Beck Depression Inventory-Fast Screen

Hemodialysis International 2012; International 2012; 16 :207–213

Beck Depression Inventory-Fast Screen (BDI-FS): An efficient tool for depression screening in patients with end-stage renal disease Andrea NEITZER,1 Sumi SUN,1 Sheila DOSS,1 John MORAN,1,2 Brigitte SCHILLER1,2 1

Satellite Satel lite Healthcare, Healthcare, San Jose, California, California, USA; 2 Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA

Abstract Depression is common in patients suffering from end-stage renal disease (ESRD). Various screening tools for depression in ESRD patients are available. This study aimed to validate the Beck Depression Inve Inventory ntory-Fast -Fast Screen (BDI(BDI-FS) FS) with the Beck Depr Depressio ession n Inven Inventorytory-II II (BDI(BDI-II) II) as depr depressio ession n screening tool in conventional hemodialysis (CHD) patients. One hundred sixty two CHD patients were studied with both screening questionnaires. We used the Pearson Correlation Coefficient to measure the agreement between BDI-II and BDI-FS scores from 134 patients who responded to both questionnaires. Receiver operating characteristics curve and area under the curve were constructed to determine a valid BDI-FS cutoff score to identify ESRD patients at risk for depression. BDI-II and BDI-FS scores strongly correlated (Pearson r 0.85, p < 0.0001). At a BDI-II cutoff 16, rece receiver iver operating characteristics showed the best balance between sensitivity and specificity for the BDI-FS cutoff value of 4 with a sensitivity of 97.2% (95% confidence interval [CI]: 85.5%, 99.9%) and a specificity of 91.8% (95% CI: 84.5%, 96.4%). When applying the above cutoff scores, prevalence of depressive symptoms in all completed questionnaires was found to be 28.7% (BDI-II) and 30.1% (BDI-FS), respectively. The BDI-FS was found to be an efficient and effective tool for depression screening in ESRD patients which can be easily implemented in routine dialysis care. =

Key wor words: ds: Depr Depress ession ion scr screen eening ing,, end end-st -stage age ren renal al dis diseas ease, e, hem hemodi odialy alysis sis,, Bec Beck k Dep Depre ressi ssion on Inventory

INTRODUCTION Depression has been recognized to be among the most common com mon psy psycho cholog logica icall dis disor order derss in end end-st -stage age re renal nal 1,2 disease (ESRD) patients. Recent investigations suggest that 20–30% of the maintenance dialysis population in the United States and Europe is affected by depression. 3–5 Depressiv Depr essivee sympt symptoms oms and the psych psychologi ological cal effects of Correspondence to: A. Neitzer, MSD, Satellite Healthcare, 300 Santana Row, Suite 300, San Jose, CA 95128, USA. E-mail: [email protected]

depression depressio n are str strongly ongly assoc associate iated d with incr increase eased d hospitali pit alizat zation ion rat rates, es, imp impair aired ed med medica icall out outcom comes, es, and 6–8 mortality. Prevalen Pre valence ce esti estimate matess vary depe depending nding on the popul populaations under investigation and/or the different depression screening tools applied. This paper focuses on the latter and attempts to make a recommendation for a routine depression screening tool in ESRD patients, based on the comparison of two commonly used tools. An instrument frequently used to screen for depression in ESRD patients is the Beck Depression Inventory-Second Edition (BDI-II). Previous studies on depressive disorders

© 2012 Satellite Healthcare, Inc. Hemodialysis International © 2012 International Society for Hemodialysis DOI:10.1111/j.1542-4758.2012.00663.x

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in this patient population have validated a cutoff score of 16 or greater. 9,10 The BDI-II is a 21-item self-report instrument that screens for the severity of depression corresponding to psychological and somatic symptoms.11 However, uremia and other symptoms of inadequate dialysis such as anorexia, sleep disturbance, fatigue, gastrointestinal disorder, and pain can overlap with the somatic symptoms of depression. 12 This can complicate the diagnosis of major depression in ESRD patients, and BDI-II results should be interpreted with caution. 2 To measure the severity of depression that corresponds to nonsomatic criteria, the Beck Depression Inventory Fast-Screen for Medical Patients (BDI-FS), formerly known as the Beck Depression Inventory for Primary Care, was developed. 13 It extracts the seven nonsomatic symptoms from the BDI-II (sadness, pessimism, fast failure, loss of pleasure, self-dislike, self-criticalness, and suicidal thoughts or wishes) and reduces patient burden because of its faster administration. Previous research has tested the BDI-FS in multiple sclerosis, 14 geriatric primary-care patients, 15 and compared the BDI-FS to the BDI-II in patients with chronic pain. 16 However, to date the BDI-FS has not been validated as a screen for depression in patients with chronic kidney disease (CKD) or ESRD, and the question for the appropriate cutoff score for a renal population remains open. The objectives of our study were to measure the prevalence of depressive symptoms in our in-center hemodialysis (HD) patients with both the BDI-II and the BDI-FS, to test the agreement between both depression screening tools, and to determine a reliable BDI-FS cutoff score for patients with ESRD.

MATERIALS AND METHODS A cross-sectional sample of 317 patients on conventional hemodialysis (CHD) in 20 outpatient units (15 in California, five in Texas) was approached for this study. Patients were English or Spanish speaking, at least 18 years old, and were due in April to June 2009 for their 90 days or yearly Kidney Disease Quality Of Life-36 (KDQOL-SF36) assessment required by the new Conditions for Coverage. All patients were invited to complete the BDI-II and the BDI-FS during their HD treatment. Order of completion was not specified. Questionnaires with 50% or more of the questions left blank were considered incomplete and excluded. The BDI-II is a 21-item self-report case-finding screening tool assessing various degrees of depressive symptoms.11 It was developed for the evaluation of symptoms corresponding to criteria for diagnosing depressive dis-

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orders listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, DSM-IV.17 Each item is rated on a 4-point scale from 0 to 3, with a maximum total score of 63. Higher scores indicate more severe depressive symptoms. It takes 5–10 minutes to complete, and has been widely used to screen for depression in patients with CKD and ESRD. Based on previous studies, we classified patients with a BDI-II score 16 as being in risk for depression.9,10 The BDI-FS is an extract from the 21-item BDI-II 13 with only seven items and requires less than 5 minutes for completion. Scoring is similar to the BDI-II. The BDI-FS was developed specifically for evaluating depression in patients whose behavioral and somatic symptoms are attributable to biological, medical, alcohol, and/or substance abuse problems that may confound the diagnosis of depression. It was constructed to reduce the number of false positives for depression in patients with these problems, and measures the degree of depressive symptoms that corresponds to the psychological or nonsomatic criteria for diagnosing major depression disorders as listed in the DSM-IV.

Statistical methods Patient information on gender, race, diabetic status, and length of time on dialysis was retrieved from our internal patient database. All other information was collected from the completed survey tools. Patient demographics and score on the BDI-II and BDI-FS were described by proportion (percentage) and mean ( standard deviation, SD). The Pearson correlation coefficient was used to measure the agreement between BDI-II and BDI-FS scores. The BDI-FS was validated against the BDI-II cutoff score 16 as the standard. In order to determine a BDI-FS cutoff score valid for identifying ESRD patients at risk for depression, the receiver operating characteristic (ROC) curve and area under the curve (AUC) was constructed. We further calculated the concordance and discordance between the score results of both BDIs. T -test and chisquare test were used to compare means and proportions, respectively. For all analysis two-tailed P value < 0.05 was considered significant. SAS version 9.1 (SAS Institute, Cary, NC, or http://www.sas.com) was used to conduct the statistical analyses.

RESULTS A total of 162 CHD patients returned at least one of the BDIs, the remaining 155 patients did not answer any of

Hemodialysis International 2012; 16 :207–213

Depression screening in dialysis

Table 1 Patient characteristics (n 134) =

BDI-FS scores demonstrated a strong positive linear correlation (Pearson r 0.85, p < 0.0001, (n 134) as shown in Figure 1. The ROC analysis with a BDI-II cutoff 16 as the gold standard revealed the best balance between sensitivity (true positive rate) and specificity (true negative rate) for the BDI-FS at a cutoff value of 4 (Figure 2). At this cutoff, BDI-FS results had a sensitivity of 97.2% (95% CI: 85.5%, 99.9%) and a specificity of 91.8% (95% CI: 84.5%, 96.4%). The positive predictive value (PPV) was 81.4%, and the negative predictive value (NPV) was 98.9%. Concordance for both BDIs was found to be 93.3% (125/134 patients), while discordance was only 6.7% (9/134 patients), summarized in Table 2. We calculated the AUC as 0.982, indicating that the BDI-FS had a high predictive accuracy vs. the gold standard to correctly classify patients with and without the prevalence of depressive symptoms. BDI-II scores 16 and BDI-FS scores 4 were found in 28.7% and 30.1% of our study participants, respectively. These patients were significantly younger compared to patients not classified as being at risk for depression. Except for age, no significant differences for gender, race, vintage, or prevalence of diabetes were found between these groups (Table 3). Of note was the observation that, of those patients who completed the BDI-FS but did not answer at least half of the questions on the BDI-II, over 80% missed the questions on the =

Characteristics Male, % 52 Mean age, y ( SD) 59.1  14.7 Race, % White 60 Black 22 Asian 13 Other 4 Years on dialysis, % 10 <1 1–5 71 6–10 16 10 3 > Median time on dialysis, months (range) 27.5 (2.9–252.2)

the two questionnaires. Of those 162 patients, 150 patients answered the BDI-II, and 146 answered the BDIFS. Both survey tools were returned by 134 patients, resulting in a response rate of 42%. Demographic data from those 134 patients were as follows: The participants’ ages ranged from 21 to 87 years (mean: 59.1  14.7). The majority (52%) was diabetic, and 98.5% of our patient sample was on dialysis for 90 days or longer. Other patient characteristics are summarized in Table 1. Average scores for the BDI-II (n 150) and the BDI-FS (n 146) were 12.3  10.8 and 2.7  3.4, respectively. Total BDI-II and =

=

=

Figure 1 Correlation between BDI-II and BDI-FS total scores.


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Figure 2 Receiver/Responder Operating Characteristic (ROC) curve to assess a reliable cutoff value for BDI-FS (with BDIII  16 as standard).

reverse side of the BDI-II but answered the majority or all of the questions on the front side. These patients were significantly older (p < 0.05) compared to patients who answered the complete BDI-II. Patients who did not

complete the BDI-FS but had answered the BDI-II were significantly younger (p < 0.001). Table 4 shows the mean age for patients who completed and those who did not complete the BDIs.

Table 2 Agreement between BDI-II (cutoff 16) and BDI-FS (cutoff 4)

BDI-II BDI-FS

16



<

16

Total (n)

4

35 (26.1%)

8 (6.0%)

43 (32.1%)

4

1 (0.7%)

90 (67.2%)

91 (67.9%)

Total

36 (26.9%) Sensitivity 35/36 (97.2%)

98 (73.1%) Specificity 90/98 (91.8%)



Positive predictive value 35/43 (81.4%) Negative predictive value 90/91 (98.9%) =

<

=

=

=

Table 3 Patient characteristics according to depression indicators

BDI-II 16 (n 107)

<

Mean age, y ( SD) Male, % Race, % White Black Asian Others Diabetic, % Mean time on dialysis, months ( SD)

=

BDI-FS 16 (n 43)



=

4 (n 102)

<

=

4 (n 44)



=

60.4  15.0 55.1

a

50.4  13.8 58.1

62.1  14.5 52.0

54.4  14.0b 61.4

59.8 18.7 15.0 6.5 55.1 44.8  43.6

69.8 23.3 2.3 4.7 39.5 44.9  33.8

56.9 20.6 16.7 5.9 54.9 43.4  44.3

68.2 22.7 4.6 4.6 47.7 44.0  33.1

a

p < 0.001, bp < 0.01.

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Table 4 Mean age (years) of patients who completed and those who did not complete the BDI depression screening tools

Questionnaires

Completed

Not completed

Mean age, y ( SD), range

Mean age, y ( SD), range

57.5 (15.3), 21–87 59.8 (14.8), 21–87

67.8 ( 13.8)a, 42–87 44.5 ( 14.2)b, 24–72

BDI-II BDI-FS

BDI-II completed (n 150), BDI-II not completed (n 12); BDI-FS completed (n 146), BDI-FS not completed (n 16). a p < 0.05, bp < 0.001. =

=

DISCUSSION We found a strong correlation between BDI-II and BDI-FS questionnaires in the evaluation for depression when administering both questionnaires simultaneously to patients undergoing HD. Our data suggest that a BDI-FS cutoff 4 identifies ESRD patients at risk for depression. Applying this cutoff to our patient sample reveals a prevalence of depressive symptoms of about 30%. This confirms prior data for the estimated prevalence of depression and depressive symptoms in patients on dialysis in the Unites States and Europe.3–5 In agreement with previous research, 18 we also found dialysis patients at risk for depression to be younger than those patients without depressive symptoms. Concerns that in ESRD patients the BDI-II may overestimate the risk of depression due to various questions related to somatic symptoms frequently seen in patients undergoing HD including fatigue, insomnia, and loss of appetite were not confirmed in our study. However, “screening” for depression needs to be distinguished from “diagnosing” depression, and it is a limitation of this study that we did not perform psychological interviews with those patients at risk of depression in order to confirm or reject the diagnosis. Also the “response bias” of self-report inventories needs consideration. While these tools reflect subjective perception of the patient’s well-being, they contain valuable information and metrics for patient assessment, however without a clear diagnosis. Hedayati et al.5,19 confirmed that self-report questionnaires such as the BDI-II should not be used for a clinical diagnosis of depression in CKD or ESRD patients but that they performed well as screening tools. The implementation of a framework for systematic depression screening in a dialysis facility and a depression treatment algorithm for ESRD patients has been advocated but has also proven to be challenging. 20 Nephrologists might correctly argue that the therapy of depression is not part of their area of expertise, and they often do not feel comfortable treating depression. Furthermore, it is not known whether treatment of depression impacts the outcomes of ESRD patients as randomized clinical trials are


=

=

missing. Although the prevalence of depressive symptoms was found to be very common in the incident dialysis patient,21 there are no data available indicating when to start screening patients with ESRD for depression. However, considering the high prevalence of depression in ESRD patients and the negative impact on medical outcomes, hospitalization rate, and mortality in this population, including depression screening in routine ESRD patient care is likely to add benefits and should therefore lead to more insistent effort also from the nephrologists’ side. Data from the Following Rehabilitation, Economics and Everyday-Dialysis Outcomes Measurements study recently revealed a significant improvement in BDI-II scores in patients treated with daily (six times per week) home HD over 12 months.22 Moreover, the Frequent Hemodialysis Network trial comparing more frequent center dialysis therapy to conventional thrice-weekly dialysis showed a decrease in the BDI-II score from 12.6  8.7 to 10.4  8.5 in the daily group after 12 months. Although not statistically significant this is a notable finding given the extra burden of dialysis with daily therapy. 23 From a patient’s perspective, a diagnosis of depression is often still understood as a stigma, and affected patients might tend to deny depression-related symptoms. Kleinman has shown that many depressed Chinese patients found a diagnosis of depression morally unacceptable. 24 Furthermore, resistance to the diagnosis of depression is evident from studies showing that 55% of PD patients suggested by the BDI-II as being depressed refused further assessment to confirm or rule out the diagnosis of major depression. Of those patients diagnosed with major depression by psychological evaluation, only half successfully completed 12 weeks of pharmacologic therapy.4 Patients need to be educated to understand that depression is a serious medical illness that impairs quality of life and even survival, and therefore should be seriously considered to be part of a patient-centered ESRD care approach. With ESRD patients affected by depression being younger than patients without depressive symptoms, attention to symptoms appears even more critical, as ESRD and the burden of dialysis may

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present a greater disruption of work and social life in younger patients.25 We conclude that a routine depression screening program in ESRD patients needs to be efficient and costeffective in order to have chances of success. It should be well accepted by ESRD patients, practical, and easily administered for the caretakers considering the growing demands in dialysis units because of the increasingly older and multi-morbid population. In this regard, the BDI-FS is a promising tool. It is one-sided, without risk of patients accidentally skipping questions on the reverse side of the questionnaire. Our study showed that patients with an incomplete questionnaire were significantly older, suggesting that the BDI-FS would be more suitable for these patients. Its completion takes less than 5 minutes and therefore causes little burden for the patients to complete and for the staff to evaluate. Furthermore, it focuses on nonsomatic indicators rather than on physical symptoms that might overlap with complaints due to uremia or dialysis-associated adverse events. Although administration and scoring may be easy, it is recommended that the BDI-FS should be interpreted only by professionals with appropriate clinical training and experience. 13 With the BDI-FS in hand, ESRD patients could systematically be screened for depression with an easy and reproducible questionnaire, allowing for trending over time. In accordance with the increasing focus on quality of life as a metric for outcome in ESRD, this tool will allow the multidisciplinary care team to focus on patients at risk who will likely benefit from psychosocial intervention. Moreover, it may help to develop algorithms for the more integrated ESRD care model of the future and to increase the patients’ quality of life. Manuscript received September 2011; revised November 2011.

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4 Wuerth D, Finkelstein SH, Finkelstein FO. The identification and treatment of depression in patients maintained on dialysis. Semin Dial. 2005; 18 :142–146. 5 Hedayati SS, Boswoth HB, Kuchibhatla M, Kimmel PL, Szczech LA. The predictive value of self-report scale compared with physician diagnosis of depression in hemodialysis patients. Kidney Int. 2006; 69 :1662–1668. 6 Kimmel PL, Peterson RA, Weihs KL, et al. Multiple measurements of depression predict mortality in a longitudinal study of chronic hemodialysis patients. Kidney Int. 2000; 57 :2093–2098. 7 Hedayati S, Bosworth HB, Briley LP, et al. Death or hospitalization of patients on chronic hemodialysis is associated with a physician-based diagnosis of depression. Kidney Int. 2008; 74 :930–936. 8 Riezebos RK, Nauta KJ, Honig A, Dekker FW, Siegert CEH. The association of depressive symptoms with survival in a Dutch cohort of patients with end-stage renal disease. Nephrol Dial Transplant. 2010; 25 :231–236. 9 Watnick S, Wang P, Demadura T, et al. Validation of two depression screening tools in dialysis patients. Am J Kidney Dis. 2005; 46 :919–924. 10 Chilcot J, Wellsted DM, Farrington K. Screening for depression while patients dialyze: An evaluation. Nephrol Dial Transplant. 2008; 23 :2653–2659. 11 Beck AT, Steer RA, Brown GK. BDI-II Manual. San Antonio, TX: The Psychological Corporation, Harcourt Brace & Company. 1987. 12 Cohen S, Norris L, Acquaviva K, et al. Screening, diagnosis, and treatment of depression in patients with end-stage renal disease. Clin J Am Soc Nephrol. 2007; 2:1332–1342. 13 Beck AT, Steer RA, Brown GK. BDI-FastScreen for Medical Patients, Manual. San Antonio, TX: The Psychological Corporation, A Harcourt Assessment Company. 2000. 14 Benedict RH, Fishman I, McClellan MM, et al. Validity of the Beck Depression Inventory-Fast Screen in multiple sclerosis. Mult Scler . 2003; 9 :393–396. 15 Scheinthal S, Steer RA, Giffin L, Beck AT. Evaluating geriatric medical outpatients with the Beck Depression Inventory – Fast Screen for medical patients. Aging Ment Health. 2001; 5 :143–148. 16 Poole H, Bramwell R, Murphy P. The utility of the Beck Depression Inventory Fast Screen (BDI-FS) in a pain clinic population. Eur J Pain. 2009; 13 :865–869. 17 DSM-IV, American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Washington, DC: American Psychiatric Association. 1994. 18 Drayer RA, Piraino B, Reynolds CF, et al. Characteristics of depression in hemodialysis patients: Symptoms, quality of life and mortality risk. Gen Hosp Psychiatry. 2006; 28 :306–312. 19 Hedayati SS, Minhajuddin AT, Toto RD, Morris DW, Rush AJ. Validation of depression screening scales in patients with CKD. Am J Kidney Dis. 2009; 54 :433–439.



20 Finkelstein FO, Wuerth D, Troidle LK, Finkelstein SH. Depression and end-stage renal disease: A therapeutic challenge. Kidney Int. 2008; 74 :843–845. 21 Watnick S, Kirwin P, Mahnensmith R, Concato J. The prevalence and treatment of depression among patients starting dialysis. Am J Kidney Dis. 2003; 41 :105–110. 22 Jaber BL, Lee Y, Collins AJ, et al. Effect of daily hemodialysis on depressive symptoms and postdialysis recovery time: Interim report from the FREEDOM (Following Rehabilitation, Economics and Everyday-Dialysis Outcomes Measurements) study. Am J Kidney Dis. 2010; 56:531–539.


23 Chertow GM, Levin NW, Beck GJ, et al. In-center hemodialysis six times per week versus three times per week. N Engl J Med. 2010; 363 :2287–2300. 24 Kleinman A. Culture and depression. N Engl J Med. 2004; 351:951–953. 25 Chilcot J. Studies of depression and illness representations in end-stage renal disease. A thesis submitted in partial fulfillment of the requirements of the University of Hertfordshire for the degree of Doctor of Philosophy, School of Psychology. May 2010. http://hdl.handle.net/ 2299/4796

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