Aphasic Depression Rating Scale (ADRS)

Evidence Reviewed as of before: 01-03-2011
Author(s)*: Lisa Zeltzer, MSc OT; Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc; Katie Marvin, MSc, PT Candidate

Purpose

The Aphasic Depression Rating Scale (ADRS) was developed to detect and measure Depression in patients with aphasia during the subacute stage of stroke.

In-Depth Review

Purpose of the measure

The Aphasic Depression Rating Scale (ADRS) was developed to detect and measure Depression in patients with aphasia during the subacute stage of stroke.

Available versions

The ADRS was developed by Benaim, Cailly, Perennou, and Pelissier in 2004.

Features of the measure

Items:
The ADRS contains 9 items selected from the Hamilton Depression Rating Scale (HDRS) (Hamilton, 1967), the Montgomery and Asperg Depression Rating Scale (MADRS) (Montgomery & Asberg, 1979), and the Salpetriere Retardation Rating Scale (SRRS) (Dantchev & Widlocher, 1998).

The items measure insomnia, anxiety (both psychic and somatic), somatic symptoms (gastrointestinal), hypochondriasis, loss of weight, apparent sadness, mimic (slowness of facial mobility), and fatigability.

Scoring:
The ADRS is scored by adding the score of each individual item for a total possible score of 32. Each item is scored differently (see detailed scoring table below).

Item Score
1. Insomnia-Middle 0 = No difficulty

1 = Patient indicates being restless and disturbed during night/observed sleep disturbance

2 = waking during the night; any getting out of bed (except to go to bathroom)

2. Anxiety-Psychic 0 = no difficulty

1 = some tension and irritability

2 = worrying about minor matters

3 = apprehensive attitude apparent in patient’s face or speech

4 = fears indicated (verbal/non verbal expression) without questioning

3. Anxiety-Somatic 0 = absent; 1 = mild; 2 = moderate; 3 = severe; 4 = incapacitating
4. Somatic symptoms-Gastrointestinal 0 = none

1 = loss of appetite but continues to eat; heavy feelings in abdomen

2 = difficulty eating (not due to arm paresis); requests/requires laxatives or medication for bowels or for gastrointestinal symptoms

5. Hypochondriasis 0 = not present

1 = self-absorption (bodily)

2 = preoccupation with health

3 = frequent complaints, requests for help, etc

4 = hypochondriacal delusions

6. Loss of weight 0 = <0.5 kg weight loss/week

1 = 0.5 kg to 1 kg weight loss per week

2 = >1 kg weight loss per week

7. Apparent sadness 0 = no sadness

1 = between 0 and 2

2 = looks dispirited but brightens without difficulty

3 = between 2 and 4

4 = appears sad and unhappy most of the time

5 = between 4 and 6

6 = looks miserable all the time; extremely despondent

8. Mimic-Slowness of Facial Mobility 0 = the head moves freely, resting flexibility on the body with the gaze either exploring the room or fixed on the examiner or on other objects of interest in an appropriate manner

1 = there may be some reduction of mobility, not easily confirmed.

2 = reduced mobility is definite but mild; gaze, often fixed, but is still capable of shifting; mimic, although monotonous, is still expressive

3 = does not move head/explore room, usually stares at floor, seldom looking at examiner; patient is slow to smile; expression is unchanging

4 = face is completely immobile and painfully inexpressive

9. Fatigability 0 = fatigability is not indicated spontaneously/after direct questioning

1 = fatigability is not indicated spontaneously, but evidence of it emerges in the course of the interview

2 = patient is distressed by fatigability in his/her everyday life (eating, washing, dressing, climbing stairs, or any physical activity the patient is usually able to do despite motor deficiency).

3 = fatigability is such that the patient must curb some activities

4 = near-total reduction of activities due to overwhelming fatigue

A cutoff score of 9/32 of the ADRS is used to determine the presence of Depression in patients with aphasia, with higher scores indicating more depressive symptoms.

Time:
The amount of time it takes to administer the ADRS has not been reported.

Subscales:
None.

Equipment:
Only the test copy and a pencil are required to complete the ADRS.

Training:
It is unclear whether training is required to administer the ADRS. However, health professionals working on a neurorehabilitation unit typically administer the ADRS.

Alternative forms of the ADRS

None published.

Client suitability

Can be used with:

  • Patients with aphasia due to stroke.

Should not be used with:

  • Individuals who may be depressed but who have not had a stroke, or patients who do not have aphasia. For these patients, other Depression measures exist that have more evidence to support their psychometric properties (e.g. Hamilton Depression Rating Scale (HDRS), Beck Depression Inventory (BDI), Geriatric Depression Scale (GDS), etc.).

In what languages is the measure available?

The ADRS is published in English only.

Summary

What does the tool measure? Depression.
What types of clients can the tool be used for? Patients with aphasia during the subacute stage of stroke.
Is this a screening or assessment tool? Assessment
Time to administer The amount of time it takes to administer the ADRS has not been reported.
Versions There are no alternative versions.
Other Languages None.
Measurement Properties
Reliability Internal consistency:
No studies have examined the Internal consistency of the ADRS.
Test-retest:
One study has examined the test-retest reliability of the ADRS and reported adequate test-retest agreement between items using kappa statistics, and excellent test-retest on the global score using correlation coefficients.
Intra-rater:
No studies have examined the intra-rater reliability of the ADRS.
Inter-rater:
One study has examined the inter-rater reliability of the ARDS and reported excellent inter-rater reliability on items using kappa statistics, and excellent inter-rater reliability on the global score using correlation coefficients.
Validity

Construct:
Convergent/Discriminant: 
Excellent correlations between the ADRS and the psychiatric rating of Depression, ratings made by members of the rehabilitation team and the Hamilton Depression Rating Scale. Adequate to Excellent correlations in patients with right hemisphere stroke only and in patients with left hemisphere stroke only.

Floor/Ceiling Effects No studies have examined the floor or ceiling effects of the ADRS.
Sensitivity/Specificity One study compared the ADRS with the diagnosis made by a psychiatrist. With a score of less than or equal to 9/32 as a threshold, compared with the diagnosis made by the psychiatrist, an overall Sensitivity of 0.83 and a specificity of 0.71 was reported.
Does the tool detect change in patients? Not yet examined.
Acceptability The ADRS should not be used with individuals who may be depressed but who have not had a stroke, or patients who do not have aphasia.
Feasibility The administration of the ADRS is quick and simple. It is unclear whether training is required to administer the ADRS. The ADRS contains 9 items (insomnia, anxiety-psychic, anxiety – somatic, somatic symptoms, hypchondriasis, loss of weight, apparent sadness, mimic and fatigability) and is scored by adding the score of each individual item.
How to obtain the tool?

The ADRS is available in the study by Benaim et al. (2004) or by clicking here.

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the Aphasic Depression Rating Scale (ADRS). We identified five studies. More studies are required before definitive conclusions can be drawn regarding the reliability and validity of the ADRS.

Reliability

Test-retest:
Benaim et al. (2004) examined the test-retest reliability of the ADRS in 15 subacute patients with aphasia due to stroke admitted to a neurorehabilitation unit. Patients were assessed twice at a 2-week interval by the same rehabilitation team. Agreement between items were assessed with kappa coefficients, and agreement for global scores was assessed with correlation coefficients. Kappa coefficients over the 9 items was adequate (kappa =0.58) (ranging from kappa = 0.33 to 1.00). For the global ADRS score, the correlation was excellent (r = 0.89).

Inter-rater:
Benaim et al. (2004) examined the inter-rater reliability of the ADRS in 15 subacute patients with aphasia due to stroke admitted to rehabilitation unit. Patients were assessed twice within 24 hours by 2 different rehabilitation teams. Kappa coefficients over the 9 items was excellent (kappa = 0.69) (ranging from 0.37 to 1.00). For the global ADRS score, the correlation was excellent (r = 0.89).

Validity

Content:
A team of 18 neurorehabilitation clinicians were interviewed regarding the most frequently reported depressive behaviours observed in patients with aphasia. Six experts then analyzed 3 existing Depression scales that contained items on observable behaivour: the Hamilton Depression Rating Scale (HDRS); the Montgomery and Asberg Depression Rating Scale; and the Salpetriere Retardation Rating Scale (SRRS). Only items that could be completed without interviewing, that described depressive behaviours reported by the team, and that were selected by at least 4 experts were retained. A total of 15 items were selected by the experts (Benaim et al., 2004).

Criterion:
Concurrent:
Benaim et al. (2004) examined the concurrent validity of the ADRS. Both dep-psy (psychiatrist rating of Depression) and dep-rehab (ratings made by members of the rehabilitation team) were used as the ‘gold standard‘. Wilcoxon test was calculated to find the best model. The Wilcoxon test value was 0.121 for the 7-item model and 0.116 for the 8-item model which was a minor increase so the 7-item model was selected: Apparent Sadness; Insomnia-Middle; Anxiety-Psychological; Somatic Symptoms-Gastrointestinal; Mimic-Slowness of Facial Mobility; Loss of Weight; and Anxiety-Somatic.

Predictive:
Not yet examined.

Construct:
Convergent: 
Benaim et al. (2004) examined the construct validity of the ADRS by comparing it to the dep-psy (psychiatrist rating of Depression – 50 patients), dep-rehab (ratings made by members of the rehabilitation team – 50 patients), and the Hamilton Depression Rating Scale (HDRS – 25 patients). The correlations between ADRS and dep-psy, dep-rehab, and HRDS were excellent (r = 0.60; r = 0.78; r = 0.77, respectively). correlation coefficients in right hemisphere stroke (RHS) patients only and in left hemisphere stroke (LHS) patients only ranged from adequate to excellent (r = 0.58; r = 0.70; r = 0.84, for RHS; r = 0.60; r = 0.86; r = 0.64, for LHS). The ADRS correlated better with dep-psy and dep-rehab (r = 0.59; r = 0.85, respectively) than did HDRS (r = 0.40; r = 0.59, respectively).

Factorial: 
A principal component analysis was conducted to analyze the structure of the original 15 items selected during content validity. Six items were eliminated to avoid redundancies and the remaining 9 items were selected to make up the final ADRS (Benaim et al., 2004).

Responsiveness

Benaim et al. (2010) examined the responsiveness of the ADRS and the Visual Analog Mood Scale (VAMS) in 49 patients with aphasia due to stroke admitted to rehabilitation units. A trained psychologist evaluated the patients at baseline, rating the severity of their Depression on a scale from 0 (no symptoms of Depression) to 10 (extremely severe Depression); and at the 30 day follow-up, classifying their status as ‘deteriorated’, ‘stable’ or ‘improved’ where changes greater than 1-point/10 were considered to be the minimal clinically important difference. The ADRS and VAMS were also administered at baseline and at the 30-day follow-up; and ADRS scores were converted to a 10-point scale for comparison. The ADRS was found to be more sensitive than the VAMS for detecting change in patients, demonstrating a large effect size for detecting deterioration and improvement (1.18 and -0.89 respectively) compared to the moderate and small effect size demonstrated by the VAMS (0.42 and -0.50 respectively). Changes in ADRS scores also showed excellent correlation (r=0.72) with severity of Depression as rated by the trained psychologist on a scale from 0 to 10.

Sensitivity/specificity:
Benaim et al. (2004) examined the Sensitivity and specificity of the ADRS in patients with stroke. The threshold for the diagnosis of Depression was calculated by comparing ADRS scores with the diagnosis made by the psychiatrist (Depression vs. no Depression). With a score of less than or equal to 9/32 as a threshold, compared with the diagnosis made by the psychiatrist, Sensitivity of the ADRS was 0.83 and specificity was 0.71.

References

  • Benaim, C., Cailly, B., Perennou, D., Pelissier, J. (2004). Validation of the aphasic depression rating scale. Stroke, 35, 1696.
  • Benaim, C., Decavel, P., Bentabet, M., Froger, J., Pelissier, J. & Perennou, D. (2010). Sensitivity to change of two depression rating scales for stroke patients. Clinical Rehabilitation, 24, 251-257.
  • Dantchev, N., Widlocher, D. (1998). The measurement of retardation in depression. J Clin Psychiatry, 59, 19-25.
  • Hamilton, M. (1967). Development of a rating scale for primary depressive illness. Br J Soc Clin Psychol, 6, 278-296.
  • Montgomery, S. A., Asberg, M. (1979). A new depression scale designed to be sensitive to change. Br J Psychiatry, 134, 382-389.

See the measure

How to obtain the ADRS

The ADRS is available in the study by Benaim et al. (2004) or by clicking here: ADRS.

Table of contents

Beck Depression Inventory (BDI, BDI-II)

Evidence Reviewed as of before: 19-08-2008
Author(s)*: Lisa Zeltzer, MSc OT
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The Beck Depression Inventory (BDI) is one of the most widely used screening instruments for measuring the severity of Depression in both adults and adolescents over the age of 13 (McDowell & Newell, 1996). The inventory is composed of items relating to depressive symptoms such as:

  • Hopelessness and irritability
  • Cognitions (such as guilt or feelings of being punished)
  • Physical symptoms (such as fatigue, weight loss, and lack of interest in sex).

The BDI can be used, but is not limited to, persons with stroke.

In-Depth Review

Purpose of the measure

The Beck Depression Inventory (BDI) is one of the most widely used screening instruments for measuring the severity of Depression in both adults and adolescents over the age of 13 (McDowell & Newell, 1996). The inventory is composed of items relating to depressive symptoms such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight loss, and lack of interest in sex. The BDI can be used, but is not limited to, persons with stroke.

Available versions

There are two versions of the BDI

The original BDI, first published in 1961 and later revised in 1971 (BDI-IA) and the BDI-II, a revised version of the BDI that was published in 1996, created to correspond with the updated DSM-IV criteria for Depression.

Features of the measure

Items:
– The original BDI
Contains 21 items and identifies symptoms and attitudes associated with Depression. The respondent must recall the relevance of each statement for today: mood, pessimism, sense of failure, lack of satisfaction, guilt, sense of punishment, self-hate, self-accusations, self-punitive wishes, crying spells, irritability, social withdrawal, indecisiveness, body image, work inhibition, sleep disturbance, fatigability, loss of appetite, weight loss, somatic preoccupation, and loss of libido.

– The BDI-IA
Same as the original BDI, but the respondent must recall the relevance of each statement based on the previous week including today.

– The BDI-II
Contains 21 items and identifies symptoms and attitudes associated with Depression. The BDI-II dropped four items (Weight Loss, Body Image Change, Somatic Preoccupation, and Work Difficulty) from the original BDI and replaced them with four new items (Agitation, Worthlessness, Concentration Difficulty, and Loss of Energy). The respondent must recall, based on the previous two weeks, the relevance of each statement relating to: sadness, pessimism, sense of failure, loss of pleasure, guilt, expectation of punishment, dislike of self, self-accusation, suicidal ideation, episodes of crying, irritability, social withdrawal, indecisiveness, worthlessness, loss of energy, insomnia, irritability, loss of appetite, preoccupation, fatigue, and loss of interest in sex (Beck & Steer, 1988).

Scoring:
– BDI scoring:
Each item is evaluated on a severity scale ranging from 0-3, with a total score ranging from 0-63

  • 0-10 on the BDI is considered absent or minimal Depression;
  • 10-18 mild to moderate Depression;
  • 19-29 is moderate Depression;
  • 30-63 is severe Depression.

– BDI-II scoring:
0-13 is considered none or minimal range Depression;

  • 14-19 mild Depression;
  • 20-28 moderate Depression;
  • 29-63 severe Depression.

Subscales:
None typically reported.

Equipment:
Only a pencil and the test are needed.

Training:
Traditionally, the BDI was designed to be administered by a trained interviewer. Today however, the BDI is commonly self-administered as it is short and simple to use. Patients must be able to understand spoken or written language and have a fifth- to sixth-grade reading level to adequately understand the questions (Groth-Marnat, 1990).

Time:
The BDI takes from 5-10 minutes to complete when self-administered, and 15 minutes to complete when interviewer-administered (Beck & Steer, 1988; McDowell & Newell, 1996). The questions are posed around a two-week period including today, as opposed to around the past week as in the original BDI. Thus, in the early post-stroke period, the BDI may be an inappropriate tool as the responses given in the early period are unlikely to provide a valid estimate of Depression.

Alternative forms of the BDI

The BDI-SF is a short form of the BDI and is composed of 13-items (Beck & Beck, 1972). The BDI-SF appears to have a level of internal consistency (coefficient alphas) comparable to that of the long form (Beck, Steer, & Garbin, 1988). Pearson product-moment correlation coefficients between the BDI and the BDI-SF have ranged from 0.89 to 0.97 indicating that the short form is an acceptable substitute for the long (Beck, Rial, & Rickets, 1974).

The BDI-FastScreen for medical patients (formerly known as BDI-Primary Care)is a 7-item self-report inventory designed specifically for use as a screening tool in medical patients. The BDI-FastScreen takes less than five minutes to complete and questions are posed around the past two weeks including today. It is thought to be a clinically effective screen for identifying medical inpatients who should be evaluated for Depression, however, it has not been found to be as sensitive a measure as the full BDI-II (Beck, Guth, & Steer, 1997; Sharp & Lipsky, 2002).

Client suitability

Can be used with:

  • Patients with stroke.

Aben, Verhey, Lousberg, Lodder and Honig (2002) found that the BDI was as acceptable a screening tool as the Hospital Anxiety and Depression Scale (HADS), the Symptom CheckList-90 Depression Scale (SCL-90), and the Hamilton Depression Rating Scale (HDRS) for detection of post-stroke Depression. However, while the BDI is one of the more commonly used measures of post-stroke Depression, there is insufficient literature to conclude that it is a reliable and valid diagnostic tool in the stroke population (Turner-Stokes & Hassan, 2002). One concern regarding diagnosis of Depression in individuals with stroke is that the somatic symptoms commonly associated with Depression may also arise from the stroke itself, or from hospitalization (e.g. fatigue). Because of its relatively low reliance on somatic symptoms, the BDI is considered one of the more useful tools in assessing post-stroke Depression (Turner-Stokes & Hassan, 2002). Further, Aben et al. (2002) found a high rate of misdiagnosis of Depression in stroke patients (almost 40% with the BDI), which makes the BDI less suitable for diagnosis in clinical settings. In patients with stroke, self-administration of the BDI may pose a difficulty because of stroke-specific communication difficulties and/or because of age-associated declines such as decreased vision, and therefore may require a trained interviewer. Patients must be able to understand spoken or written language and have a fifth- to sixth-grade reading level to adequately understand the questions (Groth-Marnat, 1990).

Should not be used in:

  • Patients who are severely cognitively impaired. For these patients, the Structured Assessment for Depression in Brain Damaged Individuals is a potential alternative (Turner-Stokes & Hassan, 2002).
  • Patients with aphasia. For patients with aphasia, the stroke Aphasic Depression Questionnaire (SADQ) and the Aphasic Depression Rating Scale (ADRS) were developed to detect Depression.
  • Patients with seriously impaired communication but a reliable yes/no response, the Structured Assessment for Depression in Brain Damaged Individuals is a potential alternative (Turner-Stokes & Hassan, 2002).

In what languages is the measure available?

    • Arabic – validated (Abdel-Khalek et al., 1998)
    • Cambodian – translated without validation (Savin et al., 1996)
    • Chinese – validated (Zheng et al., 1988)<
    • Dutch – validated (Bosscher et al., 1986)
    • Finnish – validated (Raitasalo, 1995)
    • French – validated (Collet et al., 1986)
    • German – validated (Hautzinger, 1991)
    • Italian – translated without validation (Ranchetti, 1987)
    • Japanese – validated (Kojima et al., 2002)
    • Korean – translated without validation (Sung et al., 1992)
    • Persian – validated (Ghassemzadeh et al., 2005)
    • Polish – validated (Parnowski et al., 1977)
    • Portuguese – validated (Gorenstein et al., 1996; 1999)
    • Spanish – validated (Sanz et al., 2005)
    • Serbo – Croatian (roman script) validated (Grubac, 1989)
    • Swedish – validated (Byrne et al., 1995)
    • Turkish – validated (Hisli, 1988)
    • Xhosa – translated without validation (Drennan et al., 1991)

Summary

What does the tool measure? Depression.
What types of clients can the tool be used for? Both adults and adolescents over the age of 13. Can be used, but is not limited to, persons with stroke.
Is this a screening or assessment tool? screening.
Time to administer Self-administration: 5-10 minutes; interview-administration: 15 minutes.
The questions are posed around a two-week period including today, as opposed to around the past week as in the original BDI. Thus, in the early post-stroke period, the BDI may be an inappropriate tool as the responses given in the early period are unlikely to provide a valid estimate of Depression.
Versions Original BDI; BDI-II; BDI-FastScreen for medical patients; BDI-Short Form.
Other Languages Validated in: Arabic; Chinese; Dutch; Finnish; French; German; Japanese; Persian; Polish; Portuguese; Spanish; Serbo – Croatian (roman script); Swedish; Turkish
Translated without validation in: Cambodian; Italian; Korean; Xhosa.
Measurement Properties
Reliability Internal consistency:
Out of one study and one meta-analysis examining Internal consistency, both reported excellent Internal consistency.

Test-retest:
One study examining test-retest reliability and reported adequate test-retest.

Validity Content:
The BDI-II was designed to take into account the depressive criteria of the DSM-IV.

Criterion:
Adequate to excellent correlation coefficients with the Depression scale of the Minnesota Multiphasic Personality Inventory, Zung Self-Rating Depression Scale, Multiple Affect Adjective Checklist, Depression Scale HOPKINS Symptom Check List, Hamburg Depression Scale, Inventory to Diagnose Depression.
Poor to excellent in psychiatric patients with F-Rating; DSM-III; Hamilton Depression Rating Scale; adequate to excellent in non-psychiatric patients.

Construct:
Excellent correlation with BDI-IA; Revised Hamilton Psychiatric Rating Scale for Depression; Geriatric Depression Scale. Adequate correlation with the Beck Hopelessness Scale; Scale for Suicide Ideation; Beck Anxiety Inventory; Revised Hamilton Anxiety Rating Scale.

Does the tool detect change in patients? Out of 2 studies examined, both found that the BDI is able to detect significant change in patients with stroke and in psychiatric patients with affective and anxiety disorders.
Acceptability Although the BDI takes only 5-10 minutes, problems with completion have been noted within a stroke population. The scale has not been tested for administration using proxy respondents.
Feasibility The BDI is short and simple to administer and requires no training. There is limited information available regarding its effectiveness when used for evaluation purposes in a longitudinal study.
How to obtain the tool?

The BDI can be purchased at: http://harcourtassessment.com

Psychometric Properties

Overview

There is an abundance of research on the psychometric properties of the BDI. However, little research has been conducted specifically in a post-stroke population. For the purposes of this review, we conducted a literature search to identify all relevant publications on the psychometric properties of the BDI. We then selected to review articles from high impact journals, and from a variety of authors. We preferentially reviewed studies examining the psychometric properties of the BDI-II rather than the BDI-IA, when available, as the BDI-II corresponds closely to DSM-IV depression criteria and is found to be a more reliable measure of depression (Beck & Steer, 1988).

Reliability

Internal consistency:
In a meta-analysis by Beck and Steer (1988), the Internal consistency of the BDI had a Cronbachs alpha of 0.86 for psychiatric patients and 0.81 for non-psychiatric subjects. The BDI-II is superior to the BDI-IA in terms of its Internal consistency (Beck & Steer, 1988).

Aben et al. (2002) compared the Internal consistency of the BDI to the Hospital Anxiety and depression Scale, and the Symptom CheckList-90 depression Scale in 202 patients 1-month post-stroke. The BDI was associated with a Cronbachs alpha of 0.83, alpha for the Hospital Anxiety and depression Scale = 0.85, and for the Symptom CheckList-90, 0.88. Although, the BDI had a lower Internal consistency than the other two self-rated scales, it was considered to have excellent Internal consistency (Cronbachs alpha exceeded 0.80) in this patient population.

Test-retest:
The BDI-II test-retest, administered 1-week apart in a sample of 895 college students, had an intraclass correlation coefficient (ICC) for agreement of 0.73 (Wiebe & Penley, 2005) showing adequate test-retest reliability for the BDI-II.

Validity

Criterion:

Concurrent:
In a review article on the validity of the BDI (Richter, Werner, Heerlein, Kraus, & Sauer, 1998), studies on the concurrent validity of the BDI with other self-rating depression scales (including the depression scale of the Minnesota Multiphasic Personality Inventory (MMPI), the Zung Self-Rating depression Scale, the Multiple Affect Adjective Checklist, the depression Scale HOPKINS Symptom Check List, the Hamburg depression scale and the Inventory to Diagnose depression) indicated moderate to high correlation coefficients with all scales, with mean coefficients ranging from 0.58 to 0.79.

Coefficients of concurrent validity when using the observer rated scales (F-Rating, a clinical rating scale, in most cases, it is a four graded rating – for no severe depression; DSM-III; and Hamilton depression Rating Scale), varied to a larger degree than validity coefficients associated with self-rating (0.19 to 0.90 in psychiatric patients; 0.55 to 0.75 in non-psychiatric patients). The validity coefficients varied depending on the composition of the sample (severity of depression, number of psychotic patients).

Aben et al. (2002) interviewed 202 patients 1 month after their first stroke. First, they were interviewed with both the depression section of the Structured Clinical Interview for DSM-IV (SCID) and the Hamilton depression Rating Scale. Patients were diagnosed as having major depression if they had at least one core symptom (i.e. depressed mood or loss of interest) and at least four other symptoms of depression that had lasted at least 2 weeks. Then patients filled out the BDI at home after the interview. In these patients, using a cut-off score of 10 to represent clinically significant depression, the BDI was found to have a sensitivity of 80.0 and a specificity of 61.4 suggesting that the BDI is an acceptable screening instrument for post-stroke depression (Aben et al., 2002).

Content:

The BDI-II was designed to take into account the depressive criteria of the DSM-IV.

Construct:

The BDI is able to differentiate between a number of hypothesized relationships between biological, behavioral, and attitudinal variables indicative of depression (Beck et al, 1988). For example, Brooksbank and Coppen (1967) studied the biological correlates of depression, and reported that patients with higher BDI scores had higher concentrations of plasma 11-hydroxycorticosteroids (a biological correlate of depression) than patients with lower BDI scores. With respect to behavioral relationships, Albert and Beck (1975) reported that the BDI was positively related to teacher ratings of student maladjustment in the seventh grade (r= 0.62) and in the eighth grade (r= 0.60). Further evidence comes from the positive relationships found with depression as measured by the BDI and a variety of medical symptoms (e.g. headaches, upset stomachs) (Armstrong, Goldenberg, & Stuart, 1980; Cavanaugh, Clark, & Gibbons, 1983), depressive thoughts (Dobson & Breiter, 1983; Gotlib, 1984), suicidal behaviors (Emery, Steer, & Beck, 1981; Lester & Beck, 1975; Silver, Bohnert, Beck & Marcus, 1971), loneliness (Gould, 1982; Reynolds & Gould, 1981), and stress (Hammen & Mayol, 1982; Monroe, Imhoff, Wise, & Harris, 1983).

Analyses of convergent and divergent validity of the BDI-II have given the following correlations:

  • r = 0.93 with the BDI-IA (191 patients) (Beck, Steer, Ball, & Ranjeri, 1996)
  • r = 0.59 with the Beck Hopelessness Scale (160 patients) (Beck, Brown, Epstein, & Steer, 1988)
  • r = 0.37 with the Scale for Suicide Ideation (158 patients)
  • r = 0.48 with the Beck Anxiety Inventory (160 patients) (Beck et al., 1988)
  • r = 0.71 with the Revised Hamilton Psychiatric Rating Scale for depression (87 patients) (Riskind, Beck, Brown, & Steer, 1987)
  • r = 0.47 with the Revised Hamilton Anxiety Rating Scale (87 patients) (Riskind et al., 1987)

These results are congruent with the fact that anxiety, suicidal ideas, and hopelessness are correlated with depression, without being identical concepts.

Snyder, Stanley, Novy, Averill, and Beck (2000) demonstrated convergence between the BDI and the Geriatric depression Scale (r = 0.78). Divergence was shown between measures of anxiety (r = 0.33), worry (r = 0.39) and quality of life (r = -0.46).

In a factor analysis of the BDI responses of patients and non-patients, Beck and Steer (1988) found that 3 factors were consistently identified across diagnostic groups. These were: cognitive-affective, performance, and somatic. In a factor analysis of the BDI-II, two factors were identified: somatic-affective and cognitive (Beck & Steer, 1996).

Responsiveness

House et al. (1991) followed 128 patients over a period of one year after their first stroke. The BDI was found to be concordant with DSM criteria over this time, and was sensitive to change. For stroke patients the somatic symptoms declined over one year, while there was no significant change in cognitive affective symptoms.

Both the BDI and the Montgomery Asberg depression Rating Scale (MADRS-S) were able to detect significant change in 86 psychiatric patients with mainly affective and anxiety disorders during treatment with antidepressants (Svanborg & Asberg, 2001).

Only two studies were identified on the psychometric properties of the BDI specific to a post-stroke population (Aben et al., 2002; Turner-Stokes & Hassan, 2002).

A 3-year randomized controlled trial (RCT) to examine the psychometric properties of the Hamilton depression Rating Scale, Hospital Anxiety and depression Scale, and BDI in patients with stroke is currently being conducted by Ching-Lin Hsieh, at the School of Occupational Therapy, College of Medicine and National Taiwan University. This study will compare the validity, responsiveness, and acceptability of these scales in 200 patients post-stroke. The inter-rater reliability of the three depression scales will be examined in the first year in 60 chronic stroke patients and in the second year, the test-retest reliability and measurement error of the three depression scales will be examined. This study is expected to be complete in July 2008.

References

  • Abdel-Khalek, A. M. (1998). Internal consistency of an Arabic adaptation of the Beck Depression Inventory in four Arab countries. Psychol Rep, 82(1), 264-266.
  • Aben, I., Verhey, F., Lousberg, R., Lodder, J., Honig, A. (2002). Validity of the Beck Depression Inventory, Hospital Anxiety and Depression Scale, SCL-90, and Hamilton Depression Rating Scale as screening instruments in stroke patients. Psychosomatics, 43, 386-393.
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See the measure

The BDI can be purchased at: http://harcourtassessment.com

Table of contents

DOC Screen

Evidence Reviewed as of before: 30-04-2019
Author(s)*: Alexandra Matteau
Editor(s): Annabel McDermott
Content consistency: Gabriel Plumier

Purpose

The DOC screen is a screening tool that can be used to identify individuals at high risk of depression, obstructive sleep apnea and cognitive impairment following a stroke.

In-Depth Review

Purpose of the measure

The DOC screen is a screening tool that identifies individuals at high risk of depression, obstructive sleep apnea and cognitive impairment following a stroke.

Available versions

The DOC screen was developed by Swartz et al. and was first published in 2013. The tool was developed by combining and modifying three existing validated brief screens, the 2-item Patient Health Questionnaire (PHQ-2), the STOP questionnaire and a 10-point version of the Montreal Cognitive Assessment (MoCA).

Features of the measure

Items:

The DOC screen comprises three screening tests:

DOC – Mood (PHQ-2)

This test comprises two items with the purpose of screening for depression. The test evaluates the degree to which an individual has experienced depressed mood and anhedonia over the past two weeks.

DOC – Apnea (STOP Questionnaire)

This test comprises four items with the purpose of screening for obstructive sleep apnea: snoring, tiredness during daytime, breathing interruption during sleep, and hypertension.

DOC – Cog (10-point version of the MoCA)

This test comprises three tasks with the purpose of screening for cognitive impairment: clock drawing, abstraction, and 5-word recall (memory).

Scoring:

Each subscale has different scoring and is interpreted independently.

DOC – Mood (total score 0-6)

The two items are scored from 0-3 whereby the respondent is asked to rate how often each symptom occurred over the last 2 weeks:

  • 0 = not at all
  • 1 = several days
  • 2 = more than half of the days
  • 3 = nearly every day.

DOC – Apnea (total score 0-4)

The four items are scored on a dichotomic scale (0 = no, 1 = yes) according to whether or not the respondent experiences each symptom.

DOC – Cog (total score 0-10)

  • Clock drawing task (0-3 points): 1 point each is given for (i) contour, (ii) numbers and (iii) the hands of the clock.
  • Abstraction task (0-2 points): 1 point is given for each item pair correctly answered.
  • Delayed recall task (0-5 points): 1 point is given for each word recalled without any cues.

The score for each task is summed to calculate the subscale score.

Each subscale is then summed to obtain a total score ranging between 0 and 20.

A raw score interpretation and a regression interpretation can be obtained at http://www.docscreen.ca/.

Time:

The DOC screen takes approximately 5 minutes to complete.

Subscales:

The DOC screen is comprised of three subscales: DOC Mood, DOC Apnea and DOC Cog.

Equipment:

A pencil and the test form are needed to complete the DOC screen.

Training:

No training requirements have been reported. The DOC screen can be administered by any individual who is able to correctly follow the instructions, but must be interpreted by a qualified health professional.

Alternative forms of the DOC Screen:

An alternative version is available and uses different words for the memory and abstraction tasks. This version must be used if the patient has previously been exposed to the MoCA or DOC screen to minimize any learning effects associated with repeated administration.

The E-DOC screen is an electronic version of the tool, which is available through the DOC screen website. The E-DOC screen has not been validated.

Client suitability

Can be used with:

  • Patients with stroke.
  • The DOC screen may also be suitable for use among patients with other neurological and vascular disorders such as multiple sclerosis, Alzheimer’s disease, mild cognitive impairment, Parkinson’s Disease and traumatic brain injury. However, no study has been conducted with this population.

Should not be used with:

While no contraindications have been reported, some considerations must be made when completing the test:

  • A translator, family member or caregiver can provide translation for patients who do not speak English fluently;
  • Provide visual aid (e.g. glasses) for patients with visual loss;
  • Speak loudly and clearly for patients with reduced hearing;
  • Motor tasks such as the clock drawing activity may be difficult for patients with motor impairments – use sound clinical judgement for this task;
  • Use alternative communication strategies for patients with aphasia.

In what languages is the measure available?

English

Summary

What does the tool measure? Depression, obstructive sleep apnea and cognitive impairment following stroke.
What types of clients can the tool be used for? Patients with stroke.
Is this a screening or assessment tool? screening.
Time to administer 5 minutes
Versions
  • DOC screen
  • E-DOC screen
  • A second version is available to minimize learning effects associated with repeated administration.
Languages The DOC screen is only available in English.
Measurement Properties
Reliability Internal consistency:
No studies have examined Internal consistency of the DOC screen.

Test-retest:
No studies have examined test-retest reliability of the DOC screen.

Intra-rater:
No studies have examined intra-rater reliability of the DOC screen.

Inter-rater:
No studies have examined inter-rater reliability of the DOC screen.

Validity Criterion:
Concurrent:
No studies have examined concurrent validity of the DOC screen.

Predictive:
No studies have examined predictive validity of the DOC screen.

Construct:
Convergent/Discriminant:
No studies have examined convergent validity of the DOC screen.

Known groups:
No studies have examined known groups validity. However, one study examined the sensitivity and specificity and reported that the DOC screen is a valid measure that can reliably identify patients at high-risk of Depression, obstructive sleep apnea and cognitive impairment.

Floor/Ceiling Effects No studies have examined the floor or ceiling effects of the DOC screen.
Does the tool detect change in patients? Not reported.
Acceptability The DOC screen is a standardized screening tool suitable for use with stroke patients.
Feasibility The measure is brief, easy to score and requires no formal training. A study on 1503 patients showed that 89% of participants completed the screen in 5 minutes or less.
How to obtain the tool?

The DOC screen is free to use for clinical and educational purposes.

The administration manual and forms are available online from the following website: http://www.docscreen.ca/

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the DOC screen in individuals with stroke. We identified only one study, which was published in part by the developers of the measure. More studies are required before definitive conclusions can be drawn regarding the reliability and validity of the DOC screen.

Floor/Ceiling Effects

No studies have examined the floor or ceiling effects of the DOC screen.

Reliability

Internal consistency:
No studies have examined the Internal consistency of the DOC screen.

Test-retest:
No studies have examined the test-retest reliability of the DOC screen.

Inter-rater:
No studies have examined the inter-rater reliability of the DOC screen.

Intra-rater:
No studies have examined the intra-rater reliability of the DOC screen.

Validity

Criterion:

Concurrent:
No studies have examined the concurrent validity of the DOC screen.

Predictive:
No studies have examined the predictive validity of the DOC screen.

Construct:

Convergent/Discriminant:
No studies have examined the convergent validity of the DOC screen.

Known groups:
No studies have examined the known groups validity of the DOC screen.

Responsiveness

No studies have examined the responsiveness of the DOC screen.

Sensitivity and Specificity:

Swartz et al. (2017) examined the sensitivity and specificity of the DOC screen for detecting depression, obstructive sleep apnea and cognitive impairment using receiver operating characteristic (ROC), area under the curve analyses (AUC) and the two-cut point approach. DOC-Mood was compared with the Structured Clinical Interview for DSM Disorders (SCID-D) and excellent sensitivity (92%) and specificity (99%) was identified for detecting depression (AUC=0.898). DOC-Apnea was compared with results on polysomnography (PSG) and excellent sensitivity (95%) and specificity (96%) for detecting obstructive sleep apnea was identified (AUC=0.660). DOC-Cog was compared to a 30-minute neuropsychological tests protocol proposed by Hachinski et al. (2006) and excellent sensitivity (100%) and specificity (95%) for detecting cognitive impairment was identified (AUC=0.776).

References

  • Hachinski, V., Iadecola, C., Petersen, R. C., Breteler, M. M., Nyenhuis, D. L., Black, S. E., … & Vinters, H. V. (2006). National Institute of Neurological Disorders and Stroke–Canadian stroke network vascular cognitive impairment harmonization standards. Stroke, 37 (9), 2220-2241.
  • Swartz, R. H., Cayley, M. L., Lanctôt, K. L., Murray, B. J., Cohen, A., Thorpe, K. E., … & Herrmann, N. (2017). The “DOC” screen: Feasible and valid screening for depression, Obstructive Sleep Apnea (OSA) and cognitive impairment in stroke prevention clinics. PloS one, 12 (4), e0174451.

See the measure

How to obtain the DOC Screen?

The form and manual of administration are available online from the following website: http://www.docscreen.ca/

The Doc screen is free to use for clinical and educational purposes and therefore no permissions are required.

Table of contents

General Health Questionnaire – 28 (GHQ-28)

Evidence Reviewed as of before: 18-01-2015
Author(s)*: Annabel McDermott, OT
Editor(s): Annie Rochette, PhD OT
Content consistency: Gabriel Plumier

Purpose

The General Health Questionnaire – 28 (GHQ-28) is a self-report questionnaire that is used as a screening tool for psychological wellbeing.

In-Depth Review

Purpose of the measure

The General Health Questionnaire – 28 (GHQ-28) is self-report screening measure used to detect possible psychological disorder. The GHQ-28 identifies two main concerns: (1) the inability to carry out normal functions; and (2) the appearance of new and distressing phenomena (Goldberg & Hillier, 1979).

Available versions

The GHQ-28 is derived from the original 60-item General Health Questionnaire. There is also a 30-item version (GHQ-30) and a 12-item version (GHQ-12).

Features of the measure

Items:
The GHQ-28 consists of 28 questions designed to identify whether an individual’s current mental state differs from his/her typical state. Questions include:

Have you recently been feeling perfectly well and in good health?
Have you recently lost much sleep over worry?
Have you recently been managing to keep yourself busy and occupied?
Have you recently felt constantly under strain?
Have you recently felt that life is entirely hopeless?

Factor analysis of the GHQ-28 identified four 7-item subscales:
Somatic symptoms (items 1-7)
Anxiety/insomnia (items 8-14)
Social dysfunction (items 15-21)
Severe depression (items 22-28).

There is a high correlation between the anxiety subscale and the total score, showing that anxiety is a common symptom of psychiatric disorders (Goldberg & Hillier, 1979). Accordingly, subscales are not independent of each other and subscores should not be used to indicate specific psychological diagnoses. Rather, the measure is used to identify the presence of symptoms compared to what is normal for the individual (Salter et al., 2013).

Scoring:
The individual is asked to rate how he/she feels in relation to each question, according to the following criteria:

  • Better than usual
  • Same as usual
  • Worse than usual
  • Much worse than usual

Different scoring methods have been reported. One scoring method adopts a Likert scale of 0 to 3, resulting in a total possible score range of 0 to 84. This Likert scoring system was used with the original 60-item GHQ (Goldberg & Hillier, 1979).

An alternative and more common method attributes a binary score system of 0 to the first and second response options (better than usual, same as usual) and a score of 1 to the third and fourth response options (worse than usual, much worse than usual).

Some note that this scoring system is not sensitive to individuals with chronic conditions, where the individual may have experienced a symptom for a prolonged period of time (O’Rourke et al., 1998). Accordingly, the chronic scoring method attributes a score of 0 to the first item (better than usual) and a score of 1 to the third and fourth items, as per the traditional scoring method. The second item (‘same as usual’) receives a score of 0 for negative items and a score of 1 for positive items.

Response option Traditional (acute) scoring method Chronic scoring method Likert scoring method
Better than usual 0 0 (all items) 0
Same as usual 0 0 (negative items)1 (positive items) 1
Worse than usual 1 1 2
Much worse than usual 1 1 3

Higher scores indicate a greater possibility of psychological distress. A score ≥5 has been reported to indicate probable cases of psychiatric disorder (Anderson et al., 1996), however this has not been validated as the most appropriate score for the stroke population (Salter et al., 2013).

What to consider before beginning:
The choice of scoring method may impact diagnosis.
The GHQ-28 is not designed to detect chronic mental health conditions.

Time:
The GHQ-28 takes approximately 5 minutes to administer.

Training requirements
No training requirements have been specified for the GHQ-28, however it is advised that clinicians read the assessment manual prior to use.

Equipment
The GHQ-28 is a self-report questionnaire that does not require specific equipment.

Client suitability

Can be used with:

  • Individuals with stroke
  • Individuals with cardiac conditions
  • Individuals with spinal cord injury
  • Individuals with musculoskeletal conditions
  • The elderly (Rehabilitation Measures Database, 2010)

Should not be used with:

  • The GHQ-28 has not been reported to be unsuitable for use with any particular population.

In what languages is the measure available?

  • The GHQ-28 is available in 38 languages (Sterling, 2011) and has cross-cultural applicability (Kilic et al., 1997).

Summary

What does the tool measure? Psychological wellbeing.
What types of clients can the tool be used for? The GHQ-28 can be used with, but is not limited to, patients with stroke.
Is this a screening or assessment tool? screening.
Time to administer 5 minutes.
ICF Domain Body Function.
Versions GHQ (original 60-item version)
GHQ-30
GHQ-28
GHQ-12
Other Languages The GHQ is available in 38 languages
Measurement Properties
Reliability Internal consistency:
No studies have reported on Internal consistency of the GHQ in a sample of individuals with stroke.

Test-retest:
One study reported excellent test-retest reliability of the GHQ-28 in a sample of individuals with stroke (time since stroke not specified).

Intra-rater:
No studies have reported on the intra-rater reliability of the GHQ in a sample of individuals with stroke.

Inter-rater:
No studies have reported on the inter-rater reliability of the GHQ in a sample of individuals with stroke.

Validity Criterion:
Concurrent:
– One study reported excellent concurrent validity between the GHQ-28 total score and the Zung Self-Rating Depression Scale, Hamilton Depression Scale and the Present State Examination.
– One study reported no difference between the GHQ-30 and HAD Scale total scores when identifying any DSM-IV diagnosis, anxiety or Depression.

Predictive:
One study reported that patients with acute to chronic stroke who were diagnosed as depressed according to ICD-10 or DSM-IIIR criteria achieved a significantly higher GHQ-28 total score than patients who were not diagnosed as depressed; a score >4 on the GHQ-28 correlated with Depression among participants.

Construct:
Convergent/Discriminant:
– One study reported adequate correlations between the GHQ-12 and the stroke and Aphasia Quality of Life scale (SAQOL) and SAQOL-39 mean scores; adequate correlations between the GHQ-12 and SAQOL subtests; and adequate to excellent correlations between the GHQ-12 and SAQOL-39 subtests.
– One study reported that individuals with stroke with a Beck Depression Inventory (BDI) score of 11-18 (mild Depression) demonstrated GHQ-28 median scores of 27.0 and 28.0 at 1 and 6 months post-stroke respectively; individuals with a BDI score ≥19 (severe Depression) demonstrated GHQ-28 median scores of 44.0 and 48.0 at 1 and 6 months post-stroke respectively.
– No studies have reported on cross-diagnostic Validity of the GHQ in a sample of individuals with stroke.

Known Groups:
No studies have reported on known-group Validity of the GHQ in a sample of patients with stroke.

Floor/Ceiling Effects

– No studies have reported on floor/ceiling effects of the GHQ within a sample of individuals with stroke.

Does the tool detect change in patients?

– The GHQ-28 is intended for use as a screening instrument and therefore is not designed to measure change over time.
– One study reported 81% sensitivity and 68% specificity of the GHQ-28 when using cutoff scores of 11/12 (optimal in relation to DSM-IIIR criteria), or 85% sensitivity and 61% specificity when using cutoff scores of 7/8 (optimal in relation to ICD-10 criteria).
– One study examined reported 80% sensitivity and 76% specificity of the GHQ-30 when using a cutoff score of 8/9.

Acceptability The GHQ-28 is non-invasive and quick to administer. Caution should be exercised with scoring.
Feasibility The GHQ-28 is suitable for administration in various settings. The assessment is quick to administer and requires minimal specialist equipment or training.
How to obtain the tool?

https://www.gl-assessment.co.uk/products/general-health-questionnaire-ghq/

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the GHQ relevant to the stroke population. Five studies were identified. Please note that three of these studies use the GHQ-28 (Lincoln et al., 2003; Robinson & Price, 1982; Thomas & Lincoln, 2006); one study that used the GHQ-30 (O’Rourke et al., 1998) and one study that used the GHQ-12 (Hilari et al., 2003) were also included.

Floor and ceiling effect

No studies have reported on the floor or ceiling effects of the GHQ in a sample of individuals with stroke.

Reliability

Internal consistency:
No studies have reported on Internal consistency of the GHQ in a sample of individuals with stroke.

Test-retest:
Robinson and Price (1982) examined test-retest reliability of the GHQ-28 with a sample of 20 individuals (time since stroke not specified) and reported excellent 2-month test-retest reliability (r=0.90).

Intra-rater:
No studies have reported on the intra-rater reliability of the GHQ in a sample of individuals with stroke.

Inter-rater:
No studies have reported on the inter-rater reliability of the GHQ in a sample of individuals with stroke.

Validity

Content:

The GHQ-28 is a scaled version of the original 60-item GHQ developed by Goldberg in 1978. Factor analysis of the original GHQ was conducted in a sample of 523 individuals who attended a primary care setting, resulting in the 28-item version with four 7-item subscales (Goldberg & Hillier, 1979).

Criterion:

Concurrent:
Robinson and Price (1982) examined concurrent validity of the GHQ-28 in a sample of 103 individuals with stroke (time since stroke not specific) by comparison with other psychopathology scales. The authors reported excellent concurrent validity between the GHQ-28 total score and the Zung Self-Rating Depression Scale (r=0.86), Hamilton Depression Scale (r=0.88) and the Present State Examination (r=0.94).

O’Rourke et al. (1998) examined concurrent validity of the GHQ-30 in a sample of 105 individuals with chronic stroke by comparison with the Hospital Anxiety and Depression (HAD) Scale. There was no difference between the GHQ-30 and HAD Scale total scores when identifying any DSM-IV diagnosis (p=0.95), anxiety (p=0.25) or Depression (p=0.56), using ROC curves.
Note: The study used the conventional 0-0-1-1 format to score the GHQ-30; this version of the GHQ is not split into subscales for Depression and anxiety.

Predictive:
Lincoln et al. (2003) examined predictive validity of the GHQ-28 in a mixed sample of 143 stroke patients with acute to chronic stroke. Patients who were diagnosed as depressed according to the ICD-10 or DSM-IIIR achieved a significantly higher (p≤0.01) GHQ-28 total score than patients who were not diagnosed as depressed (ICD-10: kappa=0.40, IQR depressed 9-19/not depressed 3-12; DSM-IIIR: kappa=0.12, IQR depressed 12-21/not depressed 5-13). A score >4 on the GHQ-28 correlated with Depression among participants.

GHQ-28 ICD-10 DSM-IIIR
Depressed (42%) Not depressed (52%) Depressed (15%) Not depressed (77%)
IQR 9-19 3-12 12-21 5-13
Kappa 0.40 0.12

Construct:

Convergent/Discriminant :
Hilari et al. (2003) examined convergent validity of the GHQ-12 in a sample of 83 individuals with chronic stroke and aphasia, by comparison with the stroke and aphasia Quality of Life scale (SAQOL) and the SAQOL-39. The study yielded an adequate correlation between the GHQ-12 and SAQOL mean (r=0.58, p<0.01) and between the GHQ-12 and the SAQOL-39 mean (0.53, p<0.01). Correlations between the GHQ-12 and SAQOL subtests were adequate (mood r=0.57, thinking r=0.41, personality r=0.57, energy r=0.32, family roles r=0.41, social roles r=0.41, work r=0.34, p<0.01). Correlations between the GHQ-12 and SAQOL-39 subtests were adequate (physical r=0.39, energy r=0.32, p<0.01) to excellent (psychosocial r=0.62, p<0.01).

Thomas and Lincoln (2006) reported on convergent validity of the GHQ-28 in a sample of 123 individuals with stroke and Depression, by comparison with the Beck Depression Inventory (BDI). Measures were taken at 1 month and 6 months post-stroke. Individuals who were diagnosed with mild Depression (BDI score of 11-18) demonstrated GHQ-28 median scores of 27.0 (IQR=21.5-36.0) and 28.0 (IQR=22.0-37.0) at 1 and 6 months post-stroke respectively. Individuals with severe Depression (BDI score ≥19) demonstrated GHQ-28 median scores of 44.0 (IQR=32.0-54.5) and 48.0 (IQR=35.0-55.0) at 1 and 6 months post-stroke respectively.

Known Group:
No studies have reported on known-group validity of the GHQ in a sample of patients with stroke.

Responsiveness

Sensitivity & Specificity:
Lincoln et al. (2003) examined Sensitivity and Specificity of the GHQ-28 in a mixed sample of 143 stroke patients with acute to chronic stroke. The study found that optimal cutoff scores for the GHQ-28 in relation to DSM-IIIR and ICD-10 criteria were 11/12 (Sensitivity 81%, Specificity 68%) and 7/8 (Sensitivity 85%, Specificity 61%) respectively.

GHQ-28 cutoff score ICD-10 diagnosis DSM-IIIR diagnosis
Sensitivity Specificity Sensitivity Specificity
5 0.98 0.35 1.00 0.24
6 0.98 0.44 1.00 0.29
7 0.88 0.55 0.95 0.41
8 0.85 0.61 0.95 0.47
9 0.78 0.63 0.95 0.52
10 0.72 0.68 0.86 0.57
11 0.63 0.72 0.81 0.63
12 0.57 0.73 0.81 0.68
13 0.48 0.76 0.76 0.73
14 0.47 0.80 0.71 0.76
15 0.43 0.84 0.67 0.80

O’Rourke et al. (1998) examined Sensitivity and Specificity of the GHQ-30 in a sample of 105 individuals with chronic stroke. Using previously recommended cutoff scores of 4/5 yielded Sensitivity and Specificity scores of 0.9 and 0.47 (respectively). The authors recommended a cutoff score of 8/9, which achieved Sensitivity and Specificity scores of 0.8 and 0.76 (respectively).

References

Anderson, C., Laubscher, S., & Burns, R. (1996). Validation of the Short Form 36 (SF-36) health survey questionnaire among stroke patients. Stroke, 27, 1812-6.

Goldberg, D.P. & Hillier, V.F. (1979). A scaled version of the General Health Questionnaire. Psychological Medicine, 9, 139-45.

Hilari, K., Byng, S., Lamping, D.L., & Smith, S.C. (2003). Stroke and Aphasia Quality of Life Scale-39 (SAQOL-39): Evaluation of acceptability, reliability and validity. Stroke, 34, 1944-50.

Kilic, C., Rezaki, M., Rezaki, B., Kaplan, I., Ozgen, C., Sagduyu, A., & Ozturk, M.O. (1997). General Health Questionnaire (GHQ12 & GHQ28): psychometric properties and factor structure of the scales in a Turkish primary care sample. Social Psychiatry and Psychiatric Epidemiology, 32, 327-31.

Lincoln, N.B., Nicholl, C.R., Flannaghan, T., Leonard, M., & Van der Gucht, E. (2003). The validity of questionnaire measures for assessing depression after stroke. Clinical Rehabilitation, 17, 840-6.

Malakouti, S.M., Fatollahi, P., Mirabzadeh, A., & Zandi, T. (2007). Reliability, validity and factor structure of the GHQ-28 used among elderly Iranians. International Psychogeriatrics, 19(4), 623-34.

O’Rourke, S., MacHale, S., Signorini, D., & Dennis, M. (1998). Detecting psychiatric morbidity after stroke: Comparison of the GHQ and HAD Scale. Stroke, 29, 980-5.

Rehabiliation Measures Database. (2010). General Health Questionnaire-28. Retrieved from http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=909

Robinson, R.G. & Price, T.R. (1982). Post-stroke depressive disorders: A follow-up study of 103 patients. Stroke, 13(5), 635-40.

Salter, K., Campbell, N., Richardson, M., Mehta, S., Jutai, J., Zettler, L., Moses, M., McClure, A., Mays, R., Foley, N., & Teasell, R. (2013). Outcome Measures in Stroke Rehabilitation. Retrieved from http://www.ebrsr.com/sites/default/files/Chapter21_Outcome-Measures_FINAL_16ed.pdf

Sterling, M. (2011). General Health Questionnaire – 28 (GHQ-28). Journal of Physiotherapy, 57, 259.

Thomas, S.A. & Lincoln, N.B. (2006). Factors relating to depression after stroke. British Journal of Clinical Psychology, 45, 49-61.

Werneke, U., Goldberg, D.P., Yalcin, I., & Ustun, B.T. (2000). The stability of the factor structure of the General Health Questionnaire. Psychological Medicine, 30, 823-9.

Willmott, S.A., Boardman, J.A.P., Henshaw, C.A., & Jones, P.W. (2004). Understanding General Health Questionnaire (GHQ-28) score and its threshold. Social Psychiatry and Psychiatric Epidemiology, 39, 613-7.

See the measure

How to obtain theGeneral Health Questionnaire – 28 (GHQ-28)?

https://www.gl-assessment.co.uk/products/general-health-questionnaire-ghq/

Table of contents

Geriatric Depression Scale (GDS)

Evidence Reviewed as of before: 12-01-2012
Author(s)*: Katie Marvin, MSc. PT (Candidate)
Editor(s): Annabel McDermott, OT; Nicol Korner-Bitensky, PhD OT

Purpose

The Geriatric Depression Scale (GDS) is a self-rating screening tool developed to detect Depression in elderly individuals (Yesavage et al., 1983).

In-Depth Review

Purpose of the measure

The Geriatric Depression Scale (GDS) is a self-rating screening tool developed to detect Depression in elderly individuals (Yesavage et al., 1983). The GDS is comprised of 30 items that were selected by researchers and clinicians for their validity in distinguishing groups of elderly people with Depression from the general population (McDowell & Newell, 1996). Questions were developed to be non-threatening and age-appropriate and require respondents to answer using yes or no (Stiles & McGarrahan, 1998).

Available versions

  • Geriatric Depression Scale (GDS)
  • Geriatric Depression Scale – Short Form (GDS-SF)

Short forms of the GDS with 1, 3, 4, 10 and 15 questions have been developed (compared to the 30 questions as seen in the original form of the scale). The short forms were developed in response to criticism that the original form of the GDS was too lengthy and time intensive to administer thus making it impractical in primary care settings (van Marwijk et al., 1995).

While many of the shortened versions of the GDS have been found to be highly correlated with the original, the short forms tend to have higher negative predictive values suggesting that the short forms might be best suited to screening out patients with possible Depression van Marwijk et al., 1995; Almeida & Almeida, 1999).

Note: There are many different short-forms comprised of different sets of questions making comparisons difficult between studies and groups (Teasell, Foley & Salter, 2011). The 15-item short form is the most commonly used short form and will be the focus of short forms reviewed in this module.

15-item GDS:
It requires approximately 5 to 7 minutes to administer.

The client must choose the best answer (yes or no) for how they have felt over the past week:

  1. Are you basically satisfied with your life?
  2. Have you dropped many of your activities and interests?
  3. Do you feel that your life is empty?
  4. Do you often get bored?
  5. Are you in good spirits most of the time?
  6. Are you afraid that something bad is going to happen to you?
  7. Do you feel happy most of the time?
  8. Do you often feel helpless?
  9. Do you prefer to stay at home, rather than going out and doing new things?
  10. Do you feel you have more problems with memory than most?
  11. Do you think it’s wonderful to be alive now?
  12. Do you feel pretty worthless the way you are now?
  13. Do you feel full of energy?
  14. Do you feel that your situation is hopeless?
  15. Do you think that most people are better off than you are?

A score of > 3 points is suggestive of post-stroke Depression.
A score of > 5 points is suggestive of Depression.
A score of > 10 points is almost always indicative of Depression (Sheik & Yesavage,1986).

Features of the measure

Items:
The original GDS is comprised of 30-items in which the participant is asked to respond by answering “yes” or “no” in reference to how they felt on the day of administration.

What to consider before beginning:
The GDS can be self-reported or administered orally. However it should be awknowledged that oral administration may result in the endorsement of fewer items when compared to the self-administered method (Cannon et al., 2002). The need to provide an answer aloud may discourage some respondents from providing an answer they may consider embarrassing (Williams, Rittman, Boylstein, Faircloth & Haijing. 2005).

Gender has been found to have an effect on the ability of the GDS to correctly classify individuals. The GDS has been reported to be more accurate in classifying women as depressed than men. In the case of male respondents, there tend to be more false negatives (Stiles & McGarrahan, 1998).

Scoring and score interpretation:
The respondent is to provide responses (“yes” or “no”) to each question with reference to the past week. One point is given for each “yes” response and the number of points is summed to provide a single score.

  • Scores from 0 to 10 are considered normal
  • Scores > 11 indicate Depression
  • Scores between 11 and 20 indicate mild Depression
  • Scores between 21 and 30 indicate moderate Depression (Brink et al.,1982; McDowell & Newell, 1996).

Time:
The test requires approximately 8-10 minutes to complete in self-administered format (McDowell & Newell, 1996). Due to the number of questions and length of time to administer, it has been suggested that the use of the GDS as a screening tool is impractical in primary care settings (van Marwijk et al., 1995). Many shortened forms of the GDS have been developed to address this potential challenge.

Training requirements:
No additional training is required to administer the GDS (Teasell, Foley & Salter, 2011).

Subscales:
There are no subscales reported for this measure.

Equipment:
A copy of the measure and a pen or a pencil.

Alternative form of the assessment

Geriatric Depression Scale – Short Forms (GDS-SF)

Client suitability

Can be used with:

  • Geriatric patients with stroke
  • Geriatric patients in in-patient, out-patient and nursing home settings (Rinaldi et al., 2003)
  • Patients who require a proxy to complete
  • Clients with aphasia: Suggestion by Dr. Rita Hargrave is to use a point-board, or a board with the scale and yes/no next to the items and have patient point out correct answer.

Should not be used with:

  • Clients with poor reading comprehension and visual ability in the self-administered format. However, in the case of illiteracy or poor vision, the items and possible responses may be read to the respondent.
  • Clients who have more than a moderate cognitive impairment (McDowell & Newell, 1996; McGivney et al., 1994; Stiles & McGarrahan, 1998).

Languages of the measure

The GDS has been adapted and translated, but not necessarily validated, into following languages:
Arabic, Brazilian, Chinese, Creole, Danish, Dutch, Farsi, French, German, Greek, Hebrew, Hindi, Hungarian, Icelandic, Irish, Italian, Japanese, Korean, Lithuania, Malay, Maltse, Norwegian, Portuguese, Romanian, Russian, Serbian, Spanish, Swedish. Thai, Turkish, Vietnamese, Welsh and Yiddish.

Summary

What does the tool measure? Depression in geriatric patients.
What types of clients can the tool be used for? Adults over the age of 65 years. Can be used with, but is not limited to, clients with stroke.
Is this a screening or assessment tool? screening tool.
Time to administer 8-10 minutes to administer
Versions Geriatric Depression Scale – Short Form (GDS-SF)
Other Languages Arabic, Brazilian, Chinese, Creole, Danish, Dutch, Farsi, French, German, Greek, Hebrew, Hindi, Hungarian, Icelandic, Irish, Italian, Japanese, Korean, Lithuania, Malay, Maltse, Norwegian, Portuguese, Romanian, Russian, Serbian, Spanish, Swedish. Thai, Turkish, Vietnamese, Welsh and Yiddish.
Measurement Properties
Reliability Internal Consistency:
Two studies examined the Internal Consistency of the GDS and reported excellent Internal Consistency.

Test-retest:
One study examined the test-retest reliability of the GDS and reported excellent test-retest reliability.

Validity Convergent:
One study examined the convergent validity between the GDS and the Hamilton Rating Scale for Depression (HRS-D) and the Zung Self-Rating Depression Scale (SDS). Excellent correlation between the GDS and both measures were found.
Floor/Ceiling Effects No studies have examined the floor or ceiling effects of the GDS.
Does the tool detect change in patients? Not applicable.
Acceptability The items were developed specifically for an elderly population. The yes/no response format is easy to understand and familiar.
Feasibility The GDS is easy to administer and requires no additional training. The GDS-SF may be more practical for use in primary care settings. When used as a screening tool, the GDS performs as well as some longer interview-based assessments but requires much less time and training to administer.
How to obtain the tool?

A copy of the English GDS and the 15-item GDS can be obtained from the following website: http://www.stanford.edu/~yesavage/GDS.html
Note: Links to some of the other language versions can also be found on this page.

Psychometric Properties

Overview

There is an abundance of research on the psychometric properties of the various GDS short-forms. However, little research has been conducted specifically in patients with stroke. For the purposes of this review, we conducted a literature search to identify all relevant publications on the psychometric properties of the GDS and the 15-item GDS relevant for patients with stroke. We then selected the original validation and reliability studies as content to be summarized and presented here.

Floor/Ceiling Effects

No studies have reported on the floor or ceiling effects of the GDS.

Reliability

Internal constancy:
Yesavage and Brink (1983) examined the internal consistency of the GDS in the original validation study involving elderly patients with depression and healthy controls. The internal consistency was excellent (alpha = 0.94).

Agrell and O’Dehlin (1989) examined the internal consistency of the GDS used as a screening test for post-stroke depression. The internal consistency was excellent (alpha = 0.90).

Test-retest:
Yesavage and Brink (1983) examined the test-retest reliability of the GDS in the original validation study. Twenty subjects completed the questionnaire twice, with one week in between each completion. test-retest reliability was found to be excellent (ICC = 0.84, p<0.001).

Intra-rater:
No studies have reported on the intra-rater reliability of the GDS with patients with stroke.

Inter-rater:
No studies have reported on the inter-rater reliability of the GDS with patients with stroke.

Validity

Content:
No studies have reported on the content validity of the GDS with patients with stroke.

Criterion:
Concurrent:
No studies have reported on the concurrent validity of the GDS with patients with stroke.

Predictive:
No studies have reported on the predictive validity of the GDS with patients with stroke.

Construct:
Convergent/Discriminant:
Yesavage and Brink (1983) examined the convergent validity between the GDS and the Hamilton Rating Scale for depression (HRS-D) and the Zung Self-Rating depression Scale (SDS). Excellent correlations between the GDS and both the HRS-D (0.83, p<0.001) and SDS (0.84, p<0.001) were found.

Known Groups:
No studies have reporte on the known groups validity of the GDS with patients with stroke.

Sensitivity/Specificity:
Agrell and Dehlin (1989) examined the Sensitivity and specificity for identifying depression of the GDS in 40 geriatric patients with stroke (mean age 80 years). A diagnosis of depression was confirmed using a clinical examination and psychiatric interview. A GDS score of >10 was found to have good Sensitivity and moderate specificity for detecting any depression (88% and 64% respectively). Based on these results, the GDS can be used as a brief screening measure for assessing depression in geriatric patients with stroke.

Almeida and Almeida (1999) examined the Sensitivity and specificity of the 15-item GDS (and other short form versions) for identifying a major depressive episode in 64 patients, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Using a cutoff score of 4/5 for the 15-item GDS produced a Sensitivity and specificity of 97% and 54.8% respectively (with a positive predictive value of 69.6% and negative predictive value of 94.4%).

Rinaldi et al. (2003) examined the Sensitivity and specificity of the 5-item and 15-item GDS in 181 geriatric patients (>65 years). A diagnosis of depression was made using a neuropsychological evaluation administered by a geriatrician using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for depression. A score of > 5 on the 15-item GDS had a Sensitivity of 0.92 and specificity of 0.83 for detecting depression.

Tang et al. (2003) evaluated an alternative language version of the GDS in 127 Chinese geriatric patients with acute stroke. Diagnoses of depression were made by a psychiatrist who conducted the Structured Clinical Interview Diagnosis from the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV). Using an optimal cut-off score of 6/7 the Sensitivity, specificity, positive and negative predictive values were 89, 73, 37, 98 and 90% respectively.

Responsiveness

Not applicable as the GDS is a screening tool.

References

  • Agrell, B. & Dehlin, O. (1989). Comparison of six depression rating scales in geriatric stroke patients. Stroke, 20, 1190-1194.
  • Almeida, O.P. & Almeida, S.A. (1999). Short versions of the geriatric depression scale: A study of their validity for the diagnosis of a major depressive episode according to ICD-10 and DSM-IV. International Journal of Geriatric Psychiatry, 14, 858-865.
  • Brink, T.L., Yesavage, J.A., Lum, O., Heersema, P.H., Adey, M. & Rose, T.L. (1982). Screening tests for geriatric depression. Clinical Gerontologist, 1, 37-43.
  • Cannon, B.J., Thaler. T. & Roos, s. (2002). Oral versus written administration of the Geriatric Depression Scale. Aging and Mental Health, 6(4), 418-422.
  • McDowell, I. & Newell, C. (1996). Measuring health. A guide to rating scales and questionnaires., 2nd ed. New York: Oxford University Press.
  • McGivney, S.A.,Mulvihill, M. & Taylor, B. (1994). Validating the GDS depression screen in the nursing home. Journal of the American Geriatrics Society, 42(5), 490-492.
  • Rinaldi, P., Mecocci, P., Benedetti, C et al. (2003). Validation of the five-item geriatric depression scale in elderly subject in three different settings. Journal of the American Geriatrics Society, 51, 694-698.
  • Sheik, J. & Yesavage, J. (1986). Geriatric Depression Scale (GDS): recent findings and development of a shorter version. In: Brink TL (ed.), Clinical Gerontology: A guide to assessment and intervention. New York, NY: Howarth Press.
  • Stiles, P.G. & McGarrahan, J.E. (1998). The Geriatric Depression Scale: A comprehensive review. Journal of Clinical Geropsychology, 4, 89-109.
  • Tang, W.K., Chan, S.S.M., Chiu, H.F.K., Kwok, T.C.Y, Mok, V. & Ungvari, G.S. (2004). Can the Geriatric Depression Scale detect post-stroke depression in the Chinese elderly. Journal of Affective Disorders, 81(2), 153-156.
  • Teasell, R., Foley, N. C., & Salter K. (2011). EBRSR: Evidence-Based Review of Stroke Rehabilitation. 13th ed. London (ON): EBRSR.
  • van Marwijk, H., Wallace, P., De Bock, G.H., Hermans, J., Kaptein, A. & Mulder, J.D. (1995). Evaluation of the feasibility, reliability and diagnostic value of shortened versions of the Geriatric Depression Scale. British Journal of General Practice, 45, 195-199.
  • Williams, C.L., Rittman, M.R., Boylstein, C., Faircloth, C. & Haijing, Q. (2005). Qualitative and quantitative measurement of depression in veterans recovering from stroke. Journal of Rehabilitation Res Dev, 42, 277-290.
  • Yesavage, J.A., Brink, T.L. (1983). Development and validation of a geriatric depression screening scale: a preliminary report. Journal of Psychiatric Research, 17, 37-49.

See the measure

How to obtain the GDS?

A copy of the English GDS and the 15-item GDS can be obtained from the following website: http://www.stanford.edu/~yesavage/GDS.html
Note: Links to some of the other language versions can also be found on this page.

Click HERE for the Stroke Specific Geriatric Depression Scale

Table of contents

Hospital Anxiety and Depression Scale (HADS)

Evidence Reviewed as of before: 19-08-2008
Author(s)*: Lisa Zeltzer, MSc OT; Lorie Kloda, PhD
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The Hospital Anxiety and Depression Scale (HADS) is a self-administered measure used to screen for the presence of Depression and anxiety. The HADS was developed to provide clinicians with an acceptable, reliable, valid and easy to use practical tool for identifying and quantifying Depression and anxiety. The HADS can be used in a variety of settings (e.g. community, primary care, in-hospital, and psychiatry). The HADS is not intended as a complete diagnostic tool, but as a means for identifying general hospital patients who need further psychiatric evaluation and assistance (Herrmann, 1997).

In-Depth Review

Purpose of the measure

The Hospital Anxiety and Depression Scale (HADS) is a self-administered measure used to screen for the presence of Depression and anxiety. The HADS was developed to provide clinicians with an acceptable, reliable, valid and easy to use practical tool for identifying and quantifying Depression and anxiety. The HADS can be used in a variety of settings (e.g. community, primary care, in-hospital, and psychiatry). The HADS is not intended as a complete diagnostic tool, but as a means for identifying general hospital patients who need further psychiatric evaluation and assistance (Herrmann, 1997).

Available versions

The HADS was developed by Dr. Phillip Snaith and Anthony Zigmond in 1983.

Features of the measure

Items:
The HADS is a self-administered measure with 14 items in total that ask the client to reflect on their mood in the past week. Seven items assess Depression, 5 of which are markers for anhedonia (an inability to experience pleasure), and 2 concern appearance and feelings of slowing down. Seven items assess anxiety, of which 2 assess autonomic anxiety (panic and butterflies in the stomach), and the remaining 5 assess tension and restlessness (Dunbar, Ford, Hunt, & Der, 2000). The HADS can be administered repeatedly without impacting on validity, but at least one week should elapse between administrations.

Scoring:
Scores for items in each subscale of the HADS are summed to produce an anxiety score (HADS-A) or a Depression score (HADS-D), or can be added to produce a total score (HADS-T). Each item is rated on a 4-point scale (ranging from 0 = no not at all, to 3 = yes definitely), for a total score ranging from 0-21 for each subscale. A higher score indicates higher distress. A number of items are reverse scored (ranging from 3 = no not at all, to 0 = yes definitely), including two from the HADS-A and four from the HADS-D.

In the original publication, a score of 0 to 7 for either subscale was regarded as in the normal range, a score of 11 or higher indicating probable presence (‘caseness’) of a mood disorder, and a score of 8 to 10 being suggestive of the presence of the state (Zigmond & Snaith, 1983). A recent publication in individuals with stroke determined that an optimal balance is achieved between specificity using a cut-off score of 11 for the total HADS, and 8 for the HADS-D (Aben, Verhey, Lousberg, Lodder, & Honig, 2002).

Time:
The HADS is a brief measure, and can be completed quickly while waiting to be seen by a clinician. Administration time ranges from 2-5 minutes. An experienced clinician can score the HADS in 1 minute (Herrmann, 1997).

Subscales:
The HADS has two subscales, the HADS-A (Anxiety subscale) and the HADS-D (Depression subscale).

Equipment:
Only the questionnaire and a pencil are required to complete the HADS.

Training:
No formal training is required for the HADS.

Alternative forms of the Hospital Anxiety and Depression Scale

The HADS can be interviewer administered in person or over the telephone for clients who may have difficulty with self-administration. However, results from a recent study of the HADS in persons in the general population aged 13-23 demonstrated that individuals aged 16-23 tended to have higher scores when interviewed over the telephone than when self-completed by post, and this was more pronounced in females (Jörngården, Wettergen, von Essen, 2006).

Client suitability

Can be used with:
The HADS can be administered to clients with stroke.

  • However, for clients with communication problems, an aphasia specific assessment such as the stroke Aphasic Depression Questionnaire (Sutcliffe & Lincoln, 1998) is recommended.

The HADS has also been validated for use with adolescents (White, Leach, Sims, Atkinson, & Cottrell, 1999); somatic and psychiatric cases; primary care patients (Olsson, Mykletun, & Dahl, 2005); and the general population.

Should not be used in:
Completion of the HADS requires that the client have adequate reading comprehension and visual ability, as it is a self-administered measure. However, in the case of illiteracy or poor vision, the items and possible responses may be read to the respondent (Snaith, 2003). Note: although a number of studies do use interviewer-administration of the HADS, to our knowledge no studies have examined the validity of this form of administration in clients with stroke.

If the client’s literacy is in question, it is advised that prior to allowing the client to self-administer the HADS, the clinician ask the respondent to read out a phrase from the questionnaire as a means of screening for illiteracy, as some individuals may pretend to read the statements and haphazardly underline responses (Snaith, 2003).

In what languages is the measure available?

The HADS has been translated by the MAPI Research Institute into the following languages:

Afrikaans Finnish Lithuanian Swedish
Arabic French Malay Tagalog
Bengali German* Malayalam Tamil
Brazilian Greek Marathi Telugu
Bulgarian Gujurati Norwegian Thai
Chinese – Cantonese Hungarian Polish Turkish
Chinese – Mandarin Icelandic Portugal Urdu
Croatian Indonesian Punjabi Ukrainian
Czech Italian Romanian Xhosa
Danish Japanese Russian Yoruba
Dutch Kannada Slovak
Estonian Korean Slovenian
Farsi Latvian Spanish

* The copyright for the German translations is held by Verlag Hans Huber, Bern, Switzerland. Please consult http://www.testzentrale.de/

The HADS has been translated and validated in:

  • Greek (Michopoulos, Douzenis, Kalkavoura, Christodoulou, Michalopoulou, Kalemi et al., 2008)
  • Hungarian (Muszbek, Szekely, Balogh, Molnar, Rohanszky, et al., 2006)
  • Iranian (Montazeri, Vahdaninia, Ebrahimi, & Jarvandi, 2003)
  • Punjabi living in United Kingdom (Lane, Jajoo, Taylor, Lip, Jolly, & BRUM Steering Committee, 2007)

Summary

What does the tool measure? Depression and anxiety.
What types of clients can the tool be used for? General hospital patients. Can be used, but is not limited to, persons with stroke.
Is this a screening or assessment tool? screening.
Time to administer The HADS is a brief measure, and can be completed quickly while waiting to be seen by a clinician. Administration time ranges from 2-5 minutes. An experienced clinician can score the HADS in 1 minute (Herrmann, 1997).
Versions The HADS was developed by Dr. Phillip Snaith and Anthony Zigmond in 1983. It is intended to be self-administered but can be interview administered in person or over the telephone for clients who may have difficulty self-administering the measure.
Other Languages Translated and validated in: Greek; Hungarian; Iranian; Punjabi living in United Kingdom
The HADS has been translated but not necessarily validated in 51 languages (see HADS module for the full list of translations).
Measurement Properties
Reliability Internal consistency:
Out of two studies examining Internal consistency of the HADS in a stroke clientele, one reported excellent and one adequate to excellent Internal consistency.

Test-retest:
No studies have examined the test-retest reliability of the HADS in clients with stroke.

Validity Criterion:
Concurrent:
The concurrent validity of the HADS has not been examined in a stroke population. Studies that have examined the concurrent validity of the HADS in other populations report excellent correlations between the HADS and Beck Depression Inventory, the General Health Questionnaire, the Clinical Anxiety Scale, the Spielberger’s State-Trait Anxiety Inventory, and the Montgomery Asberg Depression Rating Scale. Adequate to excellent correlations found between the HADS and the Symptom Checklist-90 Scale. Adequate correlations between the HADS-A and the Hamilton Anxiety Rating Scale.

Construct:
One review article of 18 studies found excellent mean correlation between the HADS-A and HADS-D. In another review, seven studies found adequate to excellent correlations between HADS-A and HADS-D in non-patient samples, and two studies reported adequate correlations in psychiatric patients.

Does the tool detect change in patients? In a study of 200 clients with stroke, the mean correlation between the Depression and anxiety subscales of the HADS was found to be excellent.
Acceptability HADS is typically self-administered, however it can be interview administered in person or by telephone for clients who are unable to self-administer the measure. The HADS is not recommended for use with clients with communication problems.
Feasibility The HADS is a short, self-administered screening tool. It takes only one minute to score by an experienced clinician and no special equipment is required.
How to obtain the tool?

The original HADS is available as an appendix in Zigmond and Snaith (1983). A copy of the article is available by clicking here. The HADS is also available from the following website: http://shop.gl-assessment.co.uk/home.php?cat=417.

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the HADS in individuals with stroke. Although the psychometric properties of the HADS have been well established in other patient populations, there are few studies to date that have examined the psychometric properties of the HADS in individuals with stroke.

Floor/Ceiling Effects

According to the commentary by Herrmann (1997) in his review, the HADS does not include severe pathological symptoms of the two disorders (anxiety and depression). This was done to enhance sensitivity of the HADS to mild cases, thus avoiding the potential for a ceiling effect often encountered with psychiatric questionnaires used for medical patients.

Reliability

Internal consistency:
Aben, Verhey, Lousberg, Lodder, and Honig (2002) administered the HADS to 200 patients one month following a first ever ischemic stroke and found the Internal consistency of the HADS to be excellent, with a Cronbach’s alpha = 0.85.

Johnston, Pollard, and Hennessey (2000) administered the HADS to 68 individuals with acute stroke within 10-20 days of the study. At 1 month post-stroke, cronbach’s alpha was adequate for the HADS-A (alpha = 0.76); HADS-D (alpha = 0.79), and overall HADS (alpha = 0.79). At 6 months post-stroke, the HADS-A and overall HADS had excellent Internal consistency (alpha = 0.87; 0.89, respectively) and the HADS-D was adequate (alpha = 0.76).

Test-retest:
To date, the test-retest reliability of the HADS has not been examined in a stroke population.

Validity

To our knowledge, the study by Aben et al. (2002) is the only study to date that has examined the validity of the HADS in individuals with stroke.

Criterion:
Concurrent:
The concurrent validity of the HADS has not been examined in a stroke population. Below we present the findings of studies that have examined the concurrent validity of the HADS in other populations.

In a review by Bjelland et al. (2002), concurrent validity of the HADS was examined against existing anxiety and depression questionnaires and interview instruments (Beck depression Inventory (BDI), Beck depression Inventory for Primary Care, Clinical Anxiety Scale, Hamilton Anxiety Scale, Montgomery-Asberg depression Rating Scale, Symptom Checklist 90 Scale, Spielberger State-Trait Anxiety Inventory, and Visual Analogue Scale). Correlations between the HADS and the BDI were excellent, ranging from r = 0.61 to 0.83. Correlations between the General Health Questionnaire and HADS ranged from adequate to excellent (r = 0.50 to 0.68). Correlations between the HADS and the Clinical Anxiety Scale were excellent, ranging from r = 0.69 to 0.75. Correlations between the HADS and the Spielberger’s State-Trait Anxiety Inventory were excellent, ranging from r = 0.64 to 0.81. Correlations between the HADS and the Symptom Checklist 90 Scale ranged from adequate to excellent (r = 0.49 to 0.73). Correlations between the HADS and the Montgomery Asberg depression Rating Scale were excellent, ranging from r = 0.62 to 0.81. Finally, adequate correlations were found between the HADS-A and the Hamilton Anxiety Rating Scale (r = 0.34 to 0.44).

Clark and Steer (1994) reported that the HADS had an excellent correlation (Pearson correlation r = 0.73) with the 13-item Cognitive-Affective Subscale of the Beck depression Inventory in a study to discriminate between depressed and non-depressed hospitalized patients.

Construct:
Convergent/Discriminant:
Aben et al. (2002) found the mean correlation between the depression and anxiety subscales of the HADS to be excellent (r = 0.67). Herrmann (1997) asserts that the correlation between the two subscales is a result of the existing overlap between the symptoms of depression and anxiety and not a reflection of a flaw in the instrument.

sensitivity and Specificity:
O’Rourke, MacHale, Signorini, and Dennis (1998) administered the HADS to 105 individuals with stroke 6 months after onset. They found the typical cutoffs for the HADS to be suboptimal when compared to the results of a blinded psychiatric assessment in which the Schedule for Affective Disorders and Schizophrenia was used to determine a DSM-IV diagnosis. A different cutoff of 6/7 for patients with stroke was suggested, which produces an improved balance between Specificity for both the HADS-A (sensitivity, 0.83; Specificity, 0.68) and the HADS-D (sensitivity, 0.8; Specificity, 0.79).

Aben et al. (2002) administered the HADS to 200 patients one month following a first ever ischemic stroke. They found that at the optimal cutoff of 5 for the HADS-A produced a sensitivity of 91.7 and a Specificity of 56.1 for major depression only (area under the curve (AUC) = 0.78), and a sensitivity of 88.5 and Specificity of 71.8 for detecting both major and minor depression (AUC = 0.77). An optimal cutoff of 8 for the HADS-D produced a sensitivity of 73.1 and a Specificity of 81.6 for detecting major depression only (AUC = 0.82), and a sensitivity of 72.5 and Specificity of 78.9 for detecting both major and minor depression (AUC = 0.83). Finally, for the total HADS, the optimal cutoff of 11 produced a sensitivity of 91.7 and a Specificity of 65.3 for detecting major depression only (AUC = 0.83), and a sensitivity of 86.8 and Specificity of 69.9 for detecting both major and minor depression (AUC = 0.84).

Johnson, Burvill, Anderson, Jamrozik, Stewart-Wynne, and Chakera (1995) administered the HADS to 93 post-stroke patients and found a sensitivity of 0.95 for the HADS-A and 0.83 for the HADS-D, with specificities of 0.46 and 0.44, respectively. The optimal cutoff scores used in this study were not disclosed, however, they were estimated by Bjelland et al. (2002) to be 5+ for HADS-A and 4+ for HADS-D.

Responsiveness

Not yet examined in a stroke population.

References

  • Aben, I., Verhey, F., Lousberg, R., Lodder, J., & Honig, A. (2002). Validity of the Beck Depression Inventory, Hospital Anxiety and Depression Scale, SCL-90, and Hamilton Depression Rating Scale as screening instruments for depression in stroke patients. Psychosomatics, 43(5), 386-393.
  • Bjelland, I., Dahl, A. A., Haug, T. T., & Neckelmann, D. (2002). The validity of the Hospital Anxiety and Depression Scale: An updated literature review. Journal of Psychosomatic Research, 52, 69-77.
  • Clark, D. A., & Steer, R. A. (1994). Use of nonsomatic symptoms to differentiate clinically depressed and non-depressed hospitalized patients with chronic medical illnesses. Psychological Reports, 75(3, Pt 1), 1089-1090.
  • Dunbar, M., Ford, G., Hunt, K., & Der, G. (2000). A confirmatory factor analysis of the Hospital Anxiety and Depression Scale: Comparing empirically and theoretically derived structures. Br J Clin Psychol, 39, 79-94.
  • Herrmann, C. (1997). International experiences with the hospital anxiety and depression scale: A review of validation data and clinical results. Journal of Psychosomatic Research, 42(1), 17-41.
  • Johnson, G., Burvill, P. W., Anderson, C. S., Jamrozik, K., Stewart-Wynne, E. G., Chakera, T. M. (1995). Screening instruments for depression and anxiety following stroke: experience in the Perth community stroke study. Acta Psychiatr Scand, 91, 252- 257.
  • Johnston, M., Pollard, B., & Hennessey, P. (2000). Construct validation of the hospital anxiety and depression scale with clinical populations. Journal of Psychosomatic Research, 48, 579-584.
  • Jörngården, A., Wettergen, L., von Essen, L. (2006). Measuring health-related quality of life in adolescents and young adults: Swedish normative data for the SF-36 and the HADS, and the influence of age, gender, and method of administration. Health and Quality of Life Outcomes, 4(91), 1-10.
  • Lane, D. A., Jajoo, J., Taylor, R. S., Lip, G.Y., Jolly, K., Birmingham Rehabilitation Uptake Maximisation (BRUM) Steering Committee (2007). Cross-cultural adaptation into Punjabi of the English version of the Hospital Anxiety and Depression Scale. BMC Psychiatry, 7, 5.
  • Michopoulos, I., Douzenis A., Kalkavoura, C., Christodoulou, C., Michalopoulou, P., Kalemi, G., et al. (2008). Hospital Anxiety and Depression Scale (HADS): Validation in a Greek general hospital sample. Annals of General Psychiatry, 7(1), 4.
  • Montazeri, A., Vahdaninia, M., Ebrahimi, M., Jarvandi, S. (2003). The Hospital Anxiety and Depression Scale (HADS): translation and validation study of the Iranian version. Health and Quality of Life Outcomes, 1, 14.
  • Muszbek, K., Szekely, A., Balogh, E. M., Molnar, M., Rohanszky, M., Ruzsa, et al. (2006). Validation of the Hungarian Translation of Hospital Anxiety and Depression Scale. Quality of Life Research, 15(4), 761-766.
  • Olsson, I., Mykletun, A., & Dahl, A. A. (2005). The hospital anxiety and depression rating scale: A cross-sectional study of psychometrics and case finding abilities in general practice. BMC Psychiatry, 14(5), 46.
  • O’Rourke, S., MacHale, S., Signorini, D., & Dennis, M. (1998). Detecting Psychiatric Morbidity After Stroke: Comparison of the GHQ and the HAD Scale. Stroke, 29, 980-985.
  • Snaith, R. P. (2003). The hospital anxiety and depression scale. Health and Quality of Life Outcomes, 1(1), 29.
  • White, D., Leach, C., Sims, R., Atkinson, M., & Cottrell, D. (1999). Validation of the Hospital Anxiety and Depression Scale for use with adolescents. British Journal of Psychiatry, 175, 452-454.
  • Zigmond, A. S., & Snaith, R. P. (1983). Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67, 361-370.

See the measure

How to obtain the HADS?

The original is available as an appendix in Zigmond and Snaith (1983). A copy of the article is available by clicking here.

The HADS is also available from the following website: http://shop.gl-assessment.co.uk/home.php?cat=417.

Table of contents

Montgomery Asberg Depression Rating Scale (MADRS)

Evidence Reviewed as of before: 21-09-2009
Author(s)*: Lisa Blum, M.Sc. OT (Candidate)
Editor(s): Nicol Korner-Bitensky, PhD OT

Purpose

The Montgomery Asberg Depression Rating Scale (MADRS) is used by clinicians to assess the severity of Depression among patients with a diagnosis of Depression. It is designed to be sensitive to change resulting from antidepressant therapy.

In-Depth Review

Purpose of the measure

The Montgomery Asberg Depression Rating Scale (MADRS) is used by clinicians to assess the severity of Depression among patients with a diagnosis of Depression. It is designed to be sensitive to change resulting from antidepressant therapy.

Available versions

The MADRS was developed by Stuart Montgomery and Marie Asberg in 1979. It was developed from Asberg’s Comprehensive Psychopathological Rating Scale, which was designed to evaluate psychiatric treatment.

Features of the measure

Items:
The MADRS has 10 items that are completed during a clinical interview. The following items are included in the MADRS:

  1. Apparent sadness
  2. Reported sadness
  3. Inner tension
  4. Reduced sleep
  5. Reduced appetite
  6. Concentration difficulties
  7. Lassitude
  8. Inability to feel
  9. Pessimistic thoughts
  10. Suicidal thoughts

Originally the MADRS was published without suggested questions for clinicians to use in eliciting the information they need to rate the items. In 2008, Williams and Kobak developed the Structured Interview Guide for the MADRS (SIGMA) to provide structured questions that should be asked exactly as written to ensure standardisation of administration. Follow-up questions are also provided to clarify symptoms if required. Inter-rater reliability using Intraclass Correlation Coefficient with the SIGMA was reported to be excellent (r = 0.93).

Scoring:
Each item has a severity scale from 0 to 6, with higher scores reflecting more severe symptoms. Ratings can be added to form an overall score (from 0 to 60). Snaith, Harrop, Newby, and Teale (1986) proposed the following cut-offs: scores of 0-6 indicate an absence of symptoms; 7-19 represent mild Depression; 20-34 moderate; 35-60 indicate severe Depression.

Time:
Interviews take 20 to 60 minutes to complete.

Subscales:
The MADRS has 10 subtests (each item is therefore considered a subtest): 1. Apparent sadness; 2. Reported sadness; 3. Inner tension; 4. Reduced sleep; 5. Reduced appetite; 6. Concentration difficulties; 7. Lassitude; 8. Inability to feel; 9. Pessimistic thoughts; 10. Suicidal thoughts

Equipment:
Only the questionnaire and a pencil are required to complete the MADRS.

Training:
No formal training is required to complete the MADRS.

Alternative form of the Montgomery Asberg Depression Rating Scale

A self-report version of the MADRS, the MADRS-S, was developed by Svanborg and Asberg in 1994. The MADRS-S has 9-items which are based on feelings over the past 3 days. The items of the MADRS-S are as follows: Mood; Feelings of unease; Sleep; Appetite; Ability to concentrate; Initiative; Emotional involvement; Pessimism; Zest for life.

Client suitability

Can be used with:

The MADRS can be administered to clients with stroke.

  • The MADRS can be used with clients with aphasia, however one study examining its use in patients with aphasia found that the MADRS was more difficult to complete than the DSM-IV, especially for patients with global, mixed non-fluent, and Wernicke types of aphasias. The MADRS also became less valid when a proxy was required (Laska, Martensson, Kahan, von Arbin, & Murray, 2007).

Should not be used with:

The MADRS is intended for use with patients with a diagnosis of a depressive illness only.

  • Although the MADRS can be used with clients with cognitive impairments, certain features of the MADRS could bias the scores of these patients in the direction of higher Depression scores and therefore should be used with caution in individuals with cognitive impairments. This is due to the complex wording of some of the subtests (especially the subtests of Concentration difficulty; Inability to feel; Lassitude; and Inner tension) (Sadavoy, Smith, Conn, & Richards, 2004).

In what languages is the measure available?

The MADRS has been translated into the following languages:

  • Afrikaans
  • Bulgarian
  • Czech
  • Danish
  • Dutch
  • English for Canada
  • English for India
  • English for South Africa
  • Estonian
  • Finnish
  • French
  • French for Canada
  • German
  • German for Austria
  • Hebrew
  • Hungarian
  • Italian
  • Japanese
  • Korean
  • Latvian
  • Lithuanian
  • Malay
  • Mandarin for China
  • Mandarin for Taiwan
  • Norwegian
  • Polish
  • Portuguese for Brazil
  • Romanian
  • Russian
  • Russian for Ukrain
  • Spanish
  • Spanish for Argentina
  • Spanish for Chile
  • Spanish for Colombia
  • Spanish for Mexico
  • Spanish for the USA
  • Swedish
  • Tagalog
  • Thai
  • Turkish
  • Ukrainian

The following translations have been validated:

  • French (Peyre, Martinez, Calache, Verdoux, Bourgeois et al., 1989)
  • German (Schmidtke, Fleckenstein, Moises, & Beckmann,1988)
  • Japanese (MADRSJ) (Kasa & Hitomi, 1987)
  • Spanish (Lobo, Chamorro, Luque, Dal-Re, Badia, Baro et al., 2002)
  • Thai (Satthapisit, Posayaanuwat, Sasaluksananont, Kaewpornsawan, & Singhakun, 2007)

Summary

What does the tool measure? Depression severity.
What types of clients can the tool be used for? Individuals with a diagnosis of Depression. Can be used, but is not limited to, persons with stroke.
Is this a screening or assessment tool? Assessment.
Time to administer The MADRS takes 20-60 minutes to be completed by interview.
Versions The MADRS was developed by Stuart Montgomery and Marie Asberg in 1979. It was developed from Asberg’s Comprehensive Psychopathological Rating Scale. A self-report version of the MADRS, the MADRS-S, was developed by Svanborg and Asberg in 1994. The MADRS-S has 9-items which are based on feelings over the past 3 days.
Other Languages Translated and validated in: French, German, Japanese, Thai, and Spanish
The MADRS has been translated but not necessarily validated in 41 languages (see MADRS module for the full list of translations)
Measurement Properties
Reliability Internal consistency:
One study examined the Internal consistency of the MADRS in a stroke clientele and reported excellent Internal consistency.

Test-retest:
No studies have examined the test-retest, intra-rater or inter-rater reliability of the MADRS in clients with stroke.

Validity Criterion:
Two studies examined the concurrent validity of the MADRS and reported excellent correlations with the Geriatric Depression Scale, the Zung Scale, the Center for Epidemiologic Studies Depression Scale, the Hamilton Rating Scale, and the Beck Depression Inventory. The scale correlated adequately with the Cornell Scale.

Construct:
One study examined the construct validity of the MADRS using factor analysis in 163 individuals stroke. They identified three distinct factors: Anhedonia; Sadness; and Agitation. The factor Anhedonia was related to cognitive impairment, Sadness to neurological impairment due to the stroke, and Agitation related to somatic factors not directly related to the stroke.

Does the tool detect change in patients? Not yet examined in a stroke population.
Acceptability MADRS is typically interview-administered, however it can be self-administered. The MADRS should be used with caution in patients with cognitive impairment as results can be skewed towards higher Depression scores, however the MADRS can be used with individuals with aphasia.
Feasibility The MADRS is easy to administer due to the Structured Interview Guide for the MADRS (SIGMA) that was developed in 2008 which provides structured questions that should be asked exactly as written to ensure standardization of administration. No special training or equipment is required to complete the measure.
How to obtain the tool? The original MADRS is available by clicking here. The structured interview version of the MADRS (SIGMA) is also available as an appendix in the article by Williams and Kobak (2008).

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the MADRS in individuals with stroke. We identified 4 studies.

Floor/Ceiling Effects

No studies were identified that examined the floor/ceiling effects of the MADRS in individuals with stroke.

Fantino and Moore (2009) examined the floor and ceiling effects of the 9-item self-administered version of the MADRS-S in 278 outpatients diagnosed with Major Depressive Disorder. All items had adequate ceiling effects (total score: 0.4%). Floor effects ranged from poor (appetite item, 21.6) to excellent (total score: 0.0%).

Reliability

Internal consistency:
Agrell and Dehlin (1989) examined the Internal consistency of 6 depression rating scales in 40 elderly individuals with stroke, 17 of whom were depressed according to clinical examination.

According to the authors, in the MADRS, all items correlated significantly and 8/10 items were very highly correlated (coefficients not provided in article) and Cronbach’s alpha was excellent (alpha = 0.89).
Note: This publication refers to the MADRS as the Comprehensive Psychopathological Rating Scale-Depression (CPRS-D), which was the original name for the MADRS (Asberg, Montgomery, Perris, Schalling, & Sedvall, 1978).

Test-retest:
No studies were identified that measured the test-retest reliability of the MADRS in a stroke population.

Fantino and Moore (2009) examined the test-retest reliability of the 9-item self-administered version of the MADRS in 278 outpatients diagnosed with Major Depressive Disorder. The test-retest reliability using intraclass correlation coefficient was excellent (r = 0.78).

Intra-rater:
No studies were identified that measured the intra-rater reliability of the MADRS in a stroke population.

Inter-rater:
No studies were identified that measured the inter-rater reliability of the MADRS in a stroke population.

Montgomery and Asberg (1979) examined the inter-rater reliability of the MADRS in 64 patients with a primary depressive illness. Comparisons were made between two English raters; two Swedish raters; one English and one Swedish rater; a trained psychiatrist and a general practitioner; and a trained psychiatrist and a psychiatric nurse. The inter-rater correlations were excellent (ranging from r = 0.89 to r = 0.97).

Validity

Content:
The MADRS covers the core symptoms of depression with the exception of motor retardation which was excluded from the primary selection, since it occurred in relatively few patients (Montgomery & Asberg, 1979).

Criterion:
Concurrent:
Agrell and Dehlin (1989) examined the concurrent validity of the MADRS with 5 other depression rating scales: Geriatric depression Scale (GDS) (Brink, Yesavage, Lum, Heersema, Adey, & Rose, 1982); Zung Scale (Zung, 1965) Center for Epidemiologic Studies depression Scale (CES-D) (Shinar, Gross, Price, Banko, Bolduc, & Robinson, 1986); Hamilton Rating Scale (HRS) (Hamilton, 1967); Cornell Scale (Alexopoulos, Abrams, Young, & Shamoian, 1988) in 40 elderly individuals with stroke using Pearson Product Moment Correlations. The MADRS had excellent correlations with the GDS (r = 0.86), the Zung Scale (r = 0.82), the CES-D (r = 0.83) and the HRS (r = 0.87). The MADRS had an adequate correlation with the Cornell Scale, which did not correlate highly with any of the scales.
Note: This publication refers to the MADRS as the Comprehensive Psychopathological Rating Scale-Depression (CPRS-D), which was the original name for the MADRS (Asberg, Montgomery, Perris, Schalling, & Sedvall, 1978).

Tamaklo, Schubert, Mentari, and Lee (1992) compared the MADRS to the Beck depression Inventory (BDI – Beck, Ward, & Mendelson, 1961) in 22 patients with stroke and found an excellent correlation (r = 0.65).

Construct:
Farner, Wagle, Flekkoy, Wyller, Fure, Stensrod, et al. (2009) examined the construct validity of the MADRS using factor analysis in 163 individuals with stroke. They identified 3 distinct factors: Anhedonia; Sadness; and Agitation. The factor Anhedonia was related to cognitive impairment, Sadness to neurological impairment due to the stroke, and Agitation related to somatic factors not directly related to the stroke.

Sensitivity/Specificity:
Sagen, Vik, Moum, Morland, Finset, and Dammen (2009) estimated the Sensitivity and specificity of the MADRS in 104 patients 4 months post-stroke by comparing it to the DSM-IV diagnosis of depression as the gold standard. At a cut-off of >6, the MADRS had a Sensitivity of 0.90 and a specificity of 0.66. At a cut-off of >12, a Sensitivity of 0.70 and a specificity of 0.86 was found. All cut-offs lower than 9 yielded sensitivities >0.80 and specificities >0.60. Of these, a cut-off of >8 had the highest overall agreement (0.74), kappa (0.40), and positive predictive value (0.41). The AUC for the MADRS was excellent (AUC = 0.91).

Responsiveness

Not yet examined in a stroke population.

References

  • Alexopoulos, G. S., Abrams, R. C., Young, R. C., & Shamoian, C. A. (1988). Cornell Scale for depression in dementia. Biol Psychiatry, 23, 271-284.
  • Asberg, M., Montgomery, S. A., Perris, C., Schalling, D., & Sedvall, G. (1978). A comprehensive psychopathological rating scale. Acta Psychiatr Scand [Suppl], 271, 5-27.
  • Beck, A.T., Ward, C., Mendelson, M. (1961). Beck Depression Inventory (BDI). Arch Gen Psychiatry, 4, 561-571.
  • Bondolfi, G., Jermann, F., Rouget, B. W., Gex-Fabry, M., McQuillan, A., Dupont-Willemin, D., et al. (2009). Self- and clinician-rated Montgomery-Ã…sberg Depression Rating Scale: Evaluation in clinical practice. Journal of Affective Disorders (in press).
  • Brink, T. L., Yesavage, J. A., Lum, O., Heersema, P. H., Adey, M., & Rose, T. L. (1982). Screening tests for geriatric depression. Clin Gerontol, l, 37-43.
  • Davidson, J., Turnbull, C. D., Strickland, R., Miller, R., & Graves, K. (1986). The Montgomery-Asberg Depression Scale: reliability and validity. Acta Psychiatrica Scandinavica 73(5), 544-548.
  • Fantino, B., Moore, N. (2009). The self-reported Montgomery-Ã…sberg depression rating scale is a useful evaluative tool in major depressive disorder. BMC Psychiatry, 9, 26.
  • Farner, L., Wagle, J., Flekkoy, K., Wyller, T. B., Fure, B., Stensrod, B., & Engedal, K. (2009). Factor analysis of the Montgomery Asberg depression rating scale in an elderly stroke population. International Journal of Geriatric Psychiatry (in press).
  • Hamilton, M. (1967). Development of a rating scale for primary depressive illness. Br J Soc Clin Psychol, 6, 278-298.
  • Kasa M, Hitomi K. 1987. The introduction of the Japanese version of comprehensive psychopathological rating scale. Rinsyo Seishin Igaku (Jpn J Clin Psychiatr), 16, 83-94.
  • Kearns, N. P., Cruickshank, C. A. & McGuigan, K. J. (1982). A comparison of depression rating scales. British Journal of Psychiatry, 141, 45-49.
  • Laska, A. C., Martensson, B., Kahan, T., von Arbin, M., Murray, V. (2007). Recognition of depression in aphasic stroke patients. Cerebrovasc Dis, 24, 74-79.
  • Lobo, A., Chamorro, L., Luque, A., Dal-Re, R., Badia, X., & Baro, E. (2002). Grupo de Validacion en Espanol de Escalas Psicometricas (GVEEP): Validation of the Spanish versions of the Montgomery-Asberg depression and Hamilton anxiety rating scales. Med Clin (Barc), 118, 493-499.
  • Montgomery, S. A., Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134(4), 382-389.
  • Peyre, F., Martinez, R., Calache, M., Verdoux, H., & Bourgeois, M. (1989). New validation of the Montgomery and Asberg Depression Scale (MADRS) on a sample of 147 hospitalized depressed patients. Ann Med Psychol (Paris), 147, 762-767.
  • Sadavoy, J., Smith, I., Conn, D. K., & Richards, B. (2004). Depression in geriatric patients with chronic medical illness, International Journal of Geriatric Psychiatry. 5(3), 187-192.
  • Sagen, U., Vik, T. G., Moum, T., Morland, T., Finset, A., & Dammen, T. (2009). Screening for anxiety and depression after stroke: Comparison of the Hospital Anxiety and Depression Scale and the Montgomery and Ã…sberg Depression Rating Scale. Journal of Psychosomatic Research (in press).
  • Satthapisit, S., Posayaanuwat, N., Sasaluksananont, C., Kaewpornsawan, T., Singhakun, S. (2007). The comparison of Montgomery and Asberg Depression Rating Scale (MADRS Thai) to Diagnostic and Statistical Manual of Mental Disorders (DSM) and to Hamilton Rating Scale for Depression (HRSD): Validity and reliability. J Med Assoc Thai, 90(3), 524-531.
  • Schmidtke, A., Fleckenstein, P., Moises, W., & Beckmann, H. (1988). Studies of the reliability and validity of the German version of the Montgomery-Asberg Depression Rating Scale (MADRS). Schweiz Arch Neurol Psychiatry, 139, 51-65.
  • Shinar, D., Gross, C. R., Price, T. R., Banko, M., Bolduc, P. L., & Robinson, R. G. (1986). Screening for depression in stroke patients: The reliability and validity of the Center for Epidemiologic Studies Depression Scale. Stroke, 17, 241-245.
  • Snaith, R. P., Harrop, F. M., Newby, D. A., & Teale, C. (1986). Grade Scores of the Montgomery-Asberg Depression and the Clinical Anxiety Scales. British Journal of Psychiatry, 148, 599-601.
  • Svanborg, P., Asberg, M. (1994). A new self-rating scale for depression and anxiety states based on the Comprehensive Psychopathological Rating Scale. Acta Psychiatr. Scand, 89, 21-28.
  • Tamaklo, W., Schubert, D. S., Mentari, A., Lee, S., Taylor, C. (1992). Assessing depression in the medical patient using the MADRS, a sensitive screening scale. Integrative Psychiatry, 8, 264-270.
  • Williams, J. B. W., & Kobak, K. A. (2008). Development and reliability of a structured interview guide for the Montgomery-Ã…sberg Depression Rating Scale (SIGMA). The British Journal of Psychiatry, 192, 52-58.
  • Zigmond, A. S., & Snaith, R. P. (1983). Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67, 361-370.
  • Zung, W. W. K. (1965). A self rating depression scale. Arch Gen Psychiatry, 12, 63-70.

See the measure

How to obtain the MADRS?

The structured interview version of the MADRS is available as an appendix in the following publication:

Williams, J. B. W., & Kobak, K. A. (2008). Development and reliability of a structured interview guide for the Montgomery-Ãsberg Depression Rating Scale (SIGMA). The British Journal of Psychiatry, 192, 52-58.

Click here to obtain the original, unstructured version of the MADRS.

Table of contents

Patient Health Questionnaire (PHQ-9)

Evidence Reviewed as of before: 11-01-2011
Author(s)*: Katie Marvin, MSc PT (Candidate)
Editor(s): Nicol Korner-Bitensky, PhD OT

Purpose

The Patient Health Questionnaire (PHQ-9) is a brief tool used to diagnose and measure severity of depression. The PHQ-9 is shorter than many of the other depression screening instruments and can be self-administered. Adapted from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), the PHQ-9 is comprised of the same diagnostic symptom criteria used in the DSM-IV:

  • Two cardinal signs of depression (anhedonia and depressed mood);
  • Cognitions (e.g. guilt/worthlessness and suicidality/thoughts of death); and
  • Physical symptoms (e.g. change in appetite, difficulty sleeping and concentrating, feeling tired/slowed down or restless).

In-Depth Review

Purpose of the measure

The PHQ-9 is a brief tool used to diagnose and measure severity of depression. The PHQ-9 is shorter than many of the other depression screening instruments and can be self-administered. Adapted from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), the PHQ-9 includes all 9 diagnostic symptom criteria used in the DSM-IV, including the two cardinal signs of depression: anhedonia and depressed mood. The PHQ-9 is widely used by clinicians and can be used with patients with stroke.

Available versions

The PHQ-9 was developed by Drs. Robert L. Spitzer, Janet W.B. Williams and Kurt Kroenke in 1999.

Features of the measure

Items:
PHQ-9 : Contains the 9 items from the DSM-IV used in the diagnosis of depression. The respondent must recall how often they have experienced the following symptoms over the last two weeks:

  1. Little interest or pleasure in doing things;
  2. Feeling down, depressed or hopeless;
  3. Trouble falling asleep, staying asleep, or sleeping too much;
  4. Feeling tired or having little energy;
  5. Poor appetite or overeating;
  6. Feeling bad about yourself, or that you’re a failure or have let yourself or your family down;
  7. Trouble concentrating on things, such as reading the newspaper or watching television;
  8. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual;
  9. Thoughts that you would be better off dead or of hurting yourself in some way; and
  10. If you indicated any problems, how difficult have those problems made it for you to do your work, take care of things at home, or get along with other people?
  • Not difficult at all
  • Somewhat difficult
  • Very difficult
  • Extremely difficult

What to consider before beginning:
Similar to when using other depression screening tools, prior to administration the clinician must rule out physical causes for depression, typical bereavement processes and a history of manic episodes.

Scoring and Score Interpretation:
Each item is evaluated on a severity scale ranging from 0 to 3 where the respondent is asked to rate how often each symptom occurred over the last 2 weeks (0-not at all; 1-several days; 2-more than half of the days or 3-nearly every day), yielding a total score ranging from 0-27. The respondent is also asked how the identified problems have interfered with work, home and/or social life, however responses to this item are not scored or included in the total score.

Score interpretation:

  • 1-4 minimal depression;
  • 5-9 mild depression;
  • 10-14 moderate depression;
  • 15-19 moderately severe depression; and
  • 20-27 severe depression

Time:
The PHQ-9 takes approximately 2-5 minutes to administer.

Training requirements:
The PHQ-9 can be self-administered or clinician administered. No-formal training is required to use the measure.

Equipment:
Only a pencil and the test are needed if the tool is self-administered.

Alternative forms of the PHQ-9

The PHQ-2 is an abbreviated version of the PHQ-9, comprised of the first two questions of the PHQ-9 in which the respondent is asked to rate how often they experience the two cardinal symptoms of depression: anhedonia and depressed mood. PHQ-2 scores range from 0-6. Results from a study by Arroll et al. (2010) suggested that the complete PHQ-9 be administered to respondents scoring ≥ 2 on the PHQ-2; and Williams et al. (2010) suggested the complete PHQ-9 be administered to patients with stroke scoring ≥ 3.

Client suitability

Can be used with:

  • Patients with stroke.
  • The PHQ-9 has also been validated for use with geriatric patients; patients with TBI; in primary care and obstetrics-gynecology settings; and in the general population.

Should not be used with:

  • If self-administered, completion of the PHQ-9 requires that the client have adequate reading comprehension and visual ability. However, in the case of illiteracy or poor vision, the items and possible responses may be read to the respondent.

In what languages is the measure available?

The PHQ-9 has been translated into Afrikaans, Arabic, Assamese, Bangla, Bengali, Cantonese, Creole, Czech, Danish, Dutch, Finnish, French, German, Gujarati, Hebrew, Hindi, Hungarian, Italian, Korean, Malayalam, Malaysian Mandarin, Mandarin, Norwegian, Oriya, Polish, Portuguese, Punjabi, Russian, Somali, Spanish, Swedish, Telugu, Tingrinian, Turkish, Urdu and Vietnamese.

These translations can be found at the following website: http://www.phqscreeners.com/

Summary

What does the tool measure? The PHQ-9 measures the severity of depression.
What types of clients can the tool be used for? Can be used with but is not limited to patients with stroke.
Is this a screening or assessment tool? The PHQ-9 has been referred to as both a screening tool and an assessment tool.
Time to administer Approximately 2-5 minutes
Versions The PHQ-9 was developed by Drs. Robert L. Spitzer, Janet W.B. Williams and Kurt Kroenke in 1999. It is intended to be self-administered but can be administered by interview in person or over the telephone.
Other Languages The PHQ-9 has been translated but not necessarily validated in over 35 languages (see PHQ-9 module for complete list).
Measurement Properties
Reliability Internal consistency:
Two studies examined the Internal consistency of the PHQ-9 and reported excellent levels of Internal consistency.

Test-retest:
One study examined the test-retest reliability of the PHQ-9 and reported excellent test-retest.

Intra-rater:
No studies have examined the intra-rater reliability of the PHQ-9.

Inter-rater:
No studies have examined the inter-rater reliability of PHQ-9.

Validity Construct:
Convergent:
One study reported that the PHQ-9 as excellent correlation with the Beck depression Inventory (BDI) and General Health Questionnaire (GHQ-12) adequate correlation with the European Quality of Life Questionnaire (EuroQOL); and adequate to excellent correlation with subscales of the Medical Outcomes Study Short Form Health Survey (SF-36).
Floor/Ceiling Effects No studies have examined the floor or ceiling effects of the PHQ-9.
Does the tool detect change in patients? No studies have examined the responsiveness of the PHQ-9 in patients with stroke.
Acceptability PHQ-9 is typically self-administered, however it can be interview-administered in person or by telephone for clients who are unable to self-administer the measure.
Feasibility The measure is brief, simple to score and only the PHQ-9 test sheet and a pencil are required to complete the measure.
How to obtain the tool?

The PHQ-9 can be obtained from:
http://www.phqscreeners.com/

Psychometric Properties

Overview

There is an abundance of research on the psychometric properties of the nine-item Patient Health Questionnaire (PHQ-9). However, little research has been conducted specifically in patients with stroke. For the purposes of this review, we conducted a literature search to identify all relevant publications on the psychometric properties of the PHQ-9. We then selected the original validation and reliability studies as content to be summarized and presented here.

Reliability

The reliability of the PHQ-9 has not been examined in a stroke population.

Internal Consistency:
Kroenke, Spitzer and Williams (2001) investigated the internal reliability of the PHQ-9 in two large studies involving 6,000 participants from primary care and obstetrics-gynecology clinics. Using Cronbach’s alpha, excellent reliability was found in both studies (0.89 and 0.86 respectively).

Test-retest:
Kroenke, Spitzer and Williams (2001) investigated the test-retest reliability of the PHQ-9 in primary care clinics. Excellent test-retest reliability (0.84) was found when the PHQ-9 was administered in clinic and then over the telephone 48 hours later.

Intra-rater:
Not yet examined in a stroke population.

Inter-rater:
Not yet examined in a stroke population.

Validity

To our knowledge, the study by Williams et al. (2005) is the only study to date that has examined the validity of the PHQ-9 in individuals with stroke.

Criterion:
Concurrent:
Not yet examined in a stroke population.

Predictive:
Not yet examined in a stroke population.

Construct:
Convergent/Discriminant:
Martin, Rief, Klaiberg and Braehler (2005) examined the convergent validity of the Brief Beck Depression Inventory (BDI), General Health Questionnaire (GHQ-12), European Quality of Life (EuroQOL) Questionnaire and Medical Outcomes Study Short Form Health Survey (SF-36) with an alternative language version of the PHQ-9, in 2060 participants from the general population. The relationships between the measures were compared using the Welch test. The BDI had excellent correlation with the PHQ-9 (r=.73) and the GHQ-12 and EuroQOL had adequate correlation (r=.59 and r=.50 respectively). The subscales of the SF-36 had adequate to excellent correlation (ranging from r=-.45 to r=-.71).

Known groups:
Not yet examined in a stroke population.

Sensitivity/ Specificity:
Kroenke, Spitzer and Williams (2001) examined the Sensitivity and Specificity of the PHQ-9 in participants from primary care settings. Mental health professionals (Clinical Psychologists and Psychiatric Social Workers) conducted telephone interviews using the Structured Clinical Interview for Depression (SCID) and PRIME-MD to confirm diagnosis of Depression. A PHQ-9 score of ≥10 had excellent Sensitivity and Specificity for detecting major Depression, 88% and 88% respectively.

Williams et al. (2010) examined the Sensitivity and Specificity of the PHQ-9 and PHQ-2 in 316 patients with stroke. A diagnosis of Depression was confirmed using the Structured Clinical Interview for Depression (SCID). A PHQ-9 score of ≥10 was found to have excellent Sensitivity and Specificity for detecting any severity of Depression (78% and 96% respectively) and major Depression (91% and 89% respectively). Based on these results, the PHQ-9 should be used as a brief screening measure for assessing Depression in patients with stroke.

Responsiveness

To date, the responsiveness of the PHQ-9 has not been examined in a stroke population but has been examined in a group of patients receiving treatment for Depression in primary care settings.

Lowe, Unutzer, Callahan, Perkins and Kroenke (2004) examined the responsiveness of the PHQ-9 and the Depression scale from the Hopkins Symptom Checklist (SCL-20) in 434 patients receiving treatment for Depression in primary care settings (mean age 70.9 years). Standardized effect size scores for the intervals between baseline and 3-months and baseline and 6-months were calculated. Large effect sizes were found for the PHQ-9 and the SCL-20, however the results of this study indicate that PHQ-9 is more responsive. Standardized effect sizes of -1.3 at the 3-month interval and -1.3 at the 6-month interval were found for the PHQ-9; and -0.9 at the 3-month interval and -1.2 at the 6-month interval for the SCL-20.

References

  • Arroll, B., Goodyear-Smith, F., Crengle, S., Gunn, J., Kerse, N. and Fishman, T. et al. (2010). Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care setting. Annals of Family Medicine, 8, 348-353.
  • Kroenke, K. Spitzer, R.L. & Williams, J.B.W. (2001). Validity of a brief depression severity measure. Journal of General Internal Medicine, 16, 606-613.
  • Martin, A., Rief, W., Klaiberg, A. & Braehler, E. (2005). Validity of the brief Patient Health Questionnaire Mood Scale (PHQ-9) in the general population. General Hospital Psychiatry, 28, 71-77.
  • Williams, L.S., Brizendine, J., Plue, L., Bakas, T., Tu, W. & Hendrie, H. et al. (2005). Performance of the PHQ-9 as a screening tool for depression after stroke. Journal of the American Heart Association, 36, 635-638.

See the measure

How to obtain the PHQ-9?

The PHQ-9 is available for free for educational and clinical purposes at:
http://www.phqscreeners.com/

Table of contents

Stroke Aphasic Depression Questionnaire (SADQ)

Evidence Reviewed as of before: 22-08-2008
Author(s)*: Lisa Zeltzer, MSc OT
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The Stroke Aphasic Depression Questionnaire (SADQ-21) was developed to detect depressed mood in clients with Stroke and significant aphasia living in the community. It is a 21-item questionnaire developed based on observable behaviours thought to be associated with depressed mood. It is completed by the client’s caregiver on behalf of the client. A shortened version of the SADQ has been developed (SADQ-10), which is comprised of 10 questions that best differentiate those with high scores on Depression questionnaires from those with low scores. A revised version of the scale has also been developed for clients in hospital to be completed by hospital staff (SADQ-H).

In-Depth Review

Purpose of the measure

The Stroke Aphasic Depression Questionnaire (SADQ-21) was developed to detect depressed mood in clients with Stroke and significant aphasia living in the community. It is a 21-item questionnaire developed based on observable behaviours thought to be associated with depressed mood. It is completed by the client’s caregiver on behalf of the client. A shortened version of the SADQ has been developed (SADQ-10), which is comprised of 10 questions that best differentiate those with high scores on Depression questionnaires from those with low scores. A revised version of the scale has also been developed for clients in hospital to be completed by hospital staff (SADQ-H).

Available versions

The original version of the SADQ and the shortened version (SADQ-10) were developed by Sutcliffe and Lincoln in 1998. The SADQ was revised by Sutcliffe, Lincoln, and Unsworth in 2000 so that the measure could be used with clients in the hospital (SADQ-H).

Features of the measure

Items:
SADQ-21
In this 21-item scale, caregivers must rate the frequency at which certain observable behaviours that are thought to be associated with depressed mood occur. Each item requires the responder to rate how often in the last week these behaviours occurred on a scale of ‘often’, ‘sometimes’, ‘rarely’, ‘never’. Examples of items include: “Did he/she take sleeping tablets; Did he/she refuse to eat meals?; Did he/she have weeping spells?”.

SADQ-10
The SADQ-10 was developed as an abbreviated version of the SADQ-21 in order to improve the validity of the SADQ. For clinical use, this version is recommended as the best version currently available for detecting depressed mood. The SADQ-10 is comprised of 10 items from the SADQ-21 that best differentiated between those with high scores on Depression questionnaires from those with low scores.

SADQ-H
The SADQ-H was developed to be used specifically with clients in the hospital. The SADQ-H is comprised of the same 21 items as the SADQ-21, but some modifications were made to the wording of the items and the response categories. Some items were rephrased in order to make them easier to answer with respect to a patient with aphasia (e.g. ‘Did he/she indicate suffering from aches and pains?’ rather than ‘Did he/she complain of aches and pains?’). Items were also reworded to take disability into account (e.g. ‘Did he/she take care of his/her appearance to the extent of his/her physical ability?’ rather than asking if he/she take care of his/her appearance). Questions were made more specific (e.g. ‘Did his/her waking cause disturbance in sleep patterns?’ rather than ‘Does he/she wake early in the morning?’, emphasizing the behaviour as a problem, rather than merely early waking per se). Moreover, the tense of the questions was altered because the rater was considering patient behaviours over the previous week. The response categories were altered, from ‘often’, ‘sometimes’, ‘rarely’ and ‘never’ to ‘every day this week’, on ‘4-6 days this week’, on ‘1-4 days this week’ and ‘not at all this week’.

SADQ-H 10
The SADQ-H 10 was developed to be used specifically with clients in the hospital. It is comprised of the same 10 items found in the SADQ-10 but these items were first modified in the SADQ-H as described above.

Scoring:
For all versions of the SADQ a score of 0-3 is selected for each question. The total score is produced by adding the individual scores from each question.

SADQ-21
Scores range from 0-63 on the SADQ-21, with higher scores indicating higher levels of Depression. No cut-off score has been established for this version of the SADQ.

SADQ-10
Scores range from 0-30 in this version. A cut-off score of 14 out of 30 on the SADQ-10 has been found to be optimal for detecting the presence of Depression (Leeds et al., 2002).

SADQ-H
Same as the above for the SADQ-21. A cut-off score of 17/18 has been found optimal for detecting the presence of Depression.
Note: The cut-off values indicate a lower figure that is the highest likely to be obtained by people without low mood and a higher figure that is the lowest likely to be obtained by people with low mood.

SADQ-H 10
Same as the above for SADQ-10. A cut-off score of 5/6 has been found optimal for detecting the presence of Depression.
Note: The cut-off values indicate a lower figure that is the highest likely to be obtained by people without low mood and a higher figure that is the lowest likely to be obtained by people with low mood.
Time: It takes approximately 2 minutes to complete the SADQ-10 (and SADQ-H 10) and approximately 4 minutes to complete the full SADQ (and SADQ-H).

Subscales:
None.

Equipment:
Only the test copy and a pencil are required to complete the SADQ.

Training of administrator:
None required.

Alternative forms of the SADQ-21

Please see the “items” section under ‘features of the measure’ for a detailed description of the alternative versions of the SADQ-21, namely the SADQ-10, SADQ-H, and SADQ-H 10.

Client suitability

Can be used with:

  • Clients with Stroke and significant aphasia.

Should not be used with:

  • Individuals who may be depressed but who have not had a Stroke or clients who do not have significant aphasia, that is, minimal ability to understand and response (Leeds, Meara, Hobson, 2002). For these clients, other Depression measures exist that have more evidence to support their psychometric properties (e.g. Hamilton Depression Rating Scale (HDRS), Beck Depression Inventory (BDI), Geriatric Depression Scale (GDS), etc.).

In what languages is the measure available?

The SADQ-21 and SADQ-10 have been translated into French and the SADQ-H and SADQ-H 10 are available in Italian. These translations are available online at: http://www.nottingham.ac.uk/IWHO/Research/PublishedAssessments.aspx

Summary

What does the tool measure? To detect depressed mood in clients with stroke and significant aphasia.
What types of clients can the tool be used for? The SADQ is intended for use with clients with stroke having significant aphasia.
Is this a screening or assessment tool? Assessment or screening.
Time to administer From 2 to 4 minutes.
Versions SADQ-10; SADQ-H; SADQ-H 10
Other Languages French; Italian
Measurement Properties
Reliability Internal consistency:
– Two studies examined the Internal consistency of the SADQ-21 and the SADQ-H and reported excellent Internal consistency.
– One study examined the Internal consistency of the SADQ-10 and reported excellent Internal consistency.
– One study examined the Internal consistency of the SADQ-H 10 and reported poor Internal consistency.

Test-retest:
One study examined the test-retest reliability of the SADQ-21 and SADQ-10. Both had adequate test-retest reliability using Spearman rho correlation.

Inter-rater:
One study examined the inter-rater reliability of the SADQ-H between patients and their nurses using Cohen’s kappa and reported 5 items had excellent inter-rater reliability and the remaining 16 items had adequate inter-rater reliability.

Validity Construct:
Convergent:
– Two studies examined convergent validity of the SADQ-21 and SADQ-10 with the Hospital Anxiety and Depression Scale (HADS) and the Wakefield Depression Inventory (WDI). Both studies found a poor correlation between SADQ-21 and the HADS Depression subscale (HADS-D) and an adequate correlation between the SADQ-21 and the WDI.
– One study reported an adequate correlation with the HADS anxiety subscale (HADS-A) and one reported a poor correlation with the HADS-A.
– One study reported a poor correlation between the SADQ-10 and the HADS-D and WDI, and an adequate correlation with the HADS-A, and one study reported an adequate correlation between the SADQ-10 and the HADS-D and an excellent correlation with the HADS-A and WDI.
– One study examined the convergent validity of the SADQ-H and SADQ-H 10 with the HADS and reported an adequate correlation with the HADS-D and a poor to adequate correlation with the HADS-A.
– One study examined the convergent validity of the SADQ-10 with the Geriatric Depression Scale-15 (GDS-15) and reported an adequate correlation.
Floor/Ceiling Effects No studies have examined the floor or ceiling effects of the SADQ.
Sensitivity/Specificity – One study reported that for the SADQ-10, a cut-off score of 14/30 produced a Sensitivity of 70% and a specificity of 77% to detect Depression.
– One study reported an optimum cut-off of 17/18 on the SADQ-H (Sensitivity of 1.00; specificity of 0.81), and an optimum cut-off of 5/6 on the SADQ-H 10 (Sensitivity of 1.00; specificity of 0.78) to detect Depression.
Note: The cut-off values indicate a lower figure that is the highest likely to be obtained by people without low mood and a higher figure that is the lowest likely to be obtained by people with low mood.
Does the tool detect change in patients? At present no studies have examined the responsiveness of the SADQ.
Acceptability The SADQ should not be used with individuals who may be depressed but who have not had a stroke, or patients who do not have aphasia.
Feasibility Completion of all versions of the SADQ is quick and simple.
How to obtain the tool?

The SADQ is available free with permission from the authors and can be obtained from the following website:
http://www.nottingham.ac.uk/IWHO/Research/PublishedAssessments.aspx

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications examining the psychometric properties of the Stroke Aphasic Depression Questionnaire (SADQ-21) and its alternative versions in individuals with aphasia.

Floor/Ceiling Effects

No studies have examined the floor or ceiling effects of the SADQ.

Reliability

Internal consistency:
Sutcliffe and Lincoln (1998) examined the Internal consistency of the SADQ-21 and SADQ-10 in 70 clients with aphasia who had been discharged from the hospital. Internal consistency was determined by performing item-total and split-half analyses. The SADQ-21 had a Cronbach’s alpha of 0.82 (excellent) and a split-half correlation of 0.79 (adequate). The SADQ-10 had excellent Internal consistency, with a Cronbach’s alpha of 0.80 and a split-half reliability of r = 0.81.

Lincoln, Sutcliffe, and Unsworth (2000) examined the Internal consistency of the SADQ in 50 in-patients with Stroke and the hospital version of the SADQ (SADQ-H) in 30 in-patients with Stroke. The primary nurse was asked to complete the SADQ in respect of the patient, for the week preceding the assessment interview. The SADQ had an excellent Cronbach’s alpha of 0.80 and an adequate split-half reliability of 0.70. The SADQ-H had an excellent Cronbach’s alpha of 0.82 and an adequate split-half reliability of 0.74.

Bennett, Thomas, Austen, Morris and Lincoln (2006) examined the Internal consistency of the hospital version of the SADQ (SADQ-H) and the shortened version (SADQ-H 10) in 100 patients with Stroke recruited from two acute hospitals. The SADQ-H had excellent Internal consistency (alpha = 0.84), and the SADQ-H 10 had poor Internal consistency (alpha = 0.68).

Test-retest:
Sutcliffe and Lincoln (1998) examined the test-retest reliability of the SADQ-21 and SADQ-10 in 17 clients with aphasia who had been discharged from hospital using Spearman correlations. The carers of clients (spouses or nursing home staff) were contacted by post and asked to complete and return the SADQ. Carers were contacted four weeks later and asked to complete and return the SADQ again. The SADQ-21 and SADQ-10 were found to have adequate test-retest reliability over a four-week interval (r = 0.72 and r = 0.69, respectively).

Inter-rater:
Lincoln et al. (2000) examined the inter-rater reliability of the SADQ-H in 30 in-patients with Stroke. Cohen’s Kappas were calculated to assess the agreement between the SADQ as completed by the nurses, and the SADQ as completed by the patients themselves for each item. Using internal statistical categories, it was found that 5 items showed an excellent agreement and 16 items showed adequate agreement between patient and nurse (Cohen’s Kappa ranging from 0.40 to 0.90).

Validity

Content:
Items comprising the SADQ were chosen based on observable behaviours thought to be associated with depressed mood and included items derived from other questionnaire measures of Depression. Ratings were compared with questionnaire responses in clients without aphasia.

Criterion:
Concurrent:
Not yet examined.

Predictive:
Not yet examined.

Construct:
Convergent/Discriminant:
Sutcliffe and Lincoln (1998) examined the convergent validity of the SADQ and SADQ-10 with the Hospital Anxiety Depression Scale (HADS – Zigmond & Snaith, 1983) and the Wakefield Depression Inventory (Snaith, Ahmed, Mehta, & Hamilton, 1971) in 70 clients with aphasia who had been discharged from the hospital. The relationship between the measures was examined using Spearman’s rank correlations. The SADQ had a poor correlation with the HADS Depression subscale (r = 0.22), an adequate correlation with the anxiety subscale (r = 0.42) and with the Wakefield Depression Inventory (r = 0.52). The SADQ-10 had an adequate correlation with the HADS Depression subscale (r = 0.32), an excellent correlation with the anxiety subscale (r = 0.63) and with the Wakefield Depression Inventory (r = 0.67).

Bennett et al. (2006) examined the convergent validity of the SADQ-H and SADQ-H 10 with the Hospital Anxiety Depression Scale (HADS – Zigmond & Snaith, 1983) in 100 patients with Stroke recruited from two acute hospitals. The relationship between the measures was examined using Spearman’s rank correlations. The SADQ-H and SADQ-H 10 had an adequate correlation with the HADS Depression subscale (r = 0.52 and 0.53, respectively), a poor to adequate correlation with the HADS anxiety subscale (r = 0.23 and 0.33, respectively), and an adequate correlation with the total HADS (r = 0.45 and 0.51, respectively).

Lincoln, Sutcliffe, and Unsworth (2000) examined the convergent validity of the SADQ and the SADQ-10 with the Hospital Anxiety and Depression Scale (HADS – Zigmond & Snaith, 1983) and the Wakefield Depression Inventory (Snaith et al., 1971) in 50 in-patients with Stroke. The SADQ had a poor correlation with both the HADS Depression (r = 0.12) and anxiety (r = 0.30) subscales, and an adequate correlation with the Wakefield Depression Inventory (r = 0.31). The SADQ-10 had an adequate correlation with the HADS anxiety subscale (r = 0.35) and a poor correlation with the HADS Depression subscale (r = 0.05). The SADQ-10 had a poor correlation with the Wakefield Depression Inventory (r = 0.29).

This study by Lincoln et al. (2000) also examined the convergent validity of the SADQ-H with the Wakefield Depression Inventory (Snaith et al., 1971) in 30 in-patients with Stroke and found that the measures were more highly correlated with the SADQ-H version than with the SADQ or SADQ-10 (r = 0.58).

Leeds, Meara, and Hobson (2002) examined the convergent validity of the SADQ-10 with the Geriatric Depression Scale-15 (GDS-15 – Sheik & Yesavage, 1986) in 65 non-aphasic patients with Stroke undergoing rehabilitation. Bivariate analysis revealed an adequate correlation between the SADQ-10 and the GDS-15 (r = 0.40).

Known groups:
Not yet examined.

Sensitivity and Specificity:
Leeds et al. (2002) administered the SADQ-10 to 65 non-aphasic clients with Stroke undergoing rehabilitation. Clients self-completed the Geriatric Depression Scale-15 (GDS-15 – Sheik & Yesavage, 1986) and a research nurse completed the SADQ-10 for each client. Using a cut-off point of ≥5 on the Geriatric Depression Scale-15 as the criterion for Depression, a cut-off score of 14 out of 30 on the SADQ-10 produced a Sensitivity of 70% and a Specificity of 77% to detect Depression.

Bennett et al. (2006) conducted receiver operating characteristic (ROC) curve analyses on the data from 100 patients with Stroke to establish the appropriate cut-off scores for the SADQ-H and SADQ-H 10 in relation to Depression and anxiety as identified on the Hospital Anxiety and Depression Scale (HADS – Zigmond & Snaith, 1983). The criterion for low mood was a score greater than 7 on the Depression or anxiety subscales of the HADS. This criterion was based on cut-offs for mild mood disturbance found in a previous study in patients with Stroke (O’Rourke MacHale, Signorini, & Dennis, 1998). Cut-off scores for Depression were identified as an optimum cut-off of 17/18 on the SADQ-H (Sensitivity of 1.00; Specificity of 0.81), and an optimum cut-off of 5/6 on the SADQ-H 10 (Sensitivity of 1.00; Specificity of 0.78). Cut-off scores for anxiety were identified as an optimum cut-off of 9/10 on the SADQ-H (Sensitivity of 0.75; Specificity of 0.40) and an optimum cut-off of 4/5 on the SADQ-H 10 (Sensitivity of 0.75; Specificity of 0.50).
Note: The cut-off values indicate a lower figure that is the highest likely to be obtained by people without low mood and a higher figure that is the lowest likely to be obtained by people with low mood.

Responsiveness

Not examined.

References

  • Benaim, C., Cailly, B., Perennou, D., Pelissier, J. (2004). Validation of the aphasic depression rating scale. Stroke, 35, 1692.
  • Bennett, H. E., Thomas, S. A., Austen, R., Morris, A. M. S., & Lincoln, N. B. (2006). Validation of screening measures for assessing mood in stroke patients. British Journal of Clinical Psychology, 45, 367-376.
  • Leeds, L., Meara, R. J., & Hobson, J. P. (2004). The utility of the Stroke Aphasia Depression Questionnaire (SADQ) in a stroke rehabilitation unit. Clinical Rehabilitation, 18, 228-231.
  • Lincoln, N. B., Sutcliffe, L. M., & Unsworth, G. (2000). Validation of the Stroke Aphasic Depression Questionnaire (SADQ) for use with patients in hospital. Clinical Neuropsychological Assessment, 1, 88-96.
  • O’Rourke, S., MacHale, S., Signorini, D., & Dennis, M. (1998). Detecting psychiatric morbidity after stroke: Comparison of the GHQ and the HAD scale. Stroke, 29, 980-985.
  • Sheik, J. A., Yesavage, J. A. (1986). Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. Clin Gerontol, 37, 819-820.
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See the measure

How to obtain the SADQ?

The SADQ is available free with permission from the authors and can be obtained from the following website: http://www.nottingham.ac.uk/medicine/about/rehabilitationageing/publishedassessments.aspx

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