Coronary artery disease
Screening for Depression in Patients With Coronary Heart Disease (Data from the Heart and Soul Study)

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Major depression is associated with adverse outcomes in patients who have coronary heart disease. How best to identify depression in busy cardiology practices is unknown. We compared the test characteristics of 4 depression screening instruments with an interview diagnosis of depression (Diagnostic Interview Schedule) in 1,024 outpatients who had coronary heart disease. Screening instruments were the 10-item Center for Epidemiologic Studies Depression Scale-10, the Patient Health Questionnaire-9, the Patient Health Questionnaire-2, and a simple 2-item instrument that asks (1) “During the past month, have you often been bothered by feeling down, depressed, or hopeless?” and (2) “During the past month, have you often been bothered by little interest or pleasure in doing things?” Of the 1,024 participants, 224 (22%) had major depression based on the Diagnostic Interview Schedule. Areas under the receiver-operating characteristic curves were similar for all instruments (range 0.84 to 0.87). In conclusion, a positive response to 1 of the 2 items was 90% sensitive and 69% specific for depression, with a negative likelihood ratio of 0.14. Thus, negative responses to the 2 items effectively ruled out depression. A score ≥10 on the Patient Health Questionnaire-9 was 54% sensitive and 90% specific, with a positive likelihood ratio of 5.4. Thus, a cutpoint ≥10 was virtually diagnostic for depression.

Section snippets

Study participants

The Heart and Soul Study is a prospective cohort study of psychosocial factors and health outcomes in patients who have CHD. Methods have been previously described.3 In brief, administrative databases were used to identify outpatients who had documented coronary artery disease at 2 Department of Veterans Affairs medical centers (Veterans Affairs Medical Center, San Francisco and the Veterans Affairs Palo Alto Health Care System, Palo Alto, California), 1 university medical center (University of

Results

Our sample of outpatients who had CHD consisted mostly of older men who were a mean age of 67 years (Table 1). Of the 1,024 participants, 224 (22%) had major depression as determined by the criterion standard computerized version of the Diagnostic Interview Schedule. Overall, the screening instruments had sensitivities of 39% to 90% and specificities of 69% to 92% using standard cutpoints (Table 2). Areas under the receiver-operating characteristic curves were similar for all screening tests,

Discussion

We found that a simple 2-item instrument was an effective tool for identifying major depression in patients who had CHD and had similar test characteristics to 3 other more time-consuming screening instruments for depression. A “no” response to the 2 items made depression highly unlikely, with a negative likelihood ratio of 0.14 and a posterior probability of 4%. Our results suggest that a simple 2-item instrument can be used to screen for depression in a diverse population of patients who have

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    This study was supported by grants from the Department of Veterans Affairs, Washington, DC; the American Federation for Aging Research (Paul Beeson Scholars Program), New York, New York; the Robert Wood Johnson Foundation (Faculty Scholars Program), Princeton, New Jersey; and the Ischemia Research and Education Foundation, South San Francisco, California.

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