Beck Depression Inventory-Fast Screen

Beck Depression Inventory-Fast Screen(BDI-FS): An efficient tool for depression

screening in patients with end-stagerenal disease

Andrea NEITZER,1 Sumi SUN,1 Sheila DOSS,1 John MORAN,1,2 Brigitte SCHILLER1,2

1Satellite Healthcare, San Jose, California, USA; 2Division of Nephrology, Stanford University School ofMedicine, Palo Alto, California, USA

AbstractDepression is common in patients suffering from end-stage renal disease (ESRD). Various screeningtools for depression in ESRD patients are available. This study aimed to validate the Beck Depres-sion Inventory-Fast Screen (BDI-FS) with the Beck Depression Inventory-II (BDI-II) as depressionscreening tool in conventional hemodialysis (CHD) patients. One hundred sixty two CHD patientswere studied with both screening questionnaires. We used the Pearson Correlation Coefficient tomeasure the agreement between BDI-II and BDI-FS scores from 134 patients who responded to bothquestionnaires. Receiver operating characteristics curve and area under the curve were constructedto determine a valid BDI-FS cutoff score to identify ESRD patients at risk for depression. BDI-II andBDI-FS scores strongly correlated (Pearson r = 0.85, p < 0.0001). At a BDI-II cutoff �16, receiveroperating characteristics showed the best balance between sensitivity and specificity for the BDI-FScutoff value of �4 with a sensitivity of 97.2% (95% confidence interval [CI]: 85.5%, 99.9%) and aspecificity of 91.8% (95% CI: 84.5%, 96.4%). When applying the above cutoff scores, prevalence ofdepressive 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 efficient and effective tool for depressionscreening in ESRD patients which can be easily implemented in routine dialysis care.

Key words: Depression screening, end-stage renal disease, hemodialysis, Beck DepressionInventory

INTRODUCTION

Depression has been recognized to be among the mostcommon psychological disorders in end-stage renaldisease (ESRD) patients.1,2 Recent investigations suggestthat 20–30% of the maintenance dialysis population inthe United States and Europe is affected by depression.3–5

Depressive symptoms and the psychological effects of

depression are strongly associated with increased hos-pitalization rates, impaired medical outcomes, andmortality.6–8

Prevalence estimates vary depending on the popula-tions under investigation and/or the different depressionscreening tools applied. This paper focuses on the latterand attempts to make a recommendation for a routinedepression screening tool in ESRD patients, based on thecomparison of two commonly used tools.

An instrument frequently used to screen for depressionin ESRD patients is the Beck Depression Inventory-SecondEdition (BDI-II). Previous studies on depressive disorders

Correspondence to: A. Neitzer, MSD, Satellite Healthcare,300 Santana Row, Suite 300, San Jose, CA 95128, USA.E-mail: [email protected]

Hemodialysis International 2012; 16:207–213

© 2012 Satellite Healthcare, Inc.Hemodialysis International © 2012 International Society for HemodialysisDOI:10.1111/j.1542-4758.2012.00663.x 207

in this patient population have validated a cutoff score of16 or greater.9,10 The BDI-II is a 21-item self-report instru-ment that screens for the severity of depression corre-sponding to psychological and somatic symptoms.11

However, uremia and other symptoms of inadequatedialysis such as anorexia, sleep disturbance, fatigue, gas-trointestinal disorder, and pain can overlap with thesomatic symptoms of depression.12 This can complicatethe diagnosis of major depression in ESRD patients, andBDI-II results should be interpreted with caution.2

To measure the severity of depression that correspondsto nonsomatic criteria, the Beck Depression InventoryFast-Screen for Medical Patients (BDI-FS), formerlyknown as the Beck Depression Inventory for PrimaryCare, was developed.13 It extracts the seven nonsomaticsymptoms from the BDI-II (sadness, pessimism, fastfailure, loss of pleasure, self-dislike, self-criticalness, andsuicidal thoughts or wishes) and reduces patient burdenbecause of its faster administration. Previous research hastested the BDI-FS in multiple sclerosis,14 geriatricprimary-care patients,15 and compared the BDI-FS to theBDI-II in patients with chronic pain.16 However, to datethe BDI-FS has not been validated as a screen for depres-sion in patients with chronic kidney disease (CKD) orESRD, and the question for the appropriate cutoff scorefor a renal population remains open. The objectives of ourstudy were to measure the prevalence of depressive symp-toms in our in-center hemodialysis (HD) patients withboth the BDI-II and the BDI-FS, to test the agreementbetween both depression screening tools, and to deter-mine a reliable BDI-FS cutoff score for patients withESRD.

MATERIALS AND METHODS

A cross-sectional sample of 317 patients on conventionalhemodialysis (CHD) in 20 outpatient units (15 in Califor-nia, five in Texas) was approached for this study. Patientswere English or Spanish speaking, at least 18 years old,and were due in April to June 2009 for their 90 days oryearly Kidney Disease Quality Of Life-36 (KDQOL-SF36)assessment required by the new Conditions for Coverage.All patients were invited to complete the BDI-II and theBDI-FS during their HD treatment. Order of completionwas not specified. Questionnaires with 50% or more of thequestions left blank were considered incomplete andexcluded.

The BDI-II is a 21-item self-report case-finding screen-ing tool assessing various degrees of depressive symp-toms.11 It was developed for the evaluation of symptomscorresponding to criteria for diagnosing depressive dis-

orders listed in the American Psychiatric Association’sDiagnostic and Statistical Manual of Mental Disorders,Fourth Edition, DSM-IV.17 Each item is rated on a 4-pointscale from 0 to 3, with a maximum total score of 63.Higher scores indicate more severe depressive symptoms.It takes 5–10 minutes to complete, and has been widelyused to screen for depression in patients with CKDand ESRD. Based on previous studies, we classifiedpatients with a BDI-II score �16 as being in risk fordepression.9,10

The BDI-FS is an extract from the 21-item BDI-II13 withonly seven items and requires less than 5 minutes forcompletion. Scoring is similar to the BDI-II. The BDI-FSwas developed specifically for evaluating depression inpatients whose behavioral and somatic symptoms areattributable to biological, medical, alcohol, and/or sub-stance abuse problems that may confound the diagnosis ofdepression. It was constructed to reduce the number offalse positives for depression in patients with these prob-lems, and measures the degree of depressive symptomsthat corresponds to the psychological or nonsomatic cri-teria for diagnosing major depression disorders as listed inthe DSM-IV.

Statistical methods

Patient information on gender, race, diabetic status, andlength of time on dialysis was retrieved from our internalpatient database. All other information was collected fromthe completed survey tools. Patient demographics andscore on the BDI-II and BDI-FS were described by pro-portion (percentage) and mean (�standard deviation,SD). The Pearson correlation coefficient was used tomeasure 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-FScutoff score valid for identifying ESRD patients at risk fordepression, the receiver operating characteristic (ROC)curve and area under the curve (AUC) was constructed.We further calculated the concordance and discordancebetween the score results of both BDIs. T-test and chi-square test were used to compare means and proportions,respectively. For all analysis two-tailed P value < 0.05 wasconsidered significant. SAS version 9.1 (SAS Institute,Cary, NC, or http://www.sas.com) was used to conduct thestatistical analyses.

RESULTS

A total of 162 CHD patients returned at least one of theBDIs, the remaining 155 patients did not answer any of

Neitzer et al.


the two questionnaires. Of those 162 patients, 150patients answered the BDI-II, and 146 answered the BDI-FS. Both survey tools were returned by 134 patients,resulting in a response rate of 42%. Demographic datafrom those 134 patients were as follows: The participants’ages ranged from 21 to 87 years (mean: 59.1 � 14.7). Themajority (52%) was diabetic, and 98.5% of our patientsample was on dialysis for 90 days or longer. Other patientcharacteristics are summarized in Table 1. Average scoresfor the BDI-II (n = 150) and the BDI-FS (n = 146) were12.3 � 10.8 and 2.7 � 3.4, respectively. Total BDI-II and

BDI-FS scores demonstrated a strong positive linearcorrelation (Pearson r = 0.85, p < 0.0001, (n = 134) asshown in Figure 1.

The ROC analysis with a BDI-II cutoff �16 as the goldstandard revealed the best balance between sensitivity(true positive rate) and specificity (true negative rate) forthe BDI-FS at a cutoff value of �4 (Figure 2). At thiscutoff, BDI-FS results had a sensitivity of 97.2% (95% CI:85.5%, 99.9%) and a specificity of 91.8% (95% CI:84.5%, 96.4%). The positive predictive value (PPV) was81.4%, and the negative predictive value (NPV) was98.9%. Concordance for both BDIs was found to be93.3% (125/134 patients), while discordance was only6.7% (9/134 patients), summarized in Table 2. We calcu-lated the AUC as 0.982, indicating that the BDI-FS had ahigh predictive accuracy vs. the gold standard to correctlyclassify patients with and without the prevalence ofdepressive symptoms.

BDI-II scores �16 and BDI-FS scores �4 were foundin 28.7% and 30.1% of our study participants, respec-tively. These patients were significantly younger com-pared to patients not classified as being at risk fordepression. Except for age, no significant differences forgender, race, vintage, or prevalence of diabetes werefound between these groups (Table 3). Of note was theobservation that, of those patients who completed theBDI-FS but did not answer at least half of the questionson the BDI-II, over 80% missed the questions on the

Table 1 Patient characteristics (n = 134)

Characteristics

Male, % 52Mean age, y (�SD) 59.1 � 14.7Race, %

White 60Black 22Asian 13Other 4

Years on dialysis, %<1 101–5 716–10 16>10 3

Median time on dialysis, months (range) 27.5 (2.9–252.2)

Figure 1 Correlation between BDI-II and BDI-FS total scores.

Depression screening in dialysis

Hemodialysis International 2012; 16:207–213 209

reverse side of the BDI-II but answered the majority or allof the questions on the front side. These patients weresignificantly older (p < 0.05) compared to patients whoanswered the complete BDI-II. Patients who did not

complete the BDI-FS but had answered the BDI-II weresignificantly younger (p < 0.001). Table 4 shows themean age for patients who completed and those who didnot complete the BDIs.

Figure 2 Receiver/Responder Operating Characteristic (ROC) curve to assess a reliable cutoff value for BDI-FS (with BDI-II � 16 as standard).

Table 2 Agreement between BDI-II (cutoff �16) and BDI-FS (cutoff �4)

BDI-II

Total (n)BDI-FS �16 <16

�4 35 (26.1%) 8 (6.0%) 43 (32.1%) Positive predictivevalue = 35/43 (81.4%)

<4 1 (0.7%) 90 (67.2%) 91 (67.9%) Negative predictivevalue = 90/91 (98.9%)

Total 36 (26.9%) 98 (73.1%)Sensitivity = 35/36 (97.2%) Specificity = 90/98 (91.8%)

Table 3 Patient characteristics according to depression indicators

BDI-II BDI-FS

<16 (n = 107) �16 (n = 43) <4 (n = 102) �4 (n = 44)

Mean age, y (�SD) 60.4 � 15.0 50.4 � 13.8a 62.1 � 14.5 54.4 � 14.0b

Male, % 55.1 58.1 52.0 61.4Race, %

White 59.8 69.8 56.9 68.2Black 18.7 23.3 20.6 22.7Asian 15.0 2.3 16.7 4.6Others 6.5 4.7 5.9 4.6

Diabetic, % 55.1 39.5 54.9 47.7Mean time on dialysis, months (�SD) 44.8 � 43.6 44.9 � 33.8 43.4 � 44.3 44.0 � 33.1

ap < 0.001, bp < 0.01.

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DISCUSSION

We found a strong correlation between BDI-II and BDI-FSquestionnaires in the evaluation for depression whenadministering both questionnaires simultaneously topatients undergoing HD.

Our data suggest that a BDI-FS cutoff �4 identifiesESRD patients at risk for depression. Applying this cutoffto our patient sample reveals a prevalence of depressivesymptoms of about 30%. This confirms prior data for theestimated prevalence of depression and depressive symp-toms in patients on dialysis in the Unites States andEurope.3–5 In agreement with previous research,18 we alsofound dialysis patients at risk for depression to be youngerthan those patients without depressive symptoms. Con-cerns that in ESRD patients the BDI-II may overestimatethe risk of depression due to various questions related tosomatic symptoms frequently seen in patients undergoingHD including fatigue, insomnia, and loss of appetite werenot confirmed in our study.

However, “screening” for depression needs to be distin-guished from “diagnosing” depression, and it is a limita-tion of this study that we did not perform psychologicalinterviews with those patients at risk of depression inorder to confirm or reject the diagnosis. Also the “responsebias” of self-report inventories needs consideration. Whilethese tools reflect subjective perception of the patient’swell-being, they contain valuable information and metricsfor patient assessment, however without a clear diagnosis.Hedayati et al.5,19 confirmed that self-report question-naires such as the BDI-II should not be used for a clinicaldiagnosis of depression in CKD or ESRD patients but thatthey performed well as screening tools.

The implementation of a framework for systematicdepression screening in a dialysis facility and a depressiontreatment algorithm for ESRD patients has been advocatedbut has also proven to be challenging.20 Nephrologistsmight correctly argue that the therapy of depression is notpart of their area of expertise, and they often do not feelcomfortable treating depression. Furthermore, it is notknown whether treatment of depression impacts the out-comes of ESRD patients as randomized clinical trials are

missing. Although the prevalence of depressive symptomswas found to be very common in the incident dialysispatient,21 there are no data available indicating when tostart screening patients with ESRD for depression.However, considering the high prevalence of depressionin ESRD patients and the negative impact on medicaloutcomes, hospitalization rate, and mortality in this popu-lation, including depression screening in routine ESRDpatient care is likely to add benefits and should thereforelead to more insistent effort also from the nephrologists’side. Data from the Following Rehabilitation, Economicsand Everyday-Dialysis Outcomes Measurements studyrecently revealed a significant improvement in BDI-IIscores in patients treated with daily (six times per week)home HD over 12 months.22 Moreover, the FrequentHemodialysis Network trial comparing more frequentcenter dialysis therapy to conventional thrice-weeklydialysis showed a decrease in the BDI-II score from12.6 � 8.7 to 10.4 � 8.5 in the daily group after 12months. Although not statistically significant this is anotable finding given the extra burden of dialysis withdaily therapy.23

From a patient’s perspective, a diagnosis of depressionis often still understood as a stigma, and affected patientsmight tend to deny depression-related symptoms. Klein-man has shown that many depressed Chinese patientsfound a diagnosis of depression morally unacceptable.24

Furthermore, resistance to the diagnosis of depression isevident from studies showing that 55% of PD patientssuggested by the BDI-II as being depressed refusedfurther assessment to confirm or rule out the diagnosis ofmajor depression. Of those patients diagnosed withmajor depression by psychological evaluation, only halfsuccessfully completed 12 weeks of pharmacologictherapy.4 Patients need to be educated to understand thatdepression is a serious medical illness that impairsquality of life and even survival, and therefore should beseriously considered to be part of a patient-centeredESRD care approach. With ESRD patients affected bydepression being younger than patients without depres-sive symptoms, attention to symptoms appears evenmore critical, as ESRD and the burden of dialysis may

Table 4 Mean age (years) of patients who completed and those who did not complete the BDI depression screening tools

Questionnaires

Completed Not completed

Mean age, y (�SD), range Mean age, y (�SD), range

BDI-II 57.5 (�15.3), 21–87 67.8 (�13.8)a, 42–87BDI-FS 59.8 (�14.8), 21–87 44.5 (�14.2)b, 24–72

BDI-II completed (n = 150), BDI-II not completed (n = 12); BDI-FS completed (n = 146), BDI-FS not completed (n = 16).ap < 0.05, bp < 0.001.



present a greater disruption of work and social life inyounger patients.25

We conclude that a routine depression screeningprogram in ESRD patients needs to be efficient and cost-effective in order to have chances of success. It should bewell accepted by ESRD patients, practical, and easilyadministered for the caretakers considering the growingdemands in dialysis units because of the increasingly olderand multi-morbid population. In this regard, the BDI-FSis a promising tool. It is one-sided, without risk of patientsaccidentally skipping questions on the reverse side of thequestionnaire. Our study showed that patients with anincomplete questionnaire were significantly older, sug-gesting that the BDI-FS would be more suitable for thesepatients. Its completion takes less than 5 minutes andtherefore causes little burden for the patients to completeand for the staff to evaluate. Furthermore, it focuses onnonsomatic indicators rather than on physical symptomsthat might overlap with complaints due to uremia ordialysis-associated adverse events. Although administra-tion and scoring may be easy, it is recommended that theBDI-FS should be interpreted only by professionals withappropriate clinical training and experience.13

With the BDI-FS in hand, ESRD patients could system-atically be screened for depression with an easy and repro-ducible questionnaire, allowing for trending over time. Inaccordance with the increasing focus on quality of life as ametric for outcome in ESRD, this tool will allow the mul-tidisciplinary care team to focus on patients at risk whowill likely benefit from psychosocial intervention. More-over, it may help to develop algorithms for the moreintegrated ESRD care model of the future and to increasethe patients’ quality of life.

Manuscript received September 2011; revised November2011.

REFERENCES1 Cohen SD, Holder-Perkins V, Kimmel PL. Psychosocial

issues in end-stage renal disease patients. In: DaugirdasJT, Blake PG, Ing TS, eds. Handbook of Dialysis, 4thedition, Philadelphia, PA: Wolters Kluwer, LippincottWilliams & Wilkins. 2007; 455–461.

2 Kimmel PL, Weihs KL, Peterson RA. Survival in hemodi-alysis patients: The role of depression. J Am Soc Nephrol.1993; 4:12–27.

3 Lopes AA, Bragg J, Young E, et al. Depression as a pre-dictor of mortality and hospitalization among hemodialy-sis patients in the United States and Europe. Kidney Int.2002; 62:199–207.

4 Wuerth D, Finkelstein SH, Finkelstein FO. The identifi-cation and treatment of depression in patients main-tained on dialysis. Semin Dial. 2005; 18:142–146.

5 Hedayati SS, Boswoth HB, Kuchibhatla M, Kimmel PL,Szczech LA. The predictive value of self-report scale com-pared with physician diagnosis of depression in hemodi-alysis patients. Kidney Int. 2006; 69:1662–1668.

6 Kimmel PL, Peterson RA, Weihs KL, et al. Multiple mea-surements of depression predict mortality in a longitudi-nal study of chronic hemodialysis patients. Kidney Int.2000; 57:2093–2098.

7 Hedayati S, Bosworth HB, Briley LP, et al. Death or hos-pitalization of patients on chronic hemodialysis is asso-ciated with a physician-based diagnosis of depression.Kidney Int. 2008; 74:930–936.

8 Riezebos RK, Nauta KJ, Honig A, Dekker FW, SiegertCEH. The association of depressive symptoms with sur-vival in a Dutch cohort of patients with end-stage renaldisease. Nephrol Dial Transplant. 2010; 25:231–236.

9 Watnick S, Wang P, Demadura T, et al. Validation of twodepression screening tools in dialysis patients. Am JKidney Dis. 2005; 46:919–924.

10 Chilcot J, Wellsted DM, Farrington K. Screening fordepression while patients dialyze: An evaluation. NephrolDial Transplant. 2008; 23:2653–2659.

11 Beck AT, Steer RA, Brown GK. BDI-II Manual. SanAntonio, TX: The Psychological Corporation, HarcourtBrace & Company. 1987.

12 Cohen S, Norris L, Acquaviva K, et al. Screening, diag-nosis, and treatment of depression in patients withend-stage renal disease. Clin J Am Soc Nephrol. 2007;2:1332–1342.

13 Beck AT, Steer RA, Brown GK. BDI-FastScreen for MedicalPatients, Manual. San Antonio, TX: The PsychologicalCorporation, A Harcourt Assessment Company. 2000.

14 Benedict RH, Fishman I, McClellan MM, et al. Validity ofthe Beck Depression Inventory-Fast Screen in multiplesclerosis. Mult Scler. 2003; 9:393–396.

15 Scheinthal S, Steer RA, Giffin L, Beck AT. Evaluatinggeriatric medical outpatients with the Beck DepressionInventory – Fast Screen for medical patients. Aging MentHealth. 2001; 5:143–148.

16 Poole H, Bramwell R, Murphy P. The utility of the BeckDepression Inventory Fast Screen (BDI-FS) in a painclinic population. Eur J Pain. 2009; 13:865–869.

17 DSM-IV, American Psychiatric Association. Diagnostic andStatistical Manual of Mental Disorders, 4th edition, Wash-ington, DC: American Psychiatric Association. 1994.

18 Drayer RA, Piraino B, Reynolds CF, et al. Characteristicsof depression in hemodialysis patients: Symptoms,quality of life and mortality risk. Gen Hosp Psychiatry.2006; 28:306–312.

19 Hedayati SS, Minhajuddin AT, Toto RD, Morris DW,Rush AJ. Validation of depression screening scales inpatients with CKD. Am J Kidney Dis. 2009; 54:433–439.

Neitzer et al.


20 Finkelstein FO, Wuerth D, Troidle LK, Finkelstein SH.Depression and end-stage renal disease: A therapeuticchallenge. Kidney Int. 2008; 74:843–845.

21 Watnick S, Kirwin P, Mahnensmith R, Concato J. Theprevalence and treatment of depression among patientsstarting dialysis. Am J Kidney Dis. 2003; 41:105–110.

22 Jaber BL, Lee Y, Collins AJ, et al. Effect of daily hemodi-alysis on depressive symptoms and postdialysis recoverytime: Interim report from the FREEDOM (FollowingRehabilitation, Economics and Everyday-Dialysis Out-comes Measurements) study. Am J Kidney Dis. 2010;56:531–539.

23 Chertow GM, Levin NW, Beck GJ, et al. In-center hemo-dialysis six times per week versus three times per week. NEngl J Med. 2010; 363:2287–2300.

24 Kleinman A. Culture and depression. N Engl J Med. 2004;351:951–953.

25 Chilcot J. Studies of depression and illness representa-tions in end-stage renal disease. A thesis submitted inpartial fulfillment of the requirements of the University ofHertfordshire for the degree of Doctor of Philosophy,School of Psychology. May 2010. http://hdl.handle.net/2299/4796



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Beck Depression Inventory-Fast Screen