Elsevier

General Hospital Psychiatry

Volume 26, Issue 5, September–October 2004, Pages 384-389
General Hospital Psychiatry

A prospective study to compare three depression screening tools in patients who are terminally ill

https://doi.org/10.1016/j.genhosppsych.2004.04.002Get rights and content

Abstract

Depression is a significant symptom for approximately one in four palliative care patients. This study investigates the performance of three screening tools. Patients were asked to verbally rate their mood on a scale of 0–10; to respond “yes” or “no” to the question “Are you depressed?,” and to complete the Edinburgh depression scale. They were also interviewed using a semi-structured clinical interview according to DSM-IV criteria. Complete data was available for 74 patients. For the single question, a “yes” answer had a sensitivity of 55% and specificity 74%. The Edinburgh depression scale at a cut-off point of ≥13 had a sensitivity of 70% and specificity of 80%. The verbal mood item with a cut-off point of ≥3 had a sensitivity of 80% and specificity of 43%. The Edinburgh depression scale proved to be the most reliable instrument for detecting clinical depression in palliative care patients.

Introduction

Depression is a significant symptom for approximately one in four palliative care patients, and is especially common in those patients with more advanced metastatic disease [1], [2]. It is well known that depression is frequently missed and therefore goes untreated [3], [4]. One reason for this low rate of detection is thought to be nondisclosure by patients who may feel either that they are wasting the doctor's time or that they are in some way to blame for their distress and so they choose to hide their feelings. In addition, medical and nursing staff may not be confident eliciting psychological and psychiatric morbidity [5]. The exact prevalence of depressive disorders in palliative care patients is difficult to establish; rates from studies using structured diagnostic interviews or well-defined criteria vary from 5% to 32% for all depressive disorders [6]. Depression has no distinct biological markers or effective diagnostic test and it can be difficult to differentiate depression from “appropriate sadness” or grief reactions as the end of life approaches [7]. Importantly, there are many antidepressants available with acceptable side effect profiles; patients identified as depressed even within the last 4–6 weeks of life may still benefit from treatment [8], but few palliative care patients are prescribed antidepressant medication [9].

Doctors may attribute somatic symptoms of depression to the cancer illness, highlighting their tendency to separate mental from physical health [10]. The complex problem of deciding which symptoms may be attributable to cancer and which may be due to depression has been discussed by Endicott [11], who proposed that somatic symptoms should be substituted for nonsomatic symptoms in the patient with cancer. Endicott also stressed the importance of asking patients with cancer about suicidal ideation.

Unfortunately, staff may perceive inquiries of psychological symptoms as adding to the patient's distress and fear the consequences of asking direct questions about feelings. Research, however, has shown that patients do not feel such questions are stressful as long as they are asked in an empathetic way [12].

There is increasing interest in the use of screening scales within palliative care. The majority are self-completion rating scales consisting of a range of depressive symptoms. The Hospital Anxiety and Depression scale [13] is the most frequently used tool used in palliative care settings [6]; however, two recent articles [14], [15] reported relatively low sensitivity and specificity for this scale when used in patients with advanced metastatic disease. There is, therefore, a need to identify a brief and valid tool for the assessment of depression in this population.

This study investigates the performance of three different screening tools: (a) the Edinburgh depression scale [16]; (b) asking the single question, “are you depressed?” [17]; and (c) verbally self-rating their mood on a scale of 0–10. All three tools are validated against a semi-structured clinical psychiatric interview according to DSM-IV criteria.

Section snippets

Method

Patients attending a palliative care day unit were recruited into the study and were required to be able to understand both written and spoken English and to participate in a semi-structured interview. Full ethical approval for this study was obtained from the local ethics committee and all patients were required to give written consent prior to participation. Baseline demographic information was obtained on age, ethnicity, diagnosis, past history of depression, performance status (Eastern

Results

One-hundred and six patients were eligible to participate in the study during the 6-month study period, but only 74 were functionally able to complete all the rating instruments and the clinical interview.

The patients' ages ranged from 28 to 89 years old with a mean age of 67.89 years (SD 13.60) and median age of 70.5 years [interquartile range (IQR), 62–78]. The distribution of patients' ages was slightly skewed, which is concurrent with the expectation that cancer primarily develops in later

Discussion

Seventy-four patients consented to participate in clinical interviews and the three rating scales for this study. Although this number is small, it is larger than many other studies concerning palliative care patients. The prevalence of major depression in the present study was found to be 27%, which concurs with the expectation that approximately one in four patients admitted to a palliative care unit will have significant depressive symptoms [23]. In this study an equal number of men and

Conclusions

Our findings suggest that at the present time the Edinburgh depression scale is the most appropriate tool to use to screen for depression in palliative care patients. Asking patients to verbally rate their mood or asking patients the question “are you depressed?” is not sufficiently robust to be adopted within routine clinical practice.

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