A preliminary investigation of the reliability and validity of the Brief Assessment Schedule Depression Cards and the Beck Depression Inventory-Fast Screen to screen for depression in older stroke survivors

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<ul><li><p>A preliminary investigation ofes</p><p>a</p><p>,</p><p>poor outcome, including mortality and physical et al., 1992) and the Beck Depression Inventory-Fast,</p><p>lhealth problems (Loke et al., 1996; Scheinthal et al.,</p><p>INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY</p><p>Int J Geriatr Psychiatry 2008; 23: 531536.</p><p>Published online 16 November 2007 in Wiley InterScience</p><p>(www.interscience.wiley.com) DOI: 10.1002/gps.1933</p><p>E-mail: ian.kneebone@surreypct.nhs.uk</p><p>Received 27 April 2007disability (Dennis et al., 2000; House et al., 2001).There are strong concerns that it goes untreatedbecause it is often undiagnosed (Hackett et al., 2004).On this basis, routine screening has been recom-mended (Royal College of Physicians, 2004).</p><p>Screen for medical patients (BDI-FS: Beck et al.2000) as meriting investigation. These instrumentshave potential for screening for depression as they arebrief, require minimal training to administer, have fewor no somatic items (which can complicate identifi-cation of depression in this client group), and havedemonstrated high sensitivity and specificity fordetecting depression in older people with physica</p><p>*Correspondence to: Dr I. I. Kneebone, Haslemere Hospital, ChurchLane, Haslemere, Surrey, GU27 2BJ, UK.INTRODUCTION</p><p>Depression affects approximately one-third of strokesurvivors (Hackett et al., 2005) and is associated with</p><p>A recent review of potential measures for routinescreening for mood disorders after stroke (Bennett andLincoln, 2006) identified the Brief AssessmentSchedule Depression Cards (BASDEC: AdsheadObjective To conduct an initial assessment of the reliability and validity of the Brief Assessment Schedule DepressionCards (BASDEC) and the Beck Depression Inventory-Fast Screen (BDI-FS) to screen for depression in older strokesurvivors.Methods Participants from four inpatient rehabilitation units completed the BASDEC and the BDI-FS together with theHospital Anxiety and Depression Scale (HADS) for comparison. The Structured Clinical Interview for DSM-IV Axis 1Disorders (SCID) was then completed with all participants to ascertain a criterion depression diagnosis. The BASDEC andBDI-FS were subsequently completed for a second time.Results Forty-nine stroke survivors (M 78.80, SD 6.79 years) were included. The BASDEC and BDI-FS demonstratedacceptable internal consistency and testretest reliability. The BASDEC (cut-off 7) resulted in a sensitivity of 1.0 andspecificity of 0.95 for detecting major depression whereas the BDI-FS (cut-off4) had a sensitivity of 0.71 and specificity of0.74. When participants with minor depression were included in analyses, sensitivity lowered to 0.69 (specificity 0.97) forthe BASDEC and 0.62 (specificity 0.78) for the BDI-FS.Conclusions The BASDEC and BDI-FS were found to have acceptable reliability. The BASDEC demonstrated someadvantage in criterion validity over the BDI-FS at the examined cut-offs. Copyright # 2007 John Wiley &amp; Sons, Ltd.</p><p>key words depression; rehabilitation; reliability and validity; screening; stroke; sensitivity and specificitySUMMARYthe Brief Assessment SchedulBeck Depression Inventory-Fadepression in older stroke surv</p><p>A. K. Healey1,2, I. I. Kneebone1,2*, M. Carroll1</p><p>1Department of Psychology, University of Surrey, Guildford2Surrey Primary Care NHS Trust, UK3South Downs Health NHS Trust, UKCopyright # 2007 John Wiley &amp; Sons, Ltd.the reliability and validity ofDepression Cards and thet Screen to screen forivors</p><p>nd S. J. Anderson3</p><p>UKAccepted 7 September 2007</p></li><li><p>2001). The BASDEC and BDI-FS also have itemsreferring to suicidal ideation, important as strokesurvivors are at an approximately doubled risk of</p><p>scored 0.5 points. The maximum possible score is 21,higher scores indicating greater depressive sympto-mology. Studies with groups of medically-ill older</p><p>532 a. k. healey ET AL.suicide (Teasdale and Endberg, 2001). The BASDEChas the added advantage of a particularly service-userfriendly design, due to its novel card format, withsimple response categories.</p><p>The aims of this study were to investigate the use ofthe BASDEC and BDI-FS as depression screeningmeasures with older stroke survivors in an inpatientrehabilitation setting by: (1) conducting an assessmentof the scales testretest and internal reliability, (2)assessing the criterion validity by comparing theresults of the scales to depression diagnosis accordingto Diagnostic and Statistical Manual IV (DSM-IV:American Psychiatric Association, 1994) criteria asassessed by the Structured Clinical Interview forDSM-IV (SCID: First et al., 1997) and (3) comparingthe performance of these scales to the HospitalAnxiety and Depression Scale (HADS: Zigmond andSnaith, 1983) which is one of the best validatedself-report scales for depression screening in strokesurvivors (Bennett and Lincoln, 2006).</p><p>METHOD</p><p>Participants</p><p>Participants, who were medically stable, were rec-ruited from four inpatient rehabilitation services forstroke survivors. Recruitment took place over a total of14 months. Exclusion criteria included being under65 years of age, under 2 weeks or more than 6 monthspost-stroke, dysphasia to the extent that completion ofthe depression rating scales or the interview would bedifficult and cognitive impairment indicated by a scoreof less than 8 on the Abbreviated Mental Test(Hodkinson, 1972) or less than 24 on the Mini-MentalState Examination (Folstein et al., 2000). Participantsgave informed consent.</p><p>Measures</p><p>The BASDEC (Adshead et al., 1992) was developedfor use with older people in a hospital wardenvironment. It is a set of 19 statements relating todepression symptoms, each written on a separate card(8.2 cm x 10.4 cm). The respondent is asked to placethe statement card next to either a True or Falsecard according to their current view. True statementsare scored 1 point, with the exception of twostatements which are weighted as 2 points. Falsestatements are scored 0. Dont Know responses are</p><p>Copyright # 2007 John Wiley &amp; Sons, Ltd.people have found high sensitivity (&gt;0.80) andspecificity values (&gt;0.90) with reference to depressiondiagnosis ascertained by structured clinical interviews(e.g. Loke et al., 1996; Yohannes et al., 2000) usingthe test developers recommended cut-off (7).</p><p>The BDI-FS (Beck et al., 2000) is comprised ofseven items from the 21-item Beck DepressionInventory-II (Beck et al., 1996). No somatic itemsare included to increase specificity for medicalpatients. Items are rated for the past 2 weeks on afour-point likert scale (03), giving a maximum totalscore of 21. An optimum cut-off score of 4 had highsensitivity (1.0) and specificity (0.84) compared todepression diagnosis from a structured diagnosticinterview in a group of older medically ill outpatients(Scheinthal et al., 2001). This optimum cut-off isconsistent with previous studies reported in the testmanual (Beck et al., 2000).</p><p>The HADS (Zigmond and Snaith, 1983) is a14-item self-report rating scale divided into anxiety(HADS-A) and depression (HADS-D) sub-scales. Itwas designed for use with hospitalised, medically illpatients. Each item is rated for the past week on afour-point likert scale (03). The maximum score,indicating highest symptomology, on each sub-scale is21. Reliability and validity data are available for itsuse as a screening measure in stroke (Bennett andLincoln, 2006). The cut-off recommended by the testdevelopers for possible clinical depression is 8 onthe HADS-D and this has been validated for strokesurvivors (Aben et al., 2002).</p><p>The SCID (First et al., 1997) is a semi-structuredinterview schedule for making the major DSM-IVAxis I diagnoses. The sections related to mooddisorder were administered to ascertain whetherparticipants met criteria for a DSM-IV diagnosis ofmajor depression or minor depression (DSM-IVresearch criteria).</p><p>Procedure</p><p>Participants first completed the BASDEC, BDI-FSand HADS. Order of completion was counterbalancedto nullify order effects (Lucas, 1992). The standar-dised instructions, questions and responses were readaloud to each participant by an assistant (graduate)psychologist. Participants also had a copy of thedepression measures in front of them. If possible,participants completed the forms or placed theBASDEC cards themselves, if not this was completed</p><p>Int J Geriatr Psychiatry 2008; 23: 531536.</p><p>DOI: 10.1002/gps</p></li><li><p>by the assistant psychologist. A doctoral trainee inclinical psychology, blind to the results of thedepression rating scales and clinical information</p><p>were discharged before the second administration ofthe depression rating scales could take place.</p><p>Validity</p><p>Total scores on the BASDEC, BDI-FS and HADS-Dwere significantly correlated beyond the 0.001 level.The correlations of the BASDEC with the BDI-FS andHADS-D, and the BDI-FS with the HADS-D, were,respectively, 0.57, 0.40 and 0.44, providing conver-gent evidence of validity.</p><p>The sensitivity, specificity, predictive values andlikelihood ratios for each measure compared to theSCID diagnosis are presented in Table 2. The median</p><p>Table 1. Distribution of scores on the depression rating scales forthe non-depressed and depressed participants</p><p>Depression Rating Non-Depressed Depressed Partici-</p><p>Int J Geriatr Psychiatry 2008; 23: 531536.</p><p>DOI: 10.1002/gps</p><p>screening for depression in older stroke survivors 533about the participant and who had completed therecommended training for administration of the SCID(First et al., 1997), conducted this interview within 7days of test administration. Following the SCID and710 days following the initial completion of thedepression rating scales, the participants werere-administered the BASDEC and BDI-FS. Demo-graphic and clinical information was collected foreach participant.</p><p>Data analysis</p><p>Internal reliability was measured by Cronbachs Alphafor the BDI-FS and HADS-D and by Kuder-Richardsons 20 Formula for the BASDEC as it isbased on dichotomous data. Testretest reliability andcorrelations between the measures were assessedusing Kendalls tau-b correlation coefficient. Firstly,as scores on the measures are ordinal data, secondly,due to the number of tied ranks in the data and thirdly,it is considered a better estimate of the correlation inthe population than Spearmans correlation coefficientand is therefore more appropriate when an estimationof the size of a relationship is of interest (Arndt et al.,1999).</p><p>A test-criterion design was used to investigate theconvergent evidence for the validity of the BASDECand BDI-FS. This was analysed by calculatingsensitivity, specificity, positive and negative predictivevalues and likelihood ratios [including their 95%Confidence Intervals (CI)] for above cut-off scores andDSM-IV diagnosis of depression assessed by theSCID considered as dichotomous variables. Agree-ment between the BASDEC and BDI-FS and the SCIDdiagnosis was also determined using the Kappastatistic which corrects for chance agreement. Valueswere calculated for the HADS-D for comparison.</p><p>RESULTS</p><p>Study participants</p><p>The participants were 21 males and 28 females whohad a mean age of 78.80 (SD 6.79). All participantswere White British or Irish, the majority were married(44.9%) or widowed (30.6%) and had lived in theirown home prior to admission (85.7%). Participantswere first assessed at a median of 41 days (range16113) post-stroke, stroke-type was classified as lefthemisphere (63%), right hemisphere (28.6%) or other</p><p>Copyright # 2007 John Wiley &amp; Sons, Ltd.(8.1%). Participants impairment in activities of dailyliving ranged from minimal to severe (data notrecorded in medical notes for seven participants)as measured by the Barthel Activities of DailyLiving Index (Mahoney and Barthel, 1965) (n 27,Mdn 9, range 019) or the Functional Indepen-dence Measure (Hamilton and Granger, 1994) (n 15,Mdn 43, range 1969).</p><p>Seven participants (14.3%) met DSM-IV criteria formajor depression as measured by the SCID and six(12.2%) met criteria for minor depression. A summaryof the distribution of total scores on the depressionmeasures according to diagnosis is given in Table 1.</p><p>Reliability</p><p>The internal consistency of the BASDEC (KR-200.77), BDI-FS (a 0.75) and HADS-D (a 0.80) wasacceptable (Field, 2005). The BASDEC (t(43) 0.66,p&lt; 0.001) and BDI-FS (t(43) 0.63, p&lt; 0.001) alsohad acceptable testretest reliability. Six participants</p><p>Scale (cut-off) Participants(n 36)</p><p>pants (n 13)</p><p>Mdn IQR Mdn IQR</p><p>BASDEC (7) 2 23.88 9 3.59.5BDI-FS (4) 1 03 6 29HADS-D (8) 4 18 9 5.511.5BASDECBrief Assessment Schedule Depression Cards;BDI-FSBeck Depression InventoryFast Screen; DepressedParticipants participants with a diagnosis of major or minordepression; HADS-DHospital Anxiety and Depression ScaleDepression Scale; IQR Interquartile Range; MdnMedian.</p></li><li><p>time between the first administration of the depressionrating scales and the interview was 3 days.</p><p>Sensitivity, specificity, predictive values and</p><p>Tab</p><p>le2</p><p>.E</p><p>ffec</p><p>tiven</p><p>ess</p><p>of</p><p>the</p><p>BA</p><p>SD</p><p>EC</p><p>,th</p><p>eB</p><p>DI-</p><p>FS</p><p>and</p><p>the</p><p>HA</p><p>DS</p><p>-Dco</p><p>mp</p><p>ared</p><p>wit</p><p>hD</p><p>SM</p><p>-IV</p><p>dia</p><p>gn</p><p>osi</p><p>s</p><p>Mea</p><p>sure</p><p>(cut-</p><p>off</p><p>)S</p><p>ensi</p><p>tiv</p><p>ity</p><p>(95</p><p>%C</p><p>I)S</p><p>pec</p><p>ifici</p><p>ty(9</p><p>5%</p><p>CI)</p><p>Po</p><p>siti</p><p>ve</p><p>pre</p><p>dic</p><p>tive</p><p>Val</p><p>ue</p><p>(95</p><p>%C</p><p>I)N</p><p>egat</p><p>ive</p><p>pre</p><p>dic</p><p>tive</p><p>Val</p><p>ue</p><p>(95</p><p>%C</p><p>I)P</p><p>osi</p><p>tive</p><p>lik</p><p>elih</p><p>oo</p><p>dra</p><p>tio</p><p>(95</p><p>%C</p><p>I)N</p><p>egat</p><p>ive</p><p>lik</p><p>elih</p><p>oo</p><p>dra</p><p>tio</p><p>(95</p><p>%C</p><p>I)</p><p>MD</p><p>MD</p><p>and</p><p>MIN</p><p>DM</p><p>DM</p><p>Dan</p><p>dM</p><p>IND</p><p>MD</p><p>MD</p><p>and</p><p>MIN</p><p>DM</p><p>DM</p><p>Dan</p><p>dM</p><p>IND</p><p>MD</p><p>MD</p><p>and</p><p>MIN</p><p>DM</p><p>DM</p><p>Dan</p><p>dM</p><p>IND</p><p>BA</p><p>SD</p><p>EC</p><p>(7</p><p>)1</p><p>.00</p><p>(0.6</p><p>51</p><p>.0)</p><p>0.6</p><p>9(0</p><p>.42</p><p>0</p><p>.87)</p><p>0.9</p><p>5(0</p><p>.84</p><p>0</p><p>.99</p><p>)0</p><p>.97</p><p>(0.8</p><p>61</p><p>.0)</p><p>0.7</p><p>8(0</p><p>.45</p><p>0</p><p>.94)</p><p>0.9</p><p>0(0</p><p>.60</p><p>0</p><p>.98)</p><p>1.0</p><p>0(0</p><p>.91</p><p>1</p><p>.0)</p><p>0.9</p><p>0(0</p><p>.76</p><p>0</p><p>.96)</p><p>21</p><p>(6.3</p><p>37</p><p>6)</p><p>24</p><p>.92</p><p>(4.6</p><p>41</p><p>43</p><p>.88</p><p>)0</p><p>.00</p><p>(0.0</p><p>00</p><p>.37</p><p>)0</p><p>.32</p><p>(0.1</p><p>30</p><p>.60)</p><p>BD</p><p>I-F</p><p>S(</p><p>4)</p><p>0.7</p><p>1(0</p><p>.36</p><p>0</p><p>.92)</p><p>0.6</p><p>2(0</p><p>.36</p><p>0</p><p>.82)</p><p>0.7</p><p>4(0</p><p>.59</p><p>0</p><p>.85</p><p>)0</p><p>.78</p><p>(0.6</p><p>20</p><p>.88)</p><p>0.3</p><p>1(0</p><p>.14</p><p>0</p><p>.56)</p><p>0.5</p><p>0(0</p><p>.28</p><p>0</p><p>.72)</p><p>0.9</p><p>4(0</p><p>.80</p><p>0</p><p>.98</p><p>)0</p><p>.85</p><p>(0.6</p><p>90</p><p>.93)</p><p>2.7</p><p>3(1</p><p>.20</p><p>5</p><p>.16)</p><p>2.7</p><p>7(1</p><p>.29</p><p>5</p><p>.76)</p><p>0.3</p><p>9(0</p><p>.11</p><p>0</p><p>.90</p><p>)0</p><p>.49</p><p>(0.2</p><p>20</p><p>.87)</p><p>HA</p><p>DS</p><p>-D(</p><p>8)</p><p>0.8</p><p>6(0</p><p>.49</p><p>0</p><p>.97)</p><p>0.6</p><p>2(0</p><p>.36</p><p>0</p><p>.82)</p><p>0.6</p><p>9(0</p><p>.54</p><p>0</p><p>.81</p><p>)0</p><p>.69</p><p>(0.5</p><p>30</p><p>.82)</p><p>0.3</p><p>2(0</p><p>.15</p><p>0</p><p>.54)</p><p>0.4</p><p>2(0</p><p>.23</p><p>0</p><p>.64)</p><p>0.9</p><p>7(0</p><p>.83</p><p>0</p><p>.99</p><p>)0</p><p>.83</p><p>(0.6</p><p>60</p><p>.93)</p><p>2.7</p><p>7(1</p><p>.40</p><p>4</p><p>.70)</p><p>2.0</p><p>1(1</p><p>.00</p><p>3</p><p>.80)</p><p>0.2</p><p>1(0</p><p>.04</p><p>0</p><p>.77</p><p>)0</p><p>.55</p><p>(0.2</p><p>51</p><p>.00)</p><p>BA</p><p>SD</p><p>EC</p><p>Bri</p><p>efA</p><p>sses</p><p>smen</p><p>tS</p><p>ched</p><p>ule</p><p>Dep</p><p>ress</p><p>ion</p><p>Car</p><p>ds;</p><p>BD</p><p>I-F</p><p>S</p><p>Bec</p><p>kD</p><p>epre</p><p>ssio</p><p>nIn</p><p>ven</p><p>tory</p><p>Fas</p><p>tS</p><p>cree</p><p>n;</p><p>DS</p><p>M-I</p><p>V</p><p>Dia</p><p>gno</p><p>stic</p><p>and</p><p>Sta</p><p>tist</p><p>ical</p><p>Man</p><p>ual</p><p>of</p><p>Men</p><p>tal</p><p>Dis</p><p>ord</p><p>ers,</p><p>4th</p><p>edn</p><p>(Am</p><p>eric</p><p>anP</p><p>sych</p><p>olo</p><p>gic</p><p>alA</p><p>sso</p><p>ciat</p><p>ion</p><p>,1</p><p>99</p><p>4);</p><p>HA</p><p>DS</p><p>-D</p><p>Ho</p><p>spit</p><p>alA</p><p>nx</p><p>iety</p><p>and</p><p>Dep</p><p>ress</p><p>ion</p><p>Sca</p><p>le</p><p>D</p><p>epre</p><p>ssio</p><p>n;</p><p>MD</p><p>Maj</p><p>or</p><p>Dep</p><p>ress</p><p>ion</p><p>;M</p><p>IND</p><p>Min</p><p>or</p><p>Dep</p><p>ress</p><p>ion.</p><p>Copyright # 2007 John Wiley &amp; Sons, Ltd.</p><p>534 a. k. healey ET AL.positive likelihood ratios were highest for theBASDEC, where a cut-off of 7 correctly identifiedall cases of major depression and produced only twofalse positives (4.1%). This resulted in an almostperfect level of agreement (k 0.85, 95%CI 0.651.0) (Landis and Koch, 1977). The BDI-FS(cut-off 4) missed two participants with majordepression (4.1%) and produced 11 false positives(22%). This is reflected in lower sensitivity andspecificity, predictive values and a fair overall levelof agreement (k 0.29, 95% CI 00.62). Forcomparison, the HADS-D (cut-off 8) missed onecase of major depression (2%) and produced 13 falsepositives (26.5%), resulting in an acceptab...</p></li></ul>

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