. Screening for depression is complicated because of overlapping symptomatology with uremia per se [11]. The Cognitive Depression Index (CDI), a truncated version of the BDI that has the somatic symptoms of depression omitted, has been used as an additional measure of depression and to reduce the possible confounding between symptoms of medical illness and the somatic components of depression measured by the BDI [10], [12]. To our knowledge, evaluation of the screening properties of the BDI and CDI has not been conducted.

Anxiety has been reported to have a more negative effect than depression on self-perceived QoL in dialysis patients [4]. The Hospital Anxiety and Depression Scale (HADS), a self-report screening measure, has been reported to perform well in assessments of both diagnosis and symptom severity of anxiety and depression [13]. However, the utility of the HADS as a screening tool for anxiety disorders in dialysis patients has been questioned [4] and the need to study HADS as a screening instrument for anxiety and depression in these patients seems warranted.

With this background, the aim of the present study was to compare the diagnostic performances of the HADS, BDI and CDI as screening tools for anxiety and depression in dialysis patients.

Section snippets

Patients

This preplanned study focused on psychiatric disorders assessed by the SCID-I as part of a larger multicenter study [3]. Consecutively admitted patients from four dialysis centers in different hospitals (two university hospitals and two regional hospitals) providing dialysis treatment to an urban population participated in this study. The study was approved by the Regional Committee for Research Ethics in Norway. Approval was obtained from the National Data Inspectorate.

All patients (≥18 years)

Participants

A total of 109 patients (30.3% female; mean age 57.8±15.7 years) participated. Eighty-four were in HD and 25 were in PD, with a median dialysis vintage of eight months (IQR=4–22 months). Sociodemographic and clinical characteristics are presented in Table 1. Participants who underwent SCID (n = 109) did not differ significantly from nonparticipants (n = 33) in age, scores on BDI, CCI, albumin, BMI or duration of dialysis. However, there were more men among the participants than among the

Discussion

Our main findings were that the BDI and HADS are useful screening instruments for depression in dialysis patients, although none of the tools was clearly superior to the other in assessing depression. According to our findings, the recommended cut-off value for BDI depression screening should be 17 (and greater) and is slightly higher than the optimal cutoff values of 16 (and greater) or 13 (and greater), which were previously suggested [16], [25].

The BDI includes somatic items such as sleep

Conclusion

The BDI, CDI and HADS had acceptable psychometric properties and can be recommended as screening instruments for depression, and the HADS-A can be recommended for anxiety screening in dialysis patients. The recommended cut-off scores for each instrument were: ≥17 for BDI, ≥11 for CDI, ≥7 for HADS depression subscale, ≥6 for HADS anxiety subscale and ≥14 for HADS total .We could not confirm that the CDI, the truncated version of the BDI, had better diagnostic accuracy. Lower cut-off for the

Acknowledgments

This study was supported by grants from the Health Region East, Norway. The authors thank the dialysis nurses and doctors at all participating dialysis units: Haukeland University Hospital, Oslo University Hospital, Buskerud Regional Hospital and Vestfold Regional Sykehus. We appreciate the assistance of Christa Bruun RN and Christina Roaldsnes RN in data collection and management.

References (32)

Cited by (69)

  • Comparison of two self-report scales to assess anxiety and depressive symptoms in hemodialysis patients

    2022, Archives of Psychiatric Nursing
    Citation Excerpt :

    Yet, 41 % of Australian dialysis patients (n = 110) had depression using the same scale (Kwan et al., 2019). Also, different cut-offs for the same instrument, such as HADS, were sometimes used by researchers (Gerogianni et al., 2019; Preljevic et al., 2012; Vasilopoulou et al., 2015), which may result in various proportions of psychiatric cases. Collectively, this necessitates the need to test and validate various screening tools on the same population to determine if disparities exist in reporting psychiatric symptoms prevalence (Wang et al., 2021).

View all citing articles on Scopus
View full text