Brief report
Validity of the ALS-Depression-Inventory (ADI-12)— A new screening instrument for depressive disorders in patients with amyotrophic lateral sclerosis

https://doi.org/10.1016/j.jad.2007.11.012Get rights and content

Abstract

Background

Depressive symptoms among patients with amyotrophic lateral sclerosis (ALS) are usually measured with conventional questionnaires. These measurements do not consider the specific circumstances of the underlying disease. The purpose of this study was to assess the validity of a new short 12 items ALS-Depression-Inventory (ADI-12). We determined convergent, criterion, and concurrent validity. The Structured Clinical Interview (SCID) for DSM-IV was used as the gold standard and the Beck Depression Inventory (BDI) and the WHO Well Being Index (WHO-5) to assess concurrent validity.

Methods

A total of 39 ALS patients in all stages of the disease were interviewed. Convergent validity was estimated by the inter-correlation between the ADI-12 and the BDI. Criterion and concurrent validity were specified with respect to sensitivity, specificity and predictive values. Receiver Operating Characteristics (ROC) and Areas Under the Curves (AUC) were calculated.

Results

All three depression scales showed excellent internal consistencies (Cronbach's α: .8–.9). The correlation between the ADI-12 and the BDI was high (r = .80). For the ADI-12 a cut-off of ≥ 30 (SE = 100%, SP = 83%) identified all patients with a current episode of major depression. A more liberal cut-off (≥ 23) identified all patients with any depressive disorder including minor depression at the cost of specificity (60%).

Conclusions

With the ADI-12 ALS patients with depressive disorders can be reliably identified. We recommend the ADI-12 for routine screening in primary care of ALS patients.

Introduction

Amyotrophic lateral sclerosis (ALS) is a fatal progressive motor neuron disease, which causes proceeding weakness of limbs and bulbar muscles. Its etiology is not yet fully understood and no curative therapy is available. In late stages of the disease, progressing paralysis can result in the so called locked-in state in which only residual muscular movement is possible (Borasio et al., 1998, Norris, 1992). Depression is associated with survival in ALS patients and therefore is a key factor to be identified (McDonald et al., 1994, Paillisse et al., 2005).

Comparing depression rates reported in the literature is difficult because different instruments have been used. The vast majority of studies relied on self-report questionnaires, such as the BDI (Beck et al., 1961). These studies reported depression rates ranging from 4% to 44% (Hogg et al., 1994, Houpt et al., 1977, Kübler et al., 2005a, Kübler et al., 2005b, Lou et al., 2003, Massman et al., 1996, Moore et al., 1998, Moore et al., 1997, Rabkin et al., 2005, Rabkin et al., 2000, Tedman et al., 1997, Trail et al., 2003). However, questionnaires provide information about the severity of depressive symptoms after a diagnosis has been made but do not allow us a formal diagnosis. Studies on depression using diagnostic interviews according to the DSM-IV (American Psychiatric Association, 2000) delivered highly consistent rates of Major Depression Disorder (MDD) of 9 to 11% among ALS patients (Ganzini et al., 1999, Rabkin et al., 2000).

Kübler et al. developed the ADI-12 to improve the detection of depressive symptoms in patients with neurodegenerative diseases (Kübler et al., 2005a). The ADI-12 is a short self-report screening questionnaire consisting of 12 items (Table 1). None of the items refer to somatic or motor-related symptoms taking into account the progressive physical impairment which may culminate in severe motor paralysis and life sustaining treatment. The ADI-12 assesses a homogeneous, one-dimensional construct that is described as “mood, anhedonia and energy” (Kübler et al., 2005a). We designed this study to reappraise the validity of the ADI-12 as a screening instrument for depressive disorders in a two-stage diagnostic process.

Section snippets

Participants

A total of 66 ALS patients were invited to participate in the study approved by the Ethical Review Board of the Medical Faculty, University of Tübingen. All patients had regular contact to either the outpatient ALS clinic of the Department of Neurology at the University of Ulm, the Marienhospital in Stuttgart, the ALS outpatient clinic or the Institute of Medical Psychology and Behavioural Neurobiology, University of Tübingen. Forty-one patients gave informed consent of which 39 were

Results

The mean ADI-12 score was 23.85 [± 7.13, range 12–42]. Using the thresholds suggested by Kübler et al. (2005a), 38.5% of the patients had no symptoms, 33.3% mild depressive symptoms, and 28% clinically relevant symptoms. Mean score of the BDI was 14.67 [± 7.13, range 1–31] and of the WHO-5 14.10 [± 5.89, range 2–22]. Cronbach's alpha for the ADI-12 was .91, for the BDI .80, and for the WHO-5 .88.

SCID results identified the majority of the ALS patients as free of a current episode of MDD. Four

Discussion

The purpose of this study was to examine the validity of the ADI-12 as a screening tool for depression in ALS patients. While ADI-12, BDI and WHO-5 demonstrated high reliability, especially ADI-12 and BDI, were highly correlated, indicating a high convergent validity of the ADI-12.

Adopting a two-stage diagnostic approach, a screening for depression was followed by a Structured Clinical Interview. Using the ADI-12 cut-off of 30 or higher, a maximum SE (100%) and an SP of 82% was achieved,

Conclusions

The broad range (0–44%) of “depression” in samples of ALS patients seems to be mainly due to the use of different instruments, including self-ratings. When standardised clinical interviews are used for diagnosis, the rate of depression (MDD) in ALS is about 10% (Ganzini et al., 1999, Rabkin et al., 2000), which was further confirmed by the presented study. Based on our data, we recommend the ADI-12 for routine screening in ALS patients, due to its shortness and high validity. We suggest a

Role of funding source

The study was not supported by a sponsor.

Conflict of interest

We all disclose any conflict of interest including any financial, personal or other relationships with other people or organizations within three years of beginning the work submitted that could inappropriately influence, or be perceived to influence, our work. We have no conflicts of interest.

Eva Maria Hammer

Sonja Häcker

Martin Hautzinger

Thomas D. Meyer

Andrea Kübler

Acknowledgements

We thank Emily Mugler and Jacqueline Boccanfuso, who assisted with the preparation and proof-reading of the manuscript.

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