Review Article

Assessing Depression in Cardiac Patients: What Measures Should Be Considered?

Table 1

Depression measures characteristics.

Tool nameValidation studyNumber of itemsTool characteristicsAdvantagesDisadvantages

Hospital Anxiety and Depression Scale
(HADS)
Zigmond and Snaith [26]. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand, 67(6), 361–370 14 itemsItem distribution is perfectly even: 7 items score for depression and 7 for anxiety. The total scale score may be used as a measure of global mood disorder according to the classification of mild (8–10), moderate (11–15), and severe anxiety or depression (16–21) scores. Clinical-practice specific. Good screening and evaluation of psychological distress symptoms in post-MI patients

Sound psychometric properties in MI patients [29] over different time frames (1 or 6 week and 6 months) allowing to determine subscaling of dimensions assessing anhedonia, psychic anxiety, and psychomotor agitation

Designed to avoid excessive reliance on common somatic symptoms of illness, fatigue, insomnia, or hypersomnia intertwined with both anxiety and depression but yet different

Good performance in screening for separate dimensions of anxiety and depression in cases of anxiety disorders and depression in patients from nonpsychiatric hospital clinics

It has at least as good screening properties as similar as but more comprehensive instruments used for identification of anxiety disorders and depression

Simple and short Likert-scale scoring
Arbitrary symptom detection due to the constriction of breadth of content, which interferes with providing an efficient first stage screening

The depression subscale is weighted towards emotional aspects such as anhedonia rather than sadness; hence, it does not include physical nor cognitive symptoms or suicidal ideation

Weak in detecting mood disorders in contexts where many medically ill patients with no psychopathologies, including cardiac units

Its use as a depression severity measure is controversial, as cutoffs rely on a tight range

Just partially useful in determining whether symptomatology meets formal diagnostic criteria for an anxiety or depressive disorder

Its idiosyncratic conception of the core symptom of depression as being anhedonia leads to oversampling and lesser applicability to the mild to moderate range of sad or blue depression symptoms

Cognitive Behavioral Assessment Hospital
Forms
(CBA-H)
Bertolotti et al. [33]. Il CBA Forma Hospital. In E. Sanavio (Ed.), Le Scale CBA (pp. 158–234). Milano: Cortina152 itemsCard A investigates the emotional reactions at the exact same time of that of the test completion (i.e., hospitalization). It has three scales: state anxiety (A1), health fears (A2), and depressive reactions (A3)
Card B includes psychophysical states and sensations perceived by the patient during the previous three months.
Card C investigates the psychological variables related to patients’ personal traits
Card D analyses stable everyday-life behaviour (family/work relationships, general lifestyle)
Cards take into account different time lags, discriminating between emotional states and behavioural changes related to the recent hospitalization or health diagnosis and the patient’s preexisting characteristics
Final score includes both quantitative and in depth measures as well as suggestions for further interventions as shown patient’s global psychological profile which allows us to implement individual hypothesis for eventual additional clinical interview
Items in simple dichotomous form, organized into four tabs with simple answering system given by the true/false options

Hospital or health context-specific
The CBA-H, developed to allow a quicker assessment within the hospital or health context, has an overall long time completion
  
It is actually a battery of different tests which do not specifically address mood disorders and depressive symptomatology
Only Card A is specifically structured to analyse patients’ situational psychological state, such as those emotional reactions that the hospitalised individual experiences at the time of completion of the tests

Card A is therefore the mainly suitable section for patients who accesses a rehabilitation cardiac program as it enquires about feeling sheltered and being ill, though it may not be enough for clinicians to use the whole CBA-H or to entirely rely on it when assessing a target condition possibly accompanying cardiac patents such as depression

Beck Depression Inventory
(BDI-II)
Beck et al. [35]. Manual for the Beck Depression Inventory, 2nd ed. San Antonio, TX 21 itemsIt assesses the severity of 21 depression symptoms rated on a 4-point scale (0–3). 13 items address cognitive or affective symptoms (hopelessness and guilt). Two of them assess the cardinal symptoms of depression: depressed mood and loss of interest or pleasure in usual activities. The remaining 8 items assess somatic symptoms (insomnia, fatigue, and poor appetite). In screening uses, a total score of 10 or higher is the most widely used cutoff for clinically significant depression. BDI total scores of 10–18 are consistent with mild, 19–29 with moderate, and 30 or higher with severe depression

Strong test-retest reliability
Designed to measure depressive symptoms severity at the present time (i.e., hospitalisation)

It has a short time completion and does not require trained personnel

It pertains to the DSM-IV manual depression criteria, namely, agitation, worthlessness, concentration difficulty, and loss of energy

It has been supported by a consisted number of studies, and it is known to correspond with over 90% of clinical diagnoses for patients suffering from depression, hence, becoming a gold-standard tool

It adequately covers the range of conditions commonly exhibited by those with depression, measuring the severity of the ailment in an accurate manner, while meeting with recent medical and psychological standards

It measures depression intensity on a weekly bases, transversely to the types of depression and different diagnostic categories, as the depressive condition is considered as a psychological trait, therefore nonpathological. That is to say that the score can be analysed in a cognitive-affective subscale and a symptomatic-somatic one

Indications of a clinical cut-off alarm are very clear
It measures attitudes and cognitions which are fairly stable over time among depressed patients and may therefore underestimate the degree of improvement during acute pharmacological treatments

Because of self-reporting, it could imply participants exaggerating answers; heart disease patients may feel more despondent at the time of the test than they would normally

Not strictly suitable as a diagnostic tool as such, better used in conjunction with other tests in order to provide a proper analysis of patients’ current mental state

Patient
Health Questionnaire (PHQ-2 and PHQ-9)
Kroenke et al. [41]. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med, 16(9), 606–613

Kroenke et al. [42]. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care, 41(11), 1284–1292
2 or 9 itemsThe Patient Health Questionnaire (PHQ) is a self-administered diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as “0" (not at all) to “3" (nearly every day)

The PHQ-2 is a two-item depression screener which uses 2 items from the PHQ that inquire about the frequency of depressed mood and anhedonia over the past 2 weeks, scoring each as 0 (“not at all") to 3 (“nearly every day")
Both questionnaires are useful tools to recognize not only major depression but also subthreshold depressive disorder in all clinical and nonclinical samples

The PHQ-2 is a very simple and rapid yes/no screening tool targeting depression directly and potentially excluding nondepressed patients immediately. A more comprehensive clinical evaluation using the PHQ-9 can be administered simply in the case of a positive answer in the PHQ-2

The PHQ-9 is half the length of many other depression measures, and it refers to the nine criteria of the DSM-IV mood disorders diagnosis

The PHQ-9 can provide a depression diagnoses and give a precise value to its symptom severity without leaving out important aspects of health-related quality of life and functional status of hospitalised patients
  
Global score can account for a severity score which can be used for treatment selection and monitoring for coronary artery disease patients

Most patients are able to complete the PHQs with no assistance in 5 minutes or just over

Brevity and completion easiness are coupled with high construct and criterion validity
Followup of heart disease patients who showed mild sigh of depression is advised, while those with high depression scores should have a specialist reviewing the answers in order to gain a clearer picture

Remission signs must be viewed in a rules of thumb logic requiring clinical evaluation of the individual heart disease patient

Interview and Structured Hamilton (DISH)Freedland et al. [37]. The Depression Interview and Structured Hamilton (DISH): rationale, development, characteristics, and clinical validity. Psychosom Med, 64(6), 897–905 47 ItemsIt is a structured interview designed to diagnose major and minor depression. The 17-item Hamilton Rating Scale for Depression (HAM-D-17) is also embedded within the DISH to assess severity of depression. Nine of the HAM-D items are rated on a 0–2 scale, and eight are rated on a 0–4 scale. HAM-D total scores can range from 0 to 50. Among medical patients, DISH scores between 10 and 23 are consistent with mild depression and scores of 24 or higher with relatively severe depression

It has fair sensitivity to change
Designed to diagnose depression in medically ill patients and to assess its severity

DISH diagnosis agrees with the major and minor depressive disorders according to the DSM-IV criteria

It allows psychiatric comorbidity assessment
Designed to minimize respondent burden without losing thoroughness nor accuracy it fails to do so as on one hand some contents are option-rigid, while others are of personal preference

Symptoms terminology is not fixed and may not find accordance between the patient and the interviewer values or meaning

Symptom vary according to how long they last in weeks and they are coded separately according to the number of days they have been present for

Only assesses the cardinal symptoms of depression (dysphoria and anhedonia)

Rigorous training is needed to be able to subminister the interview

Much power is left to the interviewer who arbitrarily decides whether the patient’s terms intertwine with the DSM-IV criteria

Long time completion of 40 minutes or above

Many symptoms cannot be so easily disqualified. And may appear ambiguous symptoms like fatigue unless there is some affirmative evidence that they linked directly to depression

Hamilton Rating Scale
for Depression (HAM-D
or HRSD)
Williams [47]. A structured interview guide for the Hamilton Depression Rating Scale. Arch Gen Psychiatry, 45(8), 742–747 21 itemsThe hamilton depression rating scale is a 17-item scale that evaluates depressed mood, vegetative and cognitive symptoms of depression, and comorbid anxiety symptoms. It quantifies the severity of depressive symptomatology

It provides partial ratings on current DSM-IV symptoms of depression

The 17-items are rated on either a 5-point (0–4) or a 3-point (0–2) scale
  
Test-retest reliability for the HAM-D using the Structured Interview Guide is somehow controversial
The average duration of the HAM-D interviews is 12 minutes

It can be used as an indicator of symptoms remission after treatment
Its reliability is low due to use by lay interviewers; the final score is greatly influenced by appropriately trained interviewees

It focuses on depression gravity in patients who have already been diagnosed

It uses different rating attributed to different symptom domains (like insomnia coded up to 6 points, while fatigue only up to 2)

It relies too much on changes which may be related to physiological improvements underestimating emotional and cognitive aspects of depression and overestimating the role of pharmacotherapy

It does not have a full overlap with DSM-IV criteria of depression as it does not include exceptions of hypersomnia, increased appetite, and concentration/indecision

Noninclusion of all symptom domains related to major depressive disorder, reverse neurovegetative symptoms in particular

Some items measure constructs related to irritability and anxiety, loss of interest, and hopelessness which differ from ‘‘pure’’ depression and may be misleading

Composite International Diagnostic Interview (CIDI)Wittchen [49]. Reliability and validity studies of the WHO-Composite International Diagnostic Interview (CIDI): a critical review. J Psychiatr Res, 28(1), 57–84 276 ItemsA comprehensive and fully standardized diagnostic interview designed for assessing mental disorders with 276 symptom questions, many of which are coupled with probe questions to evaluate symptom severity, as well as questions for assessing help-seeking behavior, psychosocial impairments, and other episode-related questions It pertains to the syndromic definitions of mood disorders proposed by both ICD-10 and DSM IV

Designed to be used by trained interviewers who are not clinicians and it is therefore advantageous in subministration flexibility

Its diagnostic sections cover many areas and may be administered independently

It performs well as a research instrument to diagnose major depression in MI patients
Primarily intended for use in epidemiological studies of mental disorders hence not referring to hospitalised patients in particular

Inflexible and insensitive to change, as it emphasizes lifetime rather than current psychopathology

May underdiagnose depressive disorders compared to other instruments. It forces the respondent into a fixed-choice interview format and it may not prove to be a sound instrument within different cultural nor environmental contexts