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
  • No studies have examined the internal consistency of the ADRS.
  • 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.
  • 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.
  • No studies have examined the intra-rater reliability of the ADRS.
Validity

Construct:
Convergent/Discriminant validity: 
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 validity.
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
Help us to improve