Elsevier

General Hospital Psychiatry

Volume 29, Issue 5, September–October 2007, Pages 417-424
General Hospital Psychiatry

Validity of the Hospital Anxiety and Depression Scale and Patient Health Questionnaire-9 to screen for depression in patients with coronary artery disease

https://doi.org/10.1016/j.genhosppsych.2007.06.005Get rights and content

Abstract

Objective

Depression is common but frequently undetected in patients with coronary artery disease (CAD). Self-report screening instruments for assessing depression such as the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire-9 (PHQ-9) are available but their validity is typically determined in depressed patients without comorbid somatic illness. We investigated the validity of these instruments relative to a referent diagnostic standard in recently hospitalized patients with CAD.

Method

Three months post-discharge for a cardiac admission, 193 CAD patients completed the HADS and PHQ-9. The Mini International Neuropsychiatric Interview (MINI) was the criterion standard. Scale reliability was calculated using Cronbach's α. Convergent validity was computed using Pearson's intercorrelations. Sensitivity and specificity for various cut-off scores for both measures and for the PHQ-9 categorical algorithm were calculated using receiver operating characteristics (ROC). For analyses, participants were assigned to two groups, ‘major depressive disorder’ or ‘any depressive disorder’.

Results

For all calculations, α was 0.05 and tests were two-tailed. Internal consistencies for the two measures were excellent. Criterion validity for the PHQ-9 and HADS was good. We found no statistical differences between the PHQ-9 and HADS for detecting either group; however, the categorical algorithm of the PHQ-9 for diagnosing major depression had a superior LR+ when compared with the summed HADS or PHQ-9. The operating characteristics of the screening instruments for ‘any depressive disorder’ were slightly lower than for ‘major depressive disorder’. Some optimum cut-off scores were lower than the generally recommended cut-off scores, particularly when screening for major depression (e.g., ≥5/6 vs. ≥10 and ≥8 for PHQ-9 and HADS, respectively). Lowering the cut off scores substantially improved the sensitivity of these instruments while retaining specificity, thereby improving their usefulness to screen for CAD patients with depression.

Conclusions

Both instruments have acceptable properties for detecting depression in recently hospitalized cardiac patients, and neither scale is statistically superior when summed scores are used. The categorical algorithm of the PHQ-9 for diagnosing major depression has a superior LR+ compared to the summed PHQ-9 and HADS scores. Use of the generally recommended cut-off scores should be cautious. In light of the aversive outcomes associated with depression in CAD, screening for depression is a clinical priority.

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.

References (63)

  • D. McManus et al.

    Screening for depression in patients with coronary heart disease (data from the Heart and Soul study)

    Am J Cardiol

    (2005)
  • K.Z. Bambauer et al.

    Using the Hospital Anxiety and Depression Scale to screen for depression in cardiac patients

    Gen Hosp Psychiatry

    (2005)
  • E. Andresen et al.

    Screening for depression in well older adults: evaluation of a short form of the CES-D (Centre for Epidemiological Studies Depression Scale)

    Am J Prev Med

    (1994)
  • D.V. Sheehan et al.

    The validity of the Mini International Neuropsychiatric Interview (M.I.N.I) according to the SCID-P and its reliability

    Eur Psychiatry

    (1997)
  • Y. Lecrubier et al.

    The Mini International Neuropsychiatric Interview (M.I.N.I.). A short diagnostic structured interview: reliability and validity according to the CIDI

    Eur Psychiatry

    (1997)
  • C. Herrmann

    International experiences with the Hospital Anxiety and Depression Scale: a review of validation data and clinical results

    J Psychosom Res

    (1997)
  • F. Cheok et al.

    Identification, course, and treatment of depression after admission for a cardiac condition: rationale and patient characteristics for the Identifying Depression as a Comorbid Condition (IDACC) project

    Am Heart J

    (2003)
  • I. Bjelland et al.

    The validity of the Hospital Anxiety and Depression Scale: An updated literature review

    J Psychosom Res

    (2002)
  • M.W. Ketterer et al.

    “Major” depressive disorder, coronary heart disease, and the DSM-IV threshold problem

    Psychosomatics

    (2006)
  • M.K. Potts et al.

    A structured interview version of the Hamilton Depression Rating Scale: evidence of reliability and versatility of administration

    J Psychiatr Res

    (1990)
  • G.E. Simon et al.

    Telephone assessment of depression severity

    J Psychiatr Res

    (1993)
  • B. Lowe et al.

    Comparative validity of three screening questionnaires for DSM-IV depressive disorders and physicians' diagnoses

    J Affect Disord

    (2004)
  • A. Forrester et al.

    Depression following myocardial infarction

    Int J Psychiatry Med

    (1992)
  • N. Frasure-Smith et al.

    Depression following myocardial infarction: impact on 6-month survival

    JAMA

    (1993)
  • N. Frasure-Smith et al.

    Depression and 18-month prognosis after myocardial infarction

    Circulation

    (1995)
  • F. Lesperance et al.

    Depression and 1-year prognosis in unstable angina

    Arch Int Med

    (2000)
  • R.M. Carney et al.

    Major depressive disorder predicts cardiac events in patients with coronary artery disease

    Psychosom Med

    (1988)
  • S. Schleifer et al.

    The nature and course of depression following myocardial infarction

    Arch Int Med

    (1989)
  • H.S. Lett et al.

    Depression as a risk factor for coronary artery disease: evidence, mechanisms and treatment

    Psychosom Med

    (2004)
  • N. Frasure-Smith et al.

    Gender, depression and one-year prognosis after myocardial infarction

    Psychosom Med

    (1999)
  • P.A. Pirraglia et al.

    Depressive symptomatology in coronary artery bypass graft surgery patients

    Int J Geriatr Psychiatry

    (1999)
  • Cited by (217)

    View all citing articles on Scopus
    View full text