NHLBI Working Group
Assessment and Treatment of Depression in Patients with Cardiovascular Disease

August 10 and 11, 2004

The Natcher Conference Center (Bldg 45, Room D)
National Institutes of Health
45 Center Drive, Bethesda, MD

Appendix - Summary of Instruments

Agenda
Working Group Meeting Participants
Summary of Assessment Recommendations
Working Group Report

Beck Depression Inventory (BDI)

The BDI assesses the severity of 21 symptoms of depression. Each item is rated on a 4-point scale (range: 0-3). Thirteen items address cognitive or affective symptoms such as hopelessness and guilt. Two of these 13 items assess the cardinal symptoms of depression: depressed mood and loss of interest or pleasure in usual activities. The remaining eight items assess somatic symptoms such as 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.

Beck AT, Ward CH, Mendelsohn M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561-71.

Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clin Psychol Rev 1988;8:77-100.

Composite International Diagnostic Interview (CIDI)

The CIDI is a comprehensive and fully standardized diagnostic interview designed for assessing mental disorders according to the definitions of the Diagnostic Criteria for Research of ICD-10 and DSM-III-R. The instrument contains 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. Although primarily intended for use in epidemiologic studies of mental disorders, it is also being used extensively for clinical and other research purposes.

WHO,1997. Composite International Diagnostic Interview (CIDI). Basis versie 2.1, 12 maanden, Red. Ter Smitten MH, Smeets RMW, Van den Brink W.

Wittchen, 1994. Reliability and validity studies of the WHO-Composite International Diagnostic Interview (CIDI): A critical review. J of Psychiatric Research, 28(1), 57-84.

Robins, L.N.; Wing, J.; Wittchen, H.U.; Helzer, J.E.; Babor, T.F.; Burke, J.; Farmer, A.; Jablensky, A.; Pickens, R.; Regier, D.A.; Sartorius, N.; and Towle, L.H. The Composite International Diagnostic Interview: An epidemiologic instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Arch Gen Psychiatry 45:1069-1077, 1989.

Richter P, Werner J, Heerlein A, Kraus A, Sauer H. On the validity of the Beck Depression Inventory. A review. Psychopathology 1998;1998;31(3):160-8.

Depression Interview and Structured Hamilton (DISH)

The DISH is a structured interview designed to diagnose major and minor depressive disorders according to the DSM-IV criteria. The17-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.

Freedland KE, Skala JA, Carney RM et al. The Depression Interview and Structured Hamilton (DISH): rationale, development, characteristics, and clinical validity. Psychosom Med 2002.

Hamilton Depression Rating Scale (HAM-D)

The Hamilton Depression Rating Scale is a 17-item scale that evaluates depressed mood, vegetative and cognitive symptoms of depression, and comorbid anxiety symptoms. The HAM-D was one of the first rating scales developed to quantify the severity of depressive symptomatology. First introduced by Max Hamilton in 1960, it has since become the most widely used and accepted outcome measure for evaluating depression severity. It provides ratings on current DSM-IV symptoms of depression, with the exceptions of hypersomnia, increased appetite, and concentration/indecision. The HAM-D was designed to be administered by a trained clinician using a semi-structured clinical interview.  The 17-items are rated on either a 5-point (0-4) or a 3-point (0-2) scale.

Williams, J.B.W., "A Structured Interview Guide for the Hamilton Depression Rating Scale," Archives of General Psychiatry, American Medical Association, August 1988, Vol. 45, Num. 8, pp. 742-747.

Inventory of Depressive Symptomatology (IDS)

The construction of the IDS-C30 and IDS-SR30 was intended to remedy deficits in the Hamilton (HAM-D) and Montgomery Asberg (MADRS) depression rating scales by, among others, including all nine symptom domains needed to diagnose a DSM-IV major depressive episode in order to assess symptom remission, improve ability to detect milder levels of symptoms than the HAM-D, and provide unconfounded and more equivalent weighting among items. There are two versions of the IDS with identical items: a clinician rating (IDS-C30) and a self-report (IDS-SR30). The self-report was developed to determine if it could be used as an alternative to the IDS-C30 in clinical or research settings, which would provide a low cost, easily used gauge of depressive symptom severity to assist patients and providers in managing the disorder.

Rush AJ, Giles DE, Schlesser MA, Fulton CL, Weissenburger J, Burns C. The Inventory for Depressive Symptomatology: preliminary findings. Psychiatry Res 1986;18:65-87.

Montgomery-Asberg Depression Rating Scale (MADRS)

The Montgomery-Asberg Depression Rating Scale is a 10 item severity scale constructed to be sensitive to change with treatment. It was designed to be sensitive for individual items and is therefore useful for measuring differential profiles of action. Ratings of patients on a 65 item comprehensive psychopathology scale were used to identify the 17 most commonly occurring symptoms in primary depressive illness, and ratings on these 17 items for 64 patients participating in studies of four different antidepressant drugs were used to create a depression scale consisting of the 10 items which showed the largest changes with treatment and the highest correlation to overall change.

Kearns NP, Cruickshank CA, McGuigan KJ, Riley SA, Shaw SP, Snaith RP. A comparison of depression rating scales. Br J Psychiatry1982 Jul;141:45-9.

Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry 1979;134:382-9.

Patient Health Questionnaire (PHQ)

The Patient Health Questionnaire (PHQ) is a self-administered version of the Primary Care Evaluation of Mental Disorders (PRIME-MD) 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). The PHQ-2 is a two-item depression screener which uses 2 items from the PHQ that inquire about the frequency of depressed mood and anhedonia over the past 2 weeks, scoring each as 0 ("not at all") to 3 ("nearly every day").

Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001 Sep; 16(9):606-13.

Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care 2003 Nov 41(11):1284-92.

Structured Clinical Interview for DSM-IV (SCID)

The SCID is a semistructured interview for making the major Axis I DSM-IV diagnoses. It is administered by a clinician and includes an introductory overview followed by nine modules, seven of which represent the major Axis I diagnostic classes. Because of its modular construction, it can be adapted for use in studies in which only particular diagnoses (e.g., depression) are of interest. Using a decision tree approach, the SCID guides the clinician in testing diagnostic hypotheses as the interview is conducted. The output of the SCID is a record of the presence or absence of each of the disorders being considered, for current episode (past month) and for lifetime occurrence.

Spitzer RL, Williams JB, Gibbon M, First MB. The Structured Clinical Interview for DSM-III-R (SCID). I: History, rationale, and description. Arch Gen Psychiatry 1992 Aug;49(8):624-9.

Williams JB, Gibbon M, First MB, Spitzer RL, Davies M, Borus J, Howes MJ, Kane J, Pope HG Jr., Rounsaville B, et al. The Structured Clinical Interview for DSM-III-R (SCID). II. Multisite test-retest reliability. Arch Gen Psychiatry1992 Aug 49(8): 630-6.

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