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Satellite Healthcare, San Jose, California, USA; 2Division 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 Inventory-Fast Screen (BDI-FS) with the Beck Depression Inventory-II (BDI-II) as depression
screening tool in conventional hemodialysis (CHD) patients. One hundred sixty two CHD patients
were studied with both screening questionnaires. We used the Pearson Correlation Coefcient 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, receiver
operating characteristics showed the best balance between sensitivity and specicity for the BDI-FS
cutoff value of 4 with a sensitivity of 97.2% (95% condence interval [CI]: 85.5%, 99.9%) and a
specicity 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 efcient and effective tool for depression
screening in ESRD patients which can be easily implemented in routine dialysis care.
Key words: Depression screening, end-stage renal disease, hemodialysis, Beck Depression
Inventory
INTRODUCTION
Depression has been recognized to be among the most
common psychological disorders in end-stage renal
disease (ESRD) patients.1,2 Recent investigations suggest
that 2030% of the maintenance dialysis population in
the United States and Europe is affected by depression.35
Depressive symptoms and the psychological effects of
Correspondence to: A. Neitzer, MSD, Satellite Healthcare,
300 Santana Row, Suite 300, San Jose, CA 95128, USA.
E-mail: neitzera@satellitehealth.com
depression are strongly associated with increased hospitalization rates, impaired medical outcomes, and
mortality.68
Prevalence estimates vary depending on the populations 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
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Neitzer et al.
208
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
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Neitzer et al.
Figure 2 Receiver/Responder Operating Characteristic (ROC) curve to assess a reliable cutoff value for BDI-FS (with BDIII 16 as standard).
<16
Total (n)
35 (26.1%)
8 (6.0%)
43 (32.1%)
<4
1 (0.7%)
90 (67.2%)
91 (67.9%)
36 (26.9%)
Sensitivity = 35/36 (97.2%)
98 (73.1%)
Specificity = 90/98 (91.8%)
BDI-FS
Total
Positive predictive
value = 35/43 (81.4%)
Negative predictive
value = 90/91 (98.9%)
BDI-FS
<16 (n = 107)
16 (n = 43)
<4 (n = 102)
4 (n = 44)
60.4 15.0
55.1
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
210
Table 4 Mean age (years) of patients who completed and those who did not complete the BDI depression screening tools
Questionnaires
Completed
Not completed
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.35 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 patients
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
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Neitzer et al.
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