It is highly recommended to promptly assess depression in heart disease patients as it represents a crucial risk factor which may result in premature deaths following acute cardiac events and a more severe psychopathology, even in cases of subsequent nonfatal cardiac events. Patients and professionals often underestimate or misjudge depressive symptomatology as cardiac symptoms; hence, quick, reliable, and early mood changes assessments are warranted. Failing to detect depressive signals may have detrimental effects on these patients’ wellbeing and full recovery. Choosing gold-standard depression investigations in cardiac patients that fit a hospitalised cardiac setting well is fundamental. This paper will examine eight well established tools following Italian and international guidelines on mood disorders diagnosis in cardiac patients: the Hospital Anxiety and Depression Scale (HADS), the Cognitive Behavioural Assessment Hospital Form (CBA-H), the Beck Depression Inventory (BDI), the two and nine-item Patient Health Questionnaire (PHQ-2, PHQ-9), the Depression Interview and Structured Hamilton (DISH), the Hamilton Rating Scale for Depression (HAM-D/HRSD), and the Composite International Diagnostic Interview (CIDI). Though their strengths and weaknesses may appear to be homogeneous, the BDI-II and the PHQ are more efficient towards an early depression assessment within cardiac hospitalised patients.
A significant number of patients with heart disease suffer from depression at some point during the course of their illness [
More or less severe depression is mainly found in hospitalised patients who had myocardial infarction [
Longitudinal studies have generally demonstrated that depression can last many months after the acute phase of a heart disease and that it causes significant loss in functioning beyond what is expected after the illness itself. In some cases, depression can evolve into disability [
Depression seems to be a cardiovascular risk factor in healthy subjects as well [
Hence, the health status of patients during the weeks and months following the acute cardiac event is often the result of a cardiovascular pathology process already developing from some time before. In fact, patients are often confronted with the risk of dying, undergoing other acute critical events, and/or being impaired for life [
However, in a fair percentage of patients, these symptoms can last longer, get worse, or later become an overt psychopathological syndrome (i.e., adjustment disorders, mood disorders, and posttraumatic stress diseases) and this depends on their personal resources, psychological characteristics, sociocultural environment, and their disease peculiarities. A cognitive adaptation theory formulated by Taylor and Brown [
Mild and severe feelings of depression, anxiety, and anger, along with their related cognitive correlates, painfully burst into the individual’s experience and accompany him/her throughout the adaptation path. In this process, several variables come into play: from personal characteristics to the disease severity, from personal coping styles to distal or closer social contexts, and from individual cognitive schemata and reality construction to the quality of the social support received. That is to say that an optimistic, self-confident individual with a high self-efficacy and self-control, a good coping capacity, and a supportive and empathic social environment is more likely to quickly and positively adapt to the disease. A pessimistic, insecure, helpless, and discouraged individual with little or inadequate coping skills, who is socially isolated or with little or no social support at all, is unlikely to adapt to the disease. Hence, he/she runs the risk of developing an adaptation disorder first and a possible mood disorder later. The cardiac patients’ main task is therefore rebuilding or accommodating to the functional cognitive assumptions which have been undermined, restoring the perception of control over the situation [
Despite the prognostic importance of depression in cardiac patients, an estimate suggests that depressive symptoms and disorders are diagnosed and treated in less than 15% of cases [
Interestingly, during and after an acute cardiac event, male patients often feel angry. Due to cultural and social reasons, anger, especially in males, works as a reaction to depressive covert feelings that are not accepted. Thus, when patients are angry, both health practitioners and family tend to minimise and underestimate such responses rather than understanding if the emotion experienced is a sign of depression [
In this paper, the analysis of eight major assessment instruments the Hospital Anxiety and Depression Scale (HADS), the Cognitive Behavioural Assessment Hospital Form (CBA-H), the Beck Depression Inventory (BDI), the two and nine-item Patient Health Questionnaire (PHQ-2, PHQ-9), the Depression Interview and Structured Hamilton (DISH), the Hamilton Rating Scale for Depression (HAM-D/HRSD), and the Composite International Diagnostic Interview (CIDI) will be performed in order to provide a comparison between them and to identify which one is more suitable in detecting mood changes within the cardiac patients hospitalised population. The aim of this work is to go through the fundamental steps that have most commonly been used to evaluate depression in cardiac hospitalised patients. The selection of the eight tools mentioned above refers to what has been suggested by international studies on heart disease patients at the National (Italian), European, and American level. The present study follows the recommendations of guidelines regarding the best path leading towards high screening quality.
Thus, the authors’ search strategy strictly refers to the indications specified by the Italian National System of guidelines (SNLG), the Italian Institute of Health (2005), the American health institutes (NHI), the National Heart, Lung and Blood Institute (2006), and finally the European guidelines for the prevention of cardiovascular disease in the clinical practice published by the European Cardiology Society (2007). The questionnaires included in this work refer to those expressively suggested in previously mentioned sources. Moreover, in this paper the best instruments amongst the eight listed in the four major guidelines above which are more likely to overcome the danger of underestimating a depressive condition in heart disease patients are outlined.
The following is therefore an overview of the tools taken into consideration by Italian, American, and European recommendations on cardiac patients depression screening. The authors’ aim is to highlight which of the eight instruments is mostly appropriate, rapidly administered, short, simple, and useful in identifying psychological aspects related to depressive symptoms underlying the condition of hospitalised cardiac patients rather than concentrating on general areas of distress or misjudging mood disorders for other medical conditions. Thus, strengths and weakness of the questionnaires, semi-structured or structured clinical interviews analysed in this review will be pointed out. Hence, the most recommendable tools will be clearly identified. It is important to verify which instrument proves itself to be more useful to evaluate depression since mood disorder screening is fundamental in later providing patients with the best possible psychological support and most suitable treatment.
In the international literature the simplest and most widely used tool is the Hospital Anxiety and Depression Scale (HADS) [
More specifically, items of the Hospital Anxiety and Depression Scale (HADS) are scored from 0 to 3 on a Likert scale with a final score ranging from 0 to 21 for either anxiety or depression. There are a large number of studies that have explored the underlying factor structure of the Hospital Anxiety and Depression Scale (HADS), many of which support the two-factor structure, although others suggest a three- or four-factor structure, while some argue that the tool is best used as a unidimensional measure of psychological distress [
The utility of the Hospital Anxiety and Depression Scale (HADS) as a screening instrument for coronary care patients following acute myocardial infarction (MI) has been investigated by Martin et al. [
Nonetheless, patients reliably and validly reporting on a continua of anxiety and depressive symptoms appear to be rather arbitrary due to the constriction of breadth of content, which interferes with providing an efficient first stage screening to determine whether they meet formal diagnostic criteria for an anxiety or depressive disorders. That is to say that the Hospital Anxiety and Depression Scale (HADS) has an idiosyncratic conception of the core symptom of depression as being anhedonia, leading towards oversampling and less applicability to the mild to moderate range of sad or blue depression symptoms. The tool may therefore be weak in detecting mood disorders in contexts where many medically ill patients without psychopathological issues can be found, including cardiac units. Such matter limits a refined discrimination of symptoms severity [
In 2005, the national guidelines on cardiac rehabilitation and secondary prevention of cardiovascular diseases were published in the Italian National System of guidelines (SNLG) of the the Italian Institute of Health with an entire chapter dedicated to psychological and educational interventions. In the document it is stated that “an agreement regarding the instrument more appropriate to use for the measurement of “psychological wellbeing” was not reached yet.” Further suggestion coming from the Italian Institute of Health guidelines on the assessment of depression in cardiac patients are proposed in the guidelines appendix, stating that the Cognitive Behavioral Assessment Hospital Form (CBA-H), which is the most commonly used instrument to assess depression which is very similar to the Hospital Anxiety and Depression Scale (HADS) and the Beck Depression Inventory (BDI) [
The Cognitive Behavioral Assessment Hospital Form (CBA-H) was developed by Bertolotti and colleagues [
Card A contains 21 items focusing on the present time (i.e., hospitalization or diagnosis communication), evaluating anxiety and depression states and fears and worries. Card B contains 23 items asking about the previous three months investigating on dysphoria and on other psychophysiological disorders and stress. Card C contains 61 items focusing on the period of time prior to the disease and it asks a self-reported patient description of his/her stable character and behaviour such as introversion/extroversion, neuroticism, social anxiety, speed and impatience, job involvement, hostility, hard driving, and irritability. Card D contains 47 items on biographical information about general lifestyle (work, affective and sexual life, smoking, eating and drinking, sleep quality, and physical exercise) and health risk factors (stressful events). The entire questionnaire scoring includes both quantitative measures and in depth examination patterns as well as suggestions for further interventions within the health psychology and behavioural medicine fields. The tool includes a software program which creates a global report on the patient’s psychological profile and hypothesis for the additional clinical interview.
Although the Cognitive Behavioral Assessment Hospital Form (CBA-H) can be considered a valid and complete tool for general psychological distress screening within the hospital context, it must be viewed as a battery of different tests which do not specifically address mood disorders and depressive symptomatology. In fact, only Card A is specifically structured to analyse the patients’ situational psychological state, such as those emotional reactions that the hospitalised individual experiences at the time of completion of the tests. This part of the tool is particularly suitable for patients who accesses a rehabilitation cardiac program as it enquires about feeling sheltered and about the experiences regarding the illness. However, it may not be enough for clinicians to use the entire Cognitive Behavioural Assessment Hospital Form (CBA-H) or to fully rely on it when assessing a target condition possibly accompanying cardiac patents, such as depression.
When it comes to the Beck Depression Inventory (BDI), it is a much more renowned gold-standard scale [
The Beck Depression Inventory has been extensively studied. Results have been consistently positive and the Beck Depression Inventory is now known to correspond with over 90% of clinical diagnoses for patients suffering from depression. It is also widely agreed that the test adequately covering the range of conditions commonly exhibited by those with depression, accurately measuring the severity of the ailment, while meeting with recent medical and psychological standards [
In 2006, one of the American health institutes (NHI), the National Heart, Lung and Blood Institute published a document with some recommendations for the evaluation and treatment of depression in cardiac patients defined by an interdisciplinary team especially created for the matter. The paper recommends the use of the Beck Depression Inventory for epidemiological studies, the Patient Health Questionnaire (the two-items form) for initial screening, and the structured interview formulated by the ENRICH Study group [
In the following year, in 2007, the fourth updated edition of the European guidelines for the prevention of cardiovascular disease in the clinical practice was published by the European Cardiology Society and nine other institutions incorporated in a single task force. In the final document, along with the classic risk factors such as hypertension, diabetes, and obesity, psychosocial factors were also considered. The assessment of depression using simple and straightforward instruments was also suggested [
An example of a direct and easy-to-use tool is represented by the two-items form of the Patient Health Questionnaire, the PHQ-2, a yes/no screening tool enquiring about the patient’s past 2 weeks and asking if she/he has noticed little interest or pleasure in doing things and/or has felt down, depressed, or hopeless. If the answer is “yes” to either question, professionals qualified in the diagnosis and management of depression should refer for more comprehensive clinical evaluation using the nine-item version of the questionnaire, the Patient Health Questionnaire Nine (PHQ-9), [
Most patients are able to complete the Patient Health Questionnaires in more or less than five minutes with no assistance, yielding a provisional depression diagnosis and a severity score which can be used for treatment selection and monitoring. The Patient Health Questionnaire Nine (PHQ-9) has been shown to have reasonable sensitivity and specificity for patients with coronary artery disease. Nonetheless, for those who display mild symptoms, it would be better to recall for a subsequent visit or followup, while for those with high depression scores, a specialised practitioner should review the answers with the patient to gain a clearer picture. On the whole, the two-items form of the Patient Health Questionnaire (PHQ-2) also shows good specificity but it has poor sensitivity in patients with coronary artery disease. Similar results have also been found for the nine-item version of the Patient Health Questionnaire (PHQ-9), [
Particularly, the Patient Health Questionnaire Nine (PHQ-9) has a double objective: establishing a provisional depressive disorder diagnosis and symptom severity rating in order to carry on treatment, since a 5-point score or above falls into the questionnaire global score and qualifies as a clinically significant response to depression intervention. In fact, each 5-point change on the Patient Health Questionnaire Nine (PHQ-9) represents a moderate effect size on multiple domains of health-related quality of life and functional status. A score of less than 10 qualifies as a partial response, while a score of less than 5 counts as remission. It is important to keep in mind that such values must be viewed in a rules of thumb logic, hence, requiring clinical evaluation of the individual heart disease patient. Brevity coupled with its construct and criterion validity makes the Patient Health Questionnaire Nine (PHQ-9) an attractive, dual-purpose instrument for making diagnoses and assessing severity of depressive disorders, particularly in the busy setting of clinical practice [
Further indications on assessing depression in cardiac patients come from the renowned Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) trial which examined the effects of cognitive behavioural therapy plus adjunctive sertraline treatment in case of insufficient response on depression, and cardiac outcomes in postmyocardial infarction (MI) patients. The research represents a target study as it demonstrated that a Cognitive Behavioural Therapy treatment provided to a very large sample of over two thousands cardiac, depressed patients did help participants reduce general depressive symptoms but failed to determine a significant reduction in death rates in the months following the cardiac episode, compared to patients who received a traditional psychological treatment [
The Depression Interview and Structured Hamilton (DISH) is suitable to screen cardiac patients for depressive disorders, diagnose major and minor depression or dysthymia according to the DSM-IV criteria, rate the severity of depression on a structured version of the Hamilton Rating Scale for Depression (HRSD), and gather the history and development of depression. The interview is divided into three sections. The first is the “Optional Opening Questions” and it is comprised of open-ended questions in order to develop therapeutic alliance and encourage the patient to open up. The second section is on the 17-item Hamilton scale and it is called the “Current Depression Symptoms.” This part of the interview includes criteria needed to diagnose major and minor depression or dysthymia and to evaluate depression severity in the past week. The depressive symptomatology is coded absent, subthreshold, present, or present due to direct physiological effects of the cardiac condition or treatment. Symptom vary according to how long they last in weeks and they are coded separately according to the number of days they have been present for, though less than two weeks [
Moreover, in the second section, compulsory questions are verbatim administered with the aim of verifying the existence of a DSM-IV depressive disorder and obtaining an Hamilton Rating Scale for Depression (HRSD) score. Some assess atypical features of depression (increased appetite, weight gain, and hypersomnia) and bereavement, while others are worded according to the patient’s personal preference for the symptoms terminology (i.e., “feeling sad/depressed” is referred to as “feeling down” or “blue”), leaving the interviewer to assess whether the patient’s terms intertwine with the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) criteria. Optional questions clarify the context, frequency, severity, duration, and qualitative features of depressive symptoms. The first items of the “Current Depression Symptoms” facilitates a rapid screening of nondepressed subjects, directly assessing the main symptoms of depression (dysphoria and loss of interest or pleasure in usual activities). Nonetheless, for cardiac patients who wish to approach their somatic symptoms first, question order may be changed to promote a better therapeutic alliance and self-disclosure. The section ends with a brief assessment of signs or symptoms of major psychiatric disorders (i.e., paranoia, delusions, hallucinations, hypomania, and confusion), aiming at verifying severe psychiatric comorbidity [
The third and last part of the Depression Interview and Structured Hamilton (DISH) is the Psychiatric History section in which most items enquire about the patient’s previous personal history and on major depression. Along with familial history of depression, the section asks about the number of past episodes, the age at first onset and at first onset of the last episode, history of bipolar disorder, alcoholism, and other disorders that might be worth of clinical attention. A Longitudinal Course Chart is used to document the interim course of any possible depressive disorders from the interview baseline to any eventual exacerbations, remissions, relapses, recurrences, or new depressive episodes [
The Hamilton Rating Scale for Depression (HAM-D or HRSD) is one of the most popular and old scales specifically developed to assess depression severity. From its original version, namely, the Hamilton Rating Scale for Depression (HAM-D) the last four items (diurnal variation, depersonalization/derealization, paranoid symptoms, and obsessive compulsive symptoms) were eliminated as they concerned symptoms later considered to be uncommon or not representative of depression severity as such [
Time administration of the interviews is around 12 minutes without taking into account that its duration may be longer due to psychomotor retardation or any other impediment given by depression or overall health conditions. The total score is obtained by summing up the score of each item, ranging from null to four, that is to say, from no symptoms to mild, moderate, or severe depression or from null to two, which corresponds to absent, slight or trivial, and clearly present depression. For the 17-item version, scores can range from 0 to 54.
Moreover, for most clinicians scores between 0 and 6 do not indicate the presence of depression, scores between 7 and 17 indicate mild depression, scores between 18 and 24 indicate moderate depression, and scores over 24 indicate severe depression. A total Hamilton Rating Scale for Depression (HAM-D or HRSD) score of 7 or less after treatment is a classic indicator of remission. A decrease of half or more symptoms from the interview baseline during the course of a depression treatment is considered an indicator of clinical response, or in other words, a clinically significant change [
A recommendation when it comes to psychosocial screening is to provide for all patients with a heart disease the use of clinical interviews and standardized questionnaires, for which Albus et al.’s publication [
The Composite International Diagnostic Interview (CIDI) is a comprehensive and fully standardised diagnostic instrument containing 276 symptom questions, many of which are used to evaluate symptom severity, help-seeking behaviour, psychosocial impairments, and single episode-related matters. Although primarily intended for use in epidemiological studies of mental disorders, it is also being extensively used for clinical and other research purposes. The Composite International Diagnostic Interview (CIDI) was judged to be acceptable for most subjects and was found to be appropriate in different kinds of settings and countries [
The interview is modular and covers somatoform disorders, anxiety disorders, depressive disorders, mania, schizophrenia, eating disorders, cognitive impairment, and substance use disorders. Two questions are used to assess drug and alcohol abuse, a screening module and 40 sections focusing on diagnoses (22 sections), functioning (four sections), treatment (two sections), risk factors (four sections), sociodemographic correlates (seven sections), and methodological factors (two sections), [
All in all, self-administered questionnaires are much more advantageous from a time consumption point of view, and also, they are dimensional rather than categorical instruments; unlike structured interviews, they allow measuring of psychological discomfort in a severity continuum. Moreover, they offer some advantages over clinician-rated scales, as they may take less time, do not require trained personnel, and their administration and scoring process appear to be more standardized. Self-rating scales also require that individuals are able to read at a minimal reading level, and that they speak the language used in at least one translation of the scale. However, some questionnaires also have a cutoff (a threshold) beyond which it is acceptable to assume the presence of a probable depressive disorder. In such cases, a structured interview can be used secondly to test the hypothesis and possibly make a safer and stronger diagnostic hypothesis.
Self-administered tools were also used in most studies investigating the role played by psychosocial factors towards the risk of developing a heart disease, with particular attention to the role played by depression. These were highly standardised and are mostly recommended for an extensive evaluation of cardiac patients [
Finally, although it is the weaker tool from a psychometric point of view, the clinical interview, even if it would only consists of a single question, could also be recommended in the clinical practice as it is easy to use during the initial phases of the cardiac interview. Hence, the interview could simply ask the following questions: “Do you feel down, depressed or discouraged? Did you lose interest or pleasure doing things in everyday life?.” A positive answer at just one of these questions could be indicative of a potential problem which needs further evaluation, such as subministration of a self-administered questionnaire and/or a referral to a psychologist, a psychotherapist or to a psychiatrist, for a specific psychodiagnostic interview.
In general, according to recent Italian, European, and American recommendations [
Among the tools analysed throughout this paper, that is to say, the Hospital Anxiety and Depression Scale (HADS), the Cognitive Behavioural Assessment Hospital Form (CBA-H), the Beck Depression Inventory (BDI), the two and nine-item Patient Health Questionnaire (PHQ-2, PHQ-9), the Depression Interview and Structured Hamilton (DISH), the Hamilton Rating Scale for Depression (HAM-D/HRSD), and the Composite International Diagnostic Interview (CIDI), two of them appear to be more advantageous within the cardiac unit context. These are the Beck Depression Inventory-II (BDI-II) and the two and nine-items Patient Health Questionnaires, as shown in the summary provided in Table
Depression measures characteristics.
Tool name | Validation study | Number of items | Tool characteristics | Advantages | Disadvantages |
---|---|---|---|---|---|
Hospital Anxiety and Depression Scale |
Zigmond and Snaith [ |
14 items | Item distribution is perfectly even: 7 items score for depression and 7 for anxiety. The total scale score may be used as a measure of global mood disorder according to the classification of mild (8–10), moderate (11–15), and severe anxiety or depression (16–21) scores. Clinical-practice specific. | Good screening and evaluation of psychological distress symptoms in post-MI patients |
Arbitrary symptom detection due to the constriction of breadth of content, which interferes with providing an efficient first stage screening |
|
|||||
Cognitive Behavioral Assessment Hospital |
Bertolotti et al. [ |
152 items | Card A investigates the emotional reactions at the exact same time of that of the test completion (i.e., hospitalization). It has three scales: state anxiety (A1), health fears (A2), and depressive reactions (A3) |
Cards take into account different time lags, discriminating between emotional states and behavioural changes related to the recent hospitalization or health diagnosis and the patient’s preexisting characteristics |
The CBA-H, developed to allow a quicker assessment within the hospital or health context, has an overall long time completion |
|
|||||
Beck Depression Inventory |
Beck et al. [ |
21 items | It assesses the severity of 21 depression symptoms rated on a 4-point scale (0–3). 13 items address cognitive or affective symptoms (hopelessness and guilt). Two of them assess the cardinal symptoms of depression: depressed mood and loss of interest or pleasure in usual activities. The remaining 8 items assess somatic symptoms (insomnia, fatigue, and poor appetite). In screening uses, a total score of 10 or higher is the most widely used cutoff for clinically significant depression. BDI total scores of 10–18 are consistent with mild, 19–29 with moderate, and 30 or higher with severe depression |
Designed to measure depressive symptoms severity at the present time (i.e., hospitalisation) |
It measures attitudes and cognitions which are fairly stable over time among depressed patients and may therefore underestimate the degree of improvement during acute pharmacological treatments |
|
|||||
Patient |
Kroenke et al. [ |
2 or 9 items | The Patient Health Questionnaire (PHQ) is a self-administered diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as “0" (not at all) to “3" (nearly every day) |
Both questionnaires are useful tools to recognize not only major depression but also subthreshold depressive disorder in all clinical and nonclinical samples |
Followup of heart disease patients who showed mild sigh of depression is advised, while those with high depression scores should have a specialist reviewing the answers in order to gain a clearer picture |
|
|||||
Interview and Structured Hamilton (DISH) | Freedland et al. [ |
47 Items | It is a structured interview designed to diagnose major and minor depression. The 17-item Hamilton Rating Scale for Depression (HAM-D-17) is also embedded within the DISH to assess severity of depression. Nine of the HAM-D items are rated on a 0–2 scale, and eight are rated on a 0–4 scale. HAM-D total scores can range from 0 to 50. Among medical patients, DISH scores between 10 and 23 are consistent with mild depression and scores of 24 or higher with relatively severe depression |
Designed to diagnose depression in medically ill patients and to assess its severity |
Designed to minimize respondent burden without losing thoroughness nor accuracy it fails to do so as on one hand some contents are option-rigid, while others are of personal preference |
|
|||||
Hamilton Rating Scale |
Williams [ |
21 items | The hamilton depression rating scale is a 17-item scale that evaluates depressed mood, vegetative and cognitive symptoms of depression, and comorbid anxiety symptoms. It quantifies the severity of depressive symptomatology |
The average duration of the HAM-D interviews is 12 minutes |
Its reliability is low due to use by lay interviewers; the final score is greatly influenced by appropriately trained interviewees |
|
|||||
Composite International Diagnostic Interview (CIDI) | Wittchen [ |
276 Items | A comprehensive and fully standardized diagnostic interview designed for assessing mental disorders with 276 symptom questions, many of which are coupled with probe questions to evaluate symptom severity, as well as questions for assessing help-seeking behavior, psychosocial impairments, and other episode-related questions | It pertains to the syndromic definitions of mood disorders proposed by both ICD-10 and DSM IV |
Primarily intended for use in epidemiological studies of mental disorders hence not referring to hospitalised patients in particular |
Though the instruments described earlier may appear to be homogeneous in their strengths and weaknesses, the Beck Depression Inventory-II (BDI-II) and the Patient Health Questionnaires are more efficient towards an early depression assessment within cardiac hospitalised patients for several reasons. Firstly, these instruments are appreciable given their short time completion and for not necessitating the strict presence of trained personnel required. The Beck Depression Inventory-II (BDI-II) and the Patient Health Questionnaires are designed to measure depressive symptoms severity at the present time, hence, embracing health-related quality of life and hospitalisation effects on patients. They are supported by a vast number of studies, becoming well-known and widely used gold-standard tools as they are able to well recognize major depression states and subthreshold depressive disorders too, also closely referring to the DSM-IV manual depression criteria, hence targeting agitation, worthlessness, concentration difficulty and significant energy-loss. Both questionnaires seem to adequately and accurately detect specific conditions that are depression-associated, without failing to conciliate with recent medical and psychological standards like other tools, like the Hospital Anxiety and Depression Scale (HADS) or the Hamilton Rating Scale for Depression (HAM-D/HRSD), do.
Moreover, compared to other tools described earlier like the Hospital Anxiety and Depression Scale (HADS), the Composite International Diagnostic Interview (CIDI), or the Cognitive Behavioural Assessment Hospital Form (CBA-H), they possess strong and clear clinical cutoffs though being rather simple and rapid to be administered and completed. The Beck Depression Inventory-II (BDI-II) and the Patient Health Questionnaires cover symptoms of both atypical and melancholic depression, while atypical symptoms are far less relevant in other instruments such as the Hospital Anxiety and Depression Scale (HADS) and the Composite International Diagnostic Interview (CIDI). Also, the Beck Depression Inventory-II (BDI-II) and the Patient Health Questionnaires assess depression with no contents which are restricted to variables and items possibly confounding by medical illness as the Hamilton Rating Scale for Depression (HAM-D/HRSD) or the Depression Interview and Structured Hamilton (DISH). All in all, most depression measures developed for medically ill populations like cardiac patients have not been adequately tested, while others may present some weaknesses. Amongst the ones selected and described by this paper, the Beck Depression Inventory-II (BDI-II) and the Patient Health Questionnaires appear to be useful and straightforward in evaluating depressive symptoms in terms of presence and severity, with the advantages regarding brevity, format for response options, and good responsiveness to change.
This review presents some relevant limitations as the selection of the eight tools proposed entirely refers to specific practice guidelines such as the Italian National System of guidelines (SNLG), the Italian Institute of Health (2005), the American health institutes (NHI), the National Heart, Lung and Blood Institute (2006), and the European guidelines for the prevention of cardiovascular disease in the clinical practice published by the European Cardiology Society (2007). Therefore, other important instruments which are often used in the clinical practice to evaluate depression in patients with cardiovascular disease may have been left out. For example, the paper does not take into account two well-established instruments such as the Primary Care Evaluation of Mental Disorders (PRIME-MD) by Spitzer and colleagues [
These instruments are often used within the primary care setting in order to identify specific mental disorders, though the first fails to adequately classify subthreshold disorders [
Cardiac patients often display depressive symptoms of some sort following an acute heart event or a cardiac surgery. Also, mood disorders in heart-disease hospitalised individuals represent a high risk factor which may result into premature death. This is why it is particularly important to understand what tools should be used by heart units professionals to efficiently and rapidly detect all forms of possible depression in cardiac patients. There are many different instruments used to measure depression within the cardiac field, of which the vast majority has been recently created or revised. According to the main Italian and international guidelines on mood disorders diagnosis in cardiac patients there are eight principal instruments to be used: the Hospital Anxiety and Depression Scale (HADS), the Cognitive Behavioural Assessment Hospital Form (CBA-H), the Beck Depression Inventory (BDI), the two and nine-item Patient Health Questionnaire (PHQ-2, PHQ-9), the Depression Interview and Structured Hamilton (DISH), the Hamilton Rating Scale for Depression (HAM-D/HRSD), and the Composite International Diagnostic Interview (CIDI). Among these questionnaires, semi-structured or structured clinical interviews, the Beck Depression Inventory-II (BDI-II) and the Patient Health Questionnaires in the two and nine-item version seem to assess any type of mood impairments rapidly and reliably, minimising possible underestimates or misjudgments of the depressive symptomatology from both patients and cardiac units professionals. They are widely used and are supported by past and current literature and represent the gold-standard instruments in the hospitalised setting.
The authors declare that there is no conflict of interests regarding the publication of this paper.