Psychiatry and Primary CareUse of the Beck depression inventory for primary care to screen for major depression disorders
Introduction
The prevalence of clinical depression in primary care outpatients has been estimated by Katon and Schulberg [1] as ranging from 5% to 10%, but a 1991 national survey of 75,858 patients being treated by family practice physicians indicated that clinically significant symptoms of depression were described by approximately 21% [2]. For medical patients with chronic diseases, such as coronary heart disease (CHD) or cancer, the prevalence of clinical depression is higher and varies with respect to specific diseases. For example, the rate of major depressive disorder (MDD) may be as high as 40% in patients with CHD and approximately 25% for cancer patients in general [3]. It is important to screen medical patients for depression because depression not only complicates their overall medical treatments [4], but also impedes their physical and social functioning [5]. However, primary care physicians underdiagnose clinical depression [6], even though a variety of rapidly administered instruments are available to help them screen for it [7].
In reviewing studies about nine widely used depression-screening instruments, Mulrow et al. [8] reported that the average rates of sensitivity and specificity were, respectively, 84% and 72%. Subsequently, Whooley et al. [9] administered a battery of six depression-screening instruments to 536 patients presenting to an urgent care clinic and found that the rates of sensitivity and specificity for diagnosing MDD ranged, from 89% to 96% and 51% to 72%, respectively. The lower rate of specificity for such instruments is attributable to the somatic and performance symptoms of depression overlapping with the types of symptoms that frequently occur in medical illnesses, such as fatigue and loss of appetite 10, 11, 12.
The Beck Depression Inventory for Primary Care (BDI-PC) [13] is a screening instrument for depression that minimizes the possibility of yielding spuriously high estimates of depression for patients with medical problems by focusing on symptoms of sadness, pessimism, past failure, loss of pleasure (anhedonia), self-dislike, self-criticalness, and suicidal thoughts or wishes. Its seven items are drawn from the Beck Depression Inventory-II [14] which reflects Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) [15] criteria for MDD. Each item is rated on a 4-point scale ranging from 0 to 3, and the BDI-PC is scored by summing up all of the highest ratings for each of its seven items. To address the minimum DSM-IV requirement for the duration of MDD symptoms, respondents are asked to describe themselves for the “past 2 weeks, including today.”
Several studies using the Mood Module (MM) from the Primary Care Evaluation of Mental Disorders (PRIME-MD) [16] to diagnose MDD have found that the BDI-PC afforded higher rates of specificity for identifying medical patients without MDD than the average rate of 72% that Mulrow et al. [8] reported for nine other instruments. For example, with 50 medical inpatients who were referred for psychiatric consultations and whose mean age was 39.72 (SD 16.81) years, Beck et al. [13] found that a BDI-PC cutoff score of 4 and above yielded both 82% sensitivity and specificity rates for identifying inpatients with and without MDD. When the BDI-PC was administered to 56 family practice outpatients whose mean age was 48.54 (SD 15.52) years, Beck et al. [17] reported that a BDI-PC cutoff score of 6 and above had sensitivity and specificity rates of 83% and 95%, respectively, for differentiating those with and those without MDD. However, it was subsequently determined that 22 (39%) of these outpatients had no current medical problems. More recently, the BDI-PC was used by Winters et al. [18] with 100 adolescents (12–17 years old) who received pediatric health-maintenance examinations, and a BDI-PC cutoff score of 4 and above had both 91% sensitivity and specificity rates respectively, for identifying adolescents with and without MDD. BDI-PC total scores have also been described as not being correlated with sex, age, or ethnicity 13, 17, 18.
The purpose of the present study was to determine how effective the BDI-PC would be in screening outpatients for MDD who were scheduled to be evaluated by physicians specializing in internal medicine. It was assumed that outpatients seeking treatment from internal medicine specialists would more likely be diagnosed with more chronic and comorbid medical disorders than the family practice outpatients who had been previously studied by Beck et al. [17] and thus reflect a higher prevalence of clinical depression 19, 20.
Section snippets
Sample
The sample was composed of 120 outpatients, 60 (50%) men and 60 (50%) women, who made consecutive office visits to see faculty physicians in the Department of Medicine at the University of Medicine and Dentistry of New Jersey’s School of Osteopathic Medicine. The Department is located in Stratford, NJ, and the present patients were evaluated by physicians specializing in General Internal Medicine, Hematology/Oncology, Pulmonary Medicine, and Rheumatology. Stratford is a suburban, predominately
Results
The mean BDI-PC score for the total sample of 120 outpatients was 2.18 (SD 2.96), and the mean BDI-PC score was 6.55 (SD 2.53) for the 29 (24%) outpatients who were diagnosed with MDD. Therefore, the mean BDI-PC score of the 29 outpatients with MDD was approximately 8.3 times higher than the mean BDI-PC score (M 0.79, SD 1.21) of the 91 outpatients without MDD, Welch’s t’ (32) = 11.84, p < 0.001. Furthermore, the mean BDI-PC score of the 29 outpatients with MDD was comparable not only to the
Discussion
The overall pattern of results supports similar findings about the clinical utility of the BDI-PC with respect to medical inpatients [13], family practice outpatients [17], and pediatric adolescent outpatients [18]. The BDI-PC was again not significantly related to sex, age, or ethnicity. The present results confirmed that the internal consistency of the BDI-PC is high (coefficient alpha 0.85) and also found that the BDI-PC was not correlated with whether or not an internal medicine specialist
Acknowledgements
The authors thank Roxanne Chiariello and David A. Logan for their help with data collection.
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