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The Beck Depression Inventory (BDI-II) and a single screening question as screening tools for depressive disorder in Dutch advanced cancer patients

The Beck Depression Inventory (BDI-II) and a single screening question as screening tools for... Purpose Depression is highly prevalent in advanced cancer were eligible to be included in the study. Complete data patients, but the diagnosis of depressive disorder in patients were obtained from 46 patients. The area under the curve of with advanced cancer is difficult. Screening instruments the receiver operating characteristics analysis of the BDI-II could facilitate diagnosing depressive disorder in patients was 0.82. The optimal cut-off point of the BDI-II was 16 with advanced cancer. The aim of this study was to with a sensitivity of 90% and a specificity of 69%. The determine the validity of the Beck Depression Inventory single screening question showed a sensitivity of 50% and a (BDI-II) and a single screening question as screening tools specificity of 94%. for depressive disorder in advanced cancer patients. Conclusions The BDI-II seems an adequate screening tool Methods Patients with advanced metastatic disease, visiting for a depressive disorder in advanced cancer patients. The the outpatient palliative care department, were asked to fill sensitivity of a single screening question is poor. out a self-questionnaire containing the Beck Depression . . . Inventory (BDI-II) and a single screening question “Are Keywords Depression Advanced cancer Validation you feeling depressed?” The mood section of the PRIME- Screening tool BDI-II MD was used as a gold standard. Introduction : : F. Warmenhoven (*) Y. Engels K. Vissers Department of Anesthesiology, Pain and Palliative Medicine, Depression seems highly prevalent in patients with ad- Radboud University Nijmegen Medical Centre, vanced cancer. In different studies, a large variation of Huispost 630, P.O. Box 9101, 6500 HB, Nijmegen, prevalence of depression in advanced cancer (4% to 58%) The Netherlands is reported [1]. This large variation in prevalence can be e-mail: f.warmenhoven@anes.umcn.nl explained by the use of different research samples with E. van Rijswijk C. van Weel different risk factors like cancer type, age, sex, history of Department of Primary and Community Care, depression, alcohol abuses, and by the use of different Radboud University Nijmegen Medical Centre, assessment tools [2–4]. In some patients with advanced Nijmegen, The Netherlands cancer, a depressive disorder as defined in the DSM-IV can C. Kan be diagnosed, whereas others experience symptoms of Department of Psychiatry, depression and low mood but do not meet the diagnostic Radboud University Nijmegen Medical Centre, criteria of the DSM-IV. Both situations are associated with Nijmegen, The Netherlands a lower quality of life and consequently cause a burden for J. Prins the patient and his caregivers [5, 6]. Department of Medical Psychology, In patients with advanced cancer, several factors can Radboud University Nijmegen Medical Centre, influence the diagnostic process of depression. Firstly, Nijmegen, The Netherlands 320 Support Care Cancer (2012) 20:319–324 specific physical signs and symptoms presented in a patient provide a useful method for screening for depression in with advanced cancer, such as weight loss or fatigue, can palliative care [24–26]. This inventory is a self-report originate from advanced cancer or from depression [7]. questionnaire that was originally developed to rate the Physical symptoms and depressive symptoms may partly severity of depressive symptoms [27]. The BDI-II has share a common pathway of distress [8], which makes it shown good psychometric qualities as a screening tool for difficult to distinguish between cause and effect: physical depression. However, the BDI-II contains several items on symptoms may increase a depressed feeling on the one somatic symptoms of depression (for example, questions hand and on the other hand a depressed feeling may result about loss of energy, fatigue, and loss of appetite), which in more physical complaints [9, 10]. Secondly, it may be may lead to an overestimation of positive cases in a patient difficult to distinguish grief from depression in patients group with somatic illness. The BDI-II has been validated with advanced cancer [11]. Thirdly, for both patient and in many samples including cancer patients [28]. physician emotional issues are difficult to address in this The aim of the present study was to assess the validity of phase of life. Only a minority (17%) of advanced cancer the BDI-II and a single screening question as screening patients explicitly express their emotional distress to their tools for depression in Dutch-speaking patients with physician and physicians themselves do not often address advanced cancer. The hypothesis was that both the BDI-II emotional problems in conversations with advanced cancer and the single screening question are adequate screening patients, possibly because they do not feel well trained in tools for depressive disorders in Dutch advanced cancer communication with palliative care patients [12, 13, 17]. patients. The recognition of depression is not optimal for oncologists [14, 15] and other physicians as well [16] because of the reasons mentioned. If patients with advanced Methods cancer who are suffering from a depressive disorder are not identified, they will not be able to benefit from the Ethical approval and informed consent pharmacological and psychological treatments that are considered beneficial [16, 18, 19]. The study received approval of the medical ethical Screening instruments could facilitate recognizing de- committee of the Radboud University Nijmegen Medical pressive disorder in this population [20]. Systematic Centre. After obtaining informed consent, patients were screening for symptoms like depression fits into the asked to fill out a self-report questionnaire. Patients who principles of advanced care planning that is promoted in were unable to read and understand the Dutch language patients with advanced cancer or in need of palliative care were excluded from participating in this study. [21]. The ideal screening instrument combines a high sensitivity with a high specificity. When using a cut score Sample and design in a screening instrument, the optimal cut score for a specific patient group can be determined with a receiver From December 2003 until March 2007, all consecutive operating characteristics analysis. The usefulness of a patients with advanced, non-curable stages of metastatic screening tool depends on the positive and negative cancer referred to a new outpatient palliative care depart- predictive value considering the main aim of the screening. ment at the Radboud University Nijmegen Medical Centre When screening for depression in patients in a palliative were asked to participate in the study by their treating trajectory, given the vulnerability of these patients and the physician. Patients considered by their physician to be too consequences of depression for their health status and ill to participate were not asked. quality of life, a high negative predictive value seems most important. False positive cases can be ruled out in further Questionnaires and data collection diagnostic assessment. Recently, screening for depression with one or two simple Patients were asked to provide demographic information. questions was suggested to be highly specific [22], although The BDI-II and a single screening question “Are you different studies report different findings on psychometric feeling depressed?” were used to screen for depression. The values of short screening methods [23]. A short screening BDI-II is a 21-item self-report questionnaire with four method is appealing because the costs would be considerably response options for each item. Items of the BDI-II relate to lower than other methods for diagnosing depressive disorder; different symptoms of depression such as sadness, hope- it is time efficient and many people can be screened for lessness, self-blame, guilt, fatigue, and loss of appetite. On depression in a quick and simple way. each item, patients are asked to choose the statement that The Beck Depression inventory (BDI-II) is one of the best describes their attitude towards the item. Scores of the most widely used screening tools for depression and it may BDI-II can vary from 0 to 63 and are often classified as Support Care Cancer (2012) 20:319–324 321 follows: 0–13 no depression, 14–19 mild depression, 20–28 breast cancer, 8% head and neck cancer, 8% lung cancer, moderate depression, and 29–63 severe depression [29]. 45% some other malignancy). Of the 61 eligible patients, Patients were asked to fill out the questionnaire during 20 patients (33%) deceased within 6 months. Seven eligible their visit at the outpatient department or at home. The patients refused to participate in the study. mood section of the PRIME-MD [30] was administered as Among the 54 patients who enrolled in the study, a gold standard for the clinical diagnosis of a depressive administration of the PRIME-MD was not completed in eight disorder by the physician, who was blind to the results of patients (Fig. 1). Therefore, complete data were obtained of the questionnaire. The PRIME-MD is a structured interview 46 patients (26 women, 20 men, mean age 60 years, median based on the DSM-IV classification for depressive disorder age 58 years). The mean BDI-II score of the 46 patients who and has been validated in oncology patients [31]. The participated in the study was 14.7 (SD 9.9). PRIME-MD provides standardized questions that focus Ten out of 46 patients (22%) were diagnosed with a directly on key diagnostic symptoms and a depressive major depressive disorder using the PRIME-MD. The area disorder was diagnosed when patients fulfilled the DSM-IV under the curve (AUC) of the ROC analysis of the BDI-II criteria. The time required to complete the PRIME-MD was 0.82 (Fig. 2). Using the traditional cut score of 14, the mood section is approximately 10 min. BDI-II demonstrated 90% sensitivity and 64% specificity. The positive and negative predictive values were 45% and Statistical analysis 97%, respectively. However, using a higher cut score of 16 retained high sensitivity (90%) while increasing specificity Statistical analysis was performed with SPSS 16.0. Means, to 69%. The positive and negative predictive values were sensitivity, specificity, and positive and negative predictive 55% and 96%, respectively. The single screening question value were computed. A receiver operating characteristics demonstrated 50% sensitivity and 94% specificity. The (ROC) analysis was performed to determine the optimal cut positive and negative predictive values of the single score for the BDI-II as a screen for depression in this screening question were 71% and 87%, respectively population. (Table 1). Results Discussion From December 2003 until March 2007, 61 patients (29 This study shows that the BDI-II is an adequate screening men, 32 women) were eligible to be included in the study. tool to detect depressive disorder in patients with advanced cancer. Using a cut-off point of 16, it has The inclusion period of this study has been relatively long because the outpatient department for palliative care good sensitivity (90%) and acceptable specificity (69%). patients was a new facility in the hospital and, consequent- The single screening question performed unsatisfactory, ly, referral numbers were low. Patients suffered from a demonstrating only 50% sensitivity and 94% specificity. variety of advanced cancers (23% colon carcinoma, 16% Given the consequences of not recognizing a depression N= 61 eligible patients N=7 refusal N=54 participation N=46 complete data N=8 no gold standard obtained (single obtained screening question, BDI-II, PRIME-MD) Fig. 1 Inclusion of patients 322 Support Care Cancer (2012) 20:319–324 the somatic items (e.g., weight loss, loss of appetite, etc.). 1,0 The Beck Depression Inventory Short Form (BDI-SF), consisting of seven items tapping exclusively affective 0,8 symptoms, might be more appropriate for this population. Love et al. performed a study in 227 women with metastatic breast disease in which the BDI-SF had a 0,6 specificity of 63% and a positive predictive value of 0.52 [33]. This needs further study to determine the psychomet- 0,4 ric properties in a more heterogeneous patient group. The sensitivity of the single screening question in this 0,2 study appeared 50%, which is almost similar to the reported sensitivity of 55% in an earlier study in 74 palliative care 0,0 patients [34]. Other previous studies, however, report a 0,0 0,2 0,4 0,6 0,8 1,0 much higher sensitivity of a single screening question in 1 - Specificity palliative care patients (72–100%) [23, 35]. The low Fig. 2 Receiving operating characteristic beck depression inventory sensitivity of the single screening question in this study (BDI-II) may point to difficulties regarding the meaning of the question. The word depression knows different translations and different interpretations in the Dutch language. The in this vulnerable patient group and the possibility to rule exact words that have been used might have influenced the out depression in further diagnostic assessment in results [36]. patients who screen positive for depression, a high This study has some limitations. Firstly, the relatively sensitivity and high negative predictive value of screen- small sample size was recruited from the recently started ing tools are important and a lower specificity and outpatient department for palliative care. Small sample size positive predictive value are accepted. is not unusual in palliative care, in which recruitment is The results of this study differ somewhat from previous difficult and dropout rates are high due to deterioration of findings on psychometric properties of the Beck Depression health status and death. Secondly, the selection of participants Inventory in a cancer patient sample. Katz et al. found that in this study was performed by the treating physician. The with a cut score of 16 the BDI had a sensitivity of 73% and number of patients that the physicians considered too ill to specificity of 100% in a sample of 60 ambulatory patients participate was not recorded. In general, though, the partici- with a malignancy of the head and neck region and pation of patients in research is high, when their “personal” identified the optimum cut score at 13 with a sensitivity treating physician invites them for participation, but it might of 92% and a specificity of 90% [32]. In the present study, introduce selection bias if the physician leaves out highly the participants originated from a heterogeneous group of distressed patients. Given the relatively high scores on the patients with advanced cancer, whereas Katz et al. used a BDI-II in this sample, severe bias seems unlikely. Thirdly, we more homogeneous group of ambulatory head and neck used the PRIME-MD as a gold standard. The PRIME-MD and cancer patients. Furthermore, Katz et al. used a different other psychiatric interviews are not validated for advanced instrument, the Schedule for Affective Disorders and cancer patients specifically. However, they have been Schizophrenia, as a gold standard. validated in cancer patients [31]. A possible shortcoming of the BDI-II as a screening tool This study offers a contribution to the diagnosis and in advanced cancer patients is that the number of identified screening of depressive disorder in advanced cancer cases could be overestimated because of the somatic items patients. The Beck Depression Inventory offers a method of the questionnaire. The specificity of the BDI-II in for brief and sensitive detection of depressive disorder in advanced cancer patients might be increased by excluding this specific group of patients. If used systematically in Table 1 Psychometric properties of single screening question and BDI-II Sensitivity (%) Specificity (%) Positive predictive value (%) Negative predictive value (%) Single screening question 50 69 71 87 BDI-II (cut score 14) 90 64 45 97 BDI-II (cut score 16) 90 69 55 96 Sensitivity Support Care Cancer (2012) 20:319–324 323 6. Henoch I, Bergman B, Gustafsson M, Gaston-Johansson F, all advanced cancer patients, this screening tool may increase Danielson E (2007) The impact of symptoms, coping capacity, and improve physician’s evaluations of not only somatic, but and social support on quality of life experience over time in also psychological complaints of their patients. patients with lung cancer. J Pain Symptom Manage 34:370– To our knowledge, this is the first validation study of the 379 7. Hotopf M, Chidgey J, Ddington-Hall J, Ly KL (2002) Depression Dutch Beck Depression Inventory and of a single screening in advanced disease: a systematic review. Part 1. Prevalence and question to screen for depression in a heterogeneous group case finding. Palliat Med 16:81–97 of advanced cancer patients. Secondly, it gives a prevalence 8. Lo C, Zimmermann C, Rydall A, Walsh A, Jones JM, Moore MJ, of depression in advanced cancer patients, based on a Shepherd FA, Gagliese L, Rodin G (2010) Longitudinal study of depressive symptoms in patients with metastatic gastrointestinal clinical diagnosis with the PRIME-MD, contrary to and lung cancer. J Clin Oncol 28:3084–3089 prevalence numbers acquired by questionnaires. In clinical 9. Jacobsen PB, Donovan KA, Weitzner MA (2003) Distinguishing practice, the screening tool can serve to alert physicians to fatigue and depression in patients with cancer. Semin Clin the possibility of depressive disorder and hence give Neuropsychiatry 8:229–240 10. Raison AH, Miller CL (2003) Depression in cancer: new attention to the mental health status of palliative care developments regarding diagnosis and treatment. Biol Psychiatry patients, if necessary followed by further diagnostic 54:283–294 assessment and appropriate treatment. 11. Periyakoil J, Hallenbeck VS (2002) Identifying and managing preparatory grief and depression at the end of life. Am Fam Physician 65:883–890 12. Anderson WG, Alexander SC, Rodriguez KL, Jeffreys AS, Conclusions Olsen MK, Pollak KI, Tulsky JA, Arnold RM (2008) What concerns me is. Expression of emotion by advanced cancer The BDI-II seems to be an adequate screening tool for patients during outpatient visits. Support Care Cancer 16:803– depressive disorders in Dutch advanced cancer patients 13. Pollak KI, Arnold RM, Jeffreys AS, Alexander SC, Olsen when using a cut score of 16. The single screening question MK, Abernethy AP, Sugg SC, Rodriguez KL, Tulsky JA is less adequate to detect depression in palliative care (2007) Oncologist communication about emotion during visits patients, considering the low sensitivity. with patients with advanced cancer. J Clin Oncol 25:5748– Diagnosing depression in patients with advanced cancer 14. Newell S, Sanson-Fisher RW, Girgis A, Bonaventura A (1998) remains a challenge. Using a valid screening tool can How well do medical oncologists’ perceptions reflect their facilitate the process of diagnosing depression in this patients’ reported physical and psychosocial problems? Data from specific group of patients. a survey of five oncologists. Cancer 83:1640–1651 15. Passik SD, Dugan W, McDonald MV, Rosenfeld B, Theobald DE, Edgerton S (1998) Oncologists’ recognition of depression in their patients with cancer. J Clin Oncol 16:1594–1600 Conflict of interest The authors declare no conflict of interest 16. Lloyd-Williams M (2000) Difficulties in diagnosing and treating relating to this manuscript. The authors have full control of the depression in the terminally ill cancer patient. Postgrad Med J primary data and the data can be reviewed on request. 76:555–558 17. Barclay S, Wyatt P, Shore S, Finlay I, Grande G, Todd C (2003) Caring for the dying: how well prepared are general practitioners? A questionnaire study in Wales. Palliat Med 17:27–39 Open Access This article is distributed under the terms of the 18. Akechi T, Okuyama T, Onishi J, Morita T, Furukawa TA (2008) Creative Commons Attribution Noncommercial License which per- Psychotherapy for depression among incurable cancer patients. mits any noncommercial use, distribution, and reproduction in any Cochrane Database Syst Rev (2):CD005537 medium, provided the original author(s) and source are credited. 19. Hopko DR, Robertson SM, Carvalho JP (2009) Sudden gains in depressed cancer patients treated with behavioral activation therapy. Behav Ther 40:346–356 References 20. Kelly B, McClement S, Chochinov HM (2006) Measurement of psychological distress in palliative care. Palliat Med 20:779– 1. Stiefel R, Die TM, Berney A, Olarte JM, Razavi A (2001) 21. Murray SA, Sheikh A, Thomas K (2006) Advance care planning Depression in palliative care: a pragmatic report from the Expert in primary care. BMJ 333:868–869 Working Group of the European Association for Palliative Care. 22. Arroll B, Goodyear-Smith F, Kerse N, Fishman T, Gunn J (2005) Support Care Cancer 9:477–488 Effect of the addition of a “help” question to two screening 2. Kelly J, Turner BJ (2009) Depression in advanced physical questions on specificity for diagnosis of depression in general illness: diagnostic and treatment issues. Med J Aust 190:S90–S93 practice: diagnostic validity study. BMJ 331:884 3. Massie MJ (2004) Prevalence of depression in patients with 23. Mitchell AJ, Kaar S, Coggan C, Herdman J (2008) Acceptability cancer. J Natl Cancer Inst Monogr (32):57–71 of common screening methods used to detect distress and related 4. Reeve JL, Lloyd-Williams M, Dowrick C (2008) Revisiting mood disorders—preferences of cancer specialists and non- depression in palliative care settings: the need to focus on clinical specialists. Psychooncology 17:226–236 utility over validity. Palliat Med 22:383–391 24. Richter P, Werner J, Heerlein A, Kraus A, Sauer H (1998) On the 5. Chochinov HM, Kristjanson LJ, Hack TF, Hassard T, McClement validity of the Beck Depression Inventory. A review. Psychopa- S, Harlos M (2007) Burden to others and the terminally ill. J Pain thology 31:160–168 Symptom Manage 34:463–471 324 Support Care Cancer (2012) 20:319–324 25. Mystakidou K, Tsilika E, Parpa E, Smyrniotis V, Galanos A, 31. Leopold KA, Ahles TA, Walch S, Amdur RJ, Mott LA, Wiegand- Vlahos L (2007) Beck Depression Inventory: exploring its Packard L, Oxman TE (1998) Prevalence of mood disorders and psychometric properties in a palliative care population of utility of the PRIME-MD in patients undergoing radiation therapy. advanced cancer patients. Eur J Cancer Care Engl 16:244– Int J Radiat Oncol Biol Phys 42:1105–1112 250 32. Katz MR, Kopek N, Waldron J, Devins GM, Tomlinson G (2004) 26. Vodemaier A, Linden W, Siu C (2009) Screening for emotional Screening for depression in head and neck cancer. Psychooncology distress in cancer patients: a systematic review of assessment 13:269–280 instruments. J Natl Cancer Inst 101:1464–1488 33. Love AW, Grabsch B, Clarke DM, Bloch S, Kissane DW (2004) 27. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J (1961) An Screening for depression in women with metastatic breast cancer: inventory for measuring depression. Arch Gen Psychiatry 4:561– a comparison of the Beck Depression Inventory Short Form and 571 the Hospital Anxiety and Depression Scale. Aust N Z J Psychiatry 28. Hopko DR, Bell JL, Armento ME, Robertson SM, Hunt MK, 38:526–531 Wolf NJ, Mullane C (2008) The phenomenology and screening of 34. Lloyd-Williams M, Dennis M, Taylor F (2004) A prospective clinical depression in cancer patients. J Psychosoc Oncol 26:31– study to compare three depression screening tools in patients who 51 are terminally ill. Gen Hosp Psychiatry 26:384–389 29. Beck AT, Steer RA, Brown GK (1996) Manual for the Beck 35. Chochinov HM, Wilson KG, Enns M, Lander S (1997) “Are you Depression Inventory-II. Ref Type: Report depressed?” Screening for depression in the terminally ill. Am J 30. Fraguas R Jr, Henriques SG Jr, De Lucia MS, Iosifescu DV, Psychiatry 154:674–676 Schwartz FH, Menezes PR, Gattaz WF, Martins MA (2006) The 36. Noguera A, Centeno C, Carvajal A, Tejedor MA, Urdiroz J, detection of depression in medical setting: a study with PRIME- Martinez M (2009) Spanish “fine tuning” of language to describe MD. J Affect Disord 91:11–17 depression and anxiety. J Palliat Med 12:707–712 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Supportive Care in Cancer Pubmed Central

The Beck Depression Inventory (BDI-II) and a single screening question as screening tools for depressive disorder in Dutch advanced cancer patients

Supportive Care in Cancer , Volume 20 (2) – Jan 18, 2011

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Pubmed Central
Copyright
© The Author(s) 2011
ISSN
0941-4355
eISSN
1433-7339
DOI
10.1007/s00520-010-1082-8
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Abstract

Purpose Depression is highly prevalent in advanced cancer were eligible to be included in the study. Complete data patients, but the diagnosis of depressive disorder in patients were obtained from 46 patients. The area under the curve of with advanced cancer is difficult. Screening instruments the receiver operating characteristics analysis of the BDI-II could facilitate diagnosing depressive disorder in patients was 0.82. The optimal cut-off point of the BDI-II was 16 with advanced cancer. The aim of this study was to with a sensitivity of 90% and a specificity of 69%. The determine the validity of the Beck Depression Inventory single screening question showed a sensitivity of 50% and a (BDI-II) and a single screening question as screening tools specificity of 94%. for depressive disorder in advanced cancer patients. Conclusions The BDI-II seems an adequate screening tool Methods Patients with advanced metastatic disease, visiting for a depressive disorder in advanced cancer patients. The the outpatient palliative care department, were asked to fill sensitivity of a single screening question is poor. out a self-questionnaire containing the Beck Depression . . . Inventory (BDI-II) and a single screening question “Are Keywords Depression Advanced cancer Validation you feeling depressed?” The mood section of the PRIME- Screening tool BDI-II MD was used as a gold standard. Introduction : : F. Warmenhoven (*) Y. Engels K. Vissers Department of Anesthesiology, Pain and Palliative Medicine, Depression seems highly prevalent in patients with ad- Radboud University Nijmegen Medical Centre, vanced cancer. In different studies, a large variation of Huispost 630, P.O. Box 9101, 6500 HB, Nijmegen, prevalence of depression in advanced cancer (4% to 58%) The Netherlands is reported [1]. This large variation in prevalence can be e-mail: f.warmenhoven@anes.umcn.nl explained by the use of different research samples with E. van Rijswijk C. van Weel different risk factors like cancer type, age, sex, history of Department of Primary and Community Care, depression, alcohol abuses, and by the use of different Radboud University Nijmegen Medical Centre, assessment tools [2–4]. In some patients with advanced Nijmegen, The Netherlands cancer, a depressive disorder as defined in the DSM-IV can C. Kan be diagnosed, whereas others experience symptoms of Department of Psychiatry, depression and low mood but do not meet the diagnostic Radboud University Nijmegen Medical Centre, criteria of the DSM-IV. Both situations are associated with Nijmegen, The Netherlands a lower quality of life and consequently cause a burden for J. Prins the patient and his caregivers [5, 6]. Department of Medical Psychology, In patients with advanced cancer, several factors can Radboud University Nijmegen Medical Centre, influence the diagnostic process of depression. Firstly, Nijmegen, The Netherlands 320 Support Care Cancer (2012) 20:319–324 specific physical signs and symptoms presented in a patient provide a useful method for screening for depression in with advanced cancer, such as weight loss or fatigue, can palliative care [24–26]. This inventory is a self-report originate from advanced cancer or from depression [7]. questionnaire that was originally developed to rate the Physical symptoms and depressive symptoms may partly severity of depressive symptoms [27]. The BDI-II has share a common pathway of distress [8], which makes it shown good psychometric qualities as a screening tool for difficult to distinguish between cause and effect: physical depression. However, the BDI-II contains several items on symptoms may increase a depressed feeling on the one somatic symptoms of depression (for example, questions hand and on the other hand a depressed feeling may result about loss of energy, fatigue, and loss of appetite), which in more physical complaints [9, 10]. Secondly, it may be may lead to an overestimation of positive cases in a patient difficult to distinguish grief from depression in patients group with somatic illness. The BDI-II has been validated with advanced cancer [11]. Thirdly, for both patient and in many samples including cancer patients [28]. physician emotional issues are difficult to address in this The aim of the present study was to assess the validity of phase of life. Only a minority (17%) of advanced cancer the BDI-II and a single screening question as screening patients explicitly express their emotional distress to their tools for depression in Dutch-speaking patients with physician and physicians themselves do not often address advanced cancer. The hypothesis was that both the BDI-II emotional problems in conversations with advanced cancer and the single screening question are adequate screening patients, possibly because they do not feel well trained in tools for depressive disorders in Dutch advanced cancer communication with palliative care patients [12, 13, 17]. patients. The recognition of depression is not optimal for oncologists [14, 15] and other physicians as well [16] because of the reasons mentioned. If patients with advanced Methods cancer who are suffering from a depressive disorder are not identified, they will not be able to benefit from the Ethical approval and informed consent pharmacological and psychological treatments that are considered beneficial [16, 18, 19]. The study received approval of the medical ethical Screening instruments could facilitate recognizing de- committee of the Radboud University Nijmegen Medical pressive disorder in this population [20]. Systematic Centre. After obtaining informed consent, patients were screening for symptoms like depression fits into the asked to fill out a self-report questionnaire. Patients who principles of advanced care planning that is promoted in were unable to read and understand the Dutch language patients with advanced cancer or in need of palliative care were excluded from participating in this study. [21]. The ideal screening instrument combines a high sensitivity with a high specificity. When using a cut score Sample and design in a screening instrument, the optimal cut score for a specific patient group can be determined with a receiver From December 2003 until March 2007, all consecutive operating characteristics analysis. The usefulness of a patients with advanced, non-curable stages of metastatic screening tool depends on the positive and negative cancer referred to a new outpatient palliative care depart- predictive value considering the main aim of the screening. ment at the Radboud University Nijmegen Medical Centre When screening for depression in patients in a palliative were asked to participate in the study by their treating trajectory, given the vulnerability of these patients and the physician. Patients considered by their physician to be too consequences of depression for their health status and ill to participate were not asked. quality of life, a high negative predictive value seems most important. False positive cases can be ruled out in further Questionnaires and data collection diagnostic assessment. Recently, screening for depression with one or two simple Patients were asked to provide demographic information. questions was suggested to be highly specific [22], although The BDI-II and a single screening question “Are you different studies report different findings on psychometric feeling depressed?” were used to screen for depression. The values of short screening methods [23]. A short screening BDI-II is a 21-item self-report questionnaire with four method is appealing because the costs would be considerably response options for each item. Items of the BDI-II relate to lower than other methods for diagnosing depressive disorder; different symptoms of depression such as sadness, hope- it is time efficient and many people can be screened for lessness, self-blame, guilt, fatigue, and loss of appetite. On depression in a quick and simple way. each item, patients are asked to choose the statement that The Beck Depression inventory (BDI-II) is one of the best describes their attitude towards the item. Scores of the most widely used screening tools for depression and it may BDI-II can vary from 0 to 63 and are often classified as Support Care Cancer (2012) 20:319–324 321 follows: 0–13 no depression, 14–19 mild depression, 20–28 breast cancer, 8% head and neck cancer, 8% lung cancer, moderate depression, and 29–63 severe depression [29]. 45% some other malignancy). Of the 61 eligible patients, Patients were asked to fill out the questionnaire during 20 patients (33%) deceased within 6 months. Seven eligible their visit at the outpatient department or at home. The patients refused to participate in the study. mood section of the PRIME-MD [30] was administered as Among the 54 patients who enrolled in the study, a gold standard for the clinical diagnosis of a depressive administration of the PRIME-MD was not completed in eight disorder by the physician, who was blind to the results of patients (Fig. 1). Therefore, complete data were obtained of the questionnaire. The PRIME-MD is a structured interview 46 patients (26 women, 20 men, mean age 60 years, median based on the DSM-IV classification for depressive disorder age 58 years). The mean BDI-II score of the 46 patients who and has been validated in oncology patients [31]. The participated in the study was 14.7 (SD 9.9). PRIME-MD provides standardized questions that focus Ten out of 46 patients (22%) were diagnosed with a directly on key diagnostic symptoms and a depressive major depressive disorder using the PRIME-MD. The area disorder was diagnosed when patients fulfilled the DSM-IV under the curve (AUC) of the ROC analysis of the BDI-II criteria. The time required to complete the PRIME-MD was 0.82 (Fig. 2). Using the traditional cut score of 14, the mood section is approximately 10 min. BDI-II demonstrated 90% sensitivity and 64% specificity. The positive and negative predictive values were 45% and Statistical analysis 97%, respectively. However, using a higher cut score of 16 retained high sensitivity (90%) while increasing specificity Statistical analysis was performed with SPSS 16.0. Means, to 69%. The positive and negative predictive values were sensitivity, specificity, and positive and negative predictive 55% and 96%, respectively. The single screening question value were computed. A receiver operating characteristics demonstrated 50% sensitivity and 94% specificity. The (ROC) analysis was performed to determine the optimal cut positive and negative predictive values of the single score for the BDI-II as a screen for depression in this screening question were 71% and 87%, respectively population. (Table 1). Results Discussion From December 2003 until March 2007, 61 patients (29 This study shows that the BDI-II is an adequate screening men, 32 women) were eligible to be included in the study. tool to detect depressive disorder in patients with advanced cancer. Using a cut-off point of 16, it has The inclusion period of this study has been relatively long because the outpatient department for palliative care good sensitivity (90%) and acceptable specificity (69%). patients was a new facility in the hospital and, consequent- The single screening question performed unsatisfactory, ly, referral numbers were low. Patients suffered from a demonstrating only 50% sensitivity and 94% specificity. variety of advanced cancers (23% colon carcinoma, 16% Given the consequences of not recognizing a depression N= 61 eligible patients N=7 refusal N=54 participation N=46 complete data N=8 no gold standard obtained (single obtained screening question, BDI-II, PRIME-MD) Fig. 1 Inclusion of patients 322 Support Care Cancer (2012) 20:319–324 the somatic items (e.g., weight loss, loss of appetite, etc.). 1,0 The Beck Depression Inventory Short Form (BDI-SF), consisting of seven items tapping exclusively affective 0,8 symptoms, might be more appropriate for this population. Love et al. performed a study in 227 women with metastatic breast disease in which the BDI-SF had a 0,6 specificity of 63% and a positive predictive value of 0.52 [33]. This needs further study to determine the psychomet- 0,4 ric properties in a more heterogeneous patient group. The sensitivity of the single screening question in this 0,2 study appeared 50%, which is almost similar to the reported sensitivity of 55% in an earlier study in 74 palliative care 0,0 patients [34]. Other previous studies, however, report a 0,0 0,2 0,4 0,6 0,8 1,0 much higher sensitivity of a single screening question in 1 - Specificity palliative care patients (72–100%) [23, 35]. The low Fig. 2 Receiving operating characteristic beck depression inventory sensitivity of the single screening question in this study (BDI-II) may point to difficulties regarding the meaning of the question. The word depression knows different translations and different interpretations in the Dutch language. The in this vulnerable patient group and the possibility to rule exact words that have been used might have influenced the out depression in further diagnostic assessment in results [36]. patients who screen positive for depression, a high This study has some limitations. Firstly, the relatively sensitivity and high negative predictive value of screen- small sample size was recruited from the recently started ing tools are important and a lower specificity and outpatient department for palliative care. Small sample size positive predictive value are accepted. is not unusual in palliative care, in which recruitment is The results of this study differ somewhat from previous difficult and dropout rates are high due to deterioration of findings on psychometric properties of the Beck Depression health status and death. Secondly, the selection of participants Inventory in a cancer patient sample. Katz et al. found that in this study was performed by the treating physician. The with a cut score of 16 the BDI had a sensitivity of 73% and number of patients that the physicians considered too ill to specificity of 100% in a sample of 60 ambulatory patients participate was not recorded. In general, though, the partici- with a malignancy of the head and neck region and pation of patients in research is high, when their “personal” identified the optimum cut score at 13 with a sensitivity treating physician invites them for participation, but it might of 92% and a specificity of 90% [32]. In the present study, introduce selection bias if the physician leaves out highly the participants originated from a heterogeneous group of distressed patients. Given the relatively high scores on the patients with advanced cancer, whereas Katz et al. used a BDI-II in this sample, severe bias seems unlikely. Thirdly, we more homogeneous group of ambulatory head and neck used the PRIME-MD as a gold standard. The PRIME-MD and cancer patients. Furthermore, Katz et al. used a different other psychiatric interviews are not validated for advanced instrument, the Schedule for Affective Disorders and cancer patients specifically. However, they have been Schizophrenia, as a gold standard. validated in cancer patients [31]. A possible shortcoming of the BDI-II as a screening tool This study offers a contribution to the diagnosis and in advanced cancer patients is that the number of identified screening of depressive disorder in advanced cancer cases could be overestimated because of the somatic items patients. The Beck Depression Inventory offers a method of the questionnaire. The specificity of the BDI-II in for brief and sensitive detection of depressive disorder in advanced cancer patients might be increased by excluding this specific group of patients. If used systematically in Table 1 Psychometric properties of single screening question and BDI-II Sensitivity (%) Specificity (%) Positive predictive value (%) Negative predictive value (%) Single screening question 50 69 71 87 BDI-II (cut score 14) 90 64 45 97 BDI-II (cut score 16) 90 69 55 96 Sensitivity Support Care Cancer (2012) 20:319–324 323 6. Henoch I, Bergman B, Gustafsson M, Gaston-Johansson F, all advanced cancer patients, this screening tool may increase Danielson E (2007) The impact of symptoms, coping capacity, and improve physician’s evaluations of not only somatic, but and social support on quality of life experience over time in also psychological complaints of their patients. patients with lung cancer. J Pain Symptom Manage 34:370– To our knowledge, this is the first validation study of the 379 7. Hotopf M, Chidgey J, Ddington-Hall J, Ly KL (2002) Depression Dutch Beck Depression Inventory and of a single screening in advanced disease: a systematic review. Part 1. Prevalence and question to screen for depression in a heterogeneous group case finding. Palliat Med 16:81–97 of advanced cancer patients. Secondly, it gives a prevalence 8. 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Journal

Supportive Care in CancerPubmed Central

Published: Jan 18, 2011

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