Determinants of a hopeful attitude among family caregivers in a palliative care setting

Objective

This study investigated the determinants of a hopeful attitude among family caregivers involved with palliative care.

Method

We investigated a broad range of factors for the patient–family dyad in a palliative care setting using a cross-sectional design. The patients' sociodemographic, clinical and psychological factors were evaluated, as well as caregiver-related sociodemographic and psychological factors, including depressive symptoms, burden, coping style and religiosity. Caregivers were divided into two groups based on a hopeful or nonhopeful attitude and assessed using the abbreviated version of the seven-item Beck Hopelessness Scale (BHS-7).

Results

Of 304 analyzed dyads, 210 (69.1%) caregivers showed a hopeful attitude, with a BHS-7 score of 0. The adjusted logistic regression analyses showed that caregivers' hopeful attitude was determined by only their psychological status: less depressive symptoms [odds ratio (OR), 0.86; 95% confidence interval (CI), 0.83–0.90], active coping strategy (OR, 1.12; 95% CI, 1.07–1.18) and lower burden (OR, 0.93; 95% CI, 0.88–0.99). In a subpopulation analysis (n= 200), higher religiosity was a significantly associated factor.

Conclusion

Healthcare providers need to pay attention to the psychological vulnerability of caregivers to encourage a hopeful attitude. Additional studies of longitudinal design for hopeful attitude throughout the trajectory of palliative care are necessary.     

IgG deficiency and expansion of CTG repeats in myotonic dystrophy

Objectives

Expansion of CTG repeats in myotonic dystrophy (DM1) alters the regulated expression of numerous genes. It is considered to explain the major clinical features of DM1. IgG deficiency is common in DM1 and is due to altered FcRn-related hypercatabolism. We hypothesized that the IgG catabolic rate is correlated with CTG repeat expansion.

Methods

Correlations between serum immunoglobulin levels, peripheral lymphocyte subset counts and CTG repeat numbers were performed in 52 DM1 patients.

Results

Serum IgG and IgG1 levels were below the normal limit respectively in 54% and 72% of patients. Increasing CTG repeat numbers were significantly correlated with decreasing serum IgG and IgG1 levels, and with decreasing CD3⁺ T-cell and CD3⁺-CD8⁺ cell counts. An abnormal immunoglobulin profile at protein electrophoresis was found in 4 patients.

Conclusion

We conclude that the catabolic rate of IgG is linked to expanded CTG repeats, possibly involving an altered immune response.     

Altered associative learning and emotional decision making in fibromyalgia

Objective

The present study examines the possibility that a chronic pain condition, such as fibromyalgia, was associated with deficits in decision making and associative learning.

Methods

Fifteen patients with fibromyalgia (aged 42-59 years) and 15 healthy controls (aged 39-61 years) participated in the experiment. Subjects completed anxiety (STAI) and depression (BDI) questionnaires, as well as standardized neuropsychological tests (Stroop and WAIS subscales). In addition, an emotional decision-making task (Iowa Gambling Task) and a conditional associative learning task (CALT) were administered to all participants.

Results

Results indicated that fibromyalgia had a poorer performance than healthy controls in both tasks, showing more perseveration errors in the learning task, and more disadvantageous decisions, as well as a more random behavior in the gambling task. Moreover, we observed that poor performance on the associative learning task was mediated by depression, whereas performance on the gambling task was not influenced by depression. No group differences were found on the standardized neuropsychological tests.

Conclusion

These findings indicate that pain and depressive symptoms in fibromyalgia might lead to significant deficits in emotionally charged cognitive tasks. Furthermore, it suggests that chronic pain might impose a high cost on executive control, undermining mainly affective processes involved in learning, memory, attention, and decision-making.     

Regulatory T cells increased while IL-1β decreased during antidepressant therapy

Background

Regulatory T cells (Tregs, CD4⁺CD25^hi) are specialized in steering the immune response and cytokine release to maintain tolerance to self-antigens. As cytokines such as interleukin (IL)-1β, IL-6 and interferon (IFN)-α have been shown to be involved in the pathophysiology of depression and cytokine levels have been shown to change during successful antidepressant treatment, we tested the involvement CD4⁺CD25^hi Tregs in these immunological processes during antidepressant therapy.

Methods

16 patients suffering from a depressive episode were included into the study and treated with antidepressants according to their doctor’s choice. Blood samples were collected during the first week after admission and after 6 weeks of treatment. Therein, we determined plasma levels of IL-1β, and measured IL-1β, IL-6 and IFN-α levels in the stimulated blood by performing a whole blood assay. We distinguished lymphocytes and identified CD4⁺CD25^hi Tregs by multiparameter flow cytometry. The psychopathological status was assessed using the Hamilton Depression Rating Scale (HAMD-21).

Results

HAMD-21 score, IL-1β serum levels as well as LPS-stimulated IL-1β and IL-6 production had decreased significantly at the end of treatment. In contrast, the amount of CD4⁺CD25^hi cells increased significantly from 2.74% ± 0.88 (mean value ± standard deviation) to 3.54% ± 1.21; p = 0.007. No significant changes in virus-induced IFN-α production was observed.

Conclusions

The increase in CD4⁺CD25^hi Tregs during antidepressant therapy may be the reason for the decrease in cytokine production and the recovery from depression.     

The activation of monocyte and T cell networks in patients with bipolar disorder

Objectives

We recently described a monocyte pro-inflammatory state in patients with bipolar disorder (BD). We hypothesized that the CD4⁺T cell system is also activated and determined percentages of Th1, Th2, Th17 and CD4⁺CD25^highFoxP3⁺ regulatory T cells.

Methods

We carried out a detailed FACS analysis to determine the various T cell subsets and used frozen stored peripheral blood mononuclear cells (PBMC) of 38 BD patients (of whom we previously had tested monocytes for pro-inflammatory gene expression ( [Drexhage et al., 2010a] and [Padmos et al., 2008])) and of 22 age/gender matched healthy controls (HC). In addition the cytokines CCL2, IL-1β, IL-6, TNF-α, PTX3, IL-10, IFN-γ, IL-17A, IL-4, IL-5 and IL-22 were measured in serum.

Results

(a) Serum sCD25 levels and percentages of anti-inflammatory CD4⁺CD25^highFoxP3+ regulatory T cells were higher, the latter in BD patients <40 years of age. Percentages of Th1, Th2 and Th17 cells were normal.(b) Of the pro-inflammatory monocyte cytokines CCL2 and PTX3 were raised in serum.(c) The monocyte pro-inflammatory state and the raised percentages of CD4⁺CD25^highFoxP3⁺ regulatory T cells occurred independently from each other.(d) In BD patients positive for thyroid autoimmune disease a significantly reduced percentage of CD4⁺CD25^highFoxP3⁺ regulatory T cells was found as compared to BD patients without AITD.

Conclusion

Our data show an enhancement of pro-inflammatory monocyte and anti-inflammatory T cell forces in BD patients. A lack of anti-inflammatory T cell forces co-occurred with AITD in BD patients.     

Behavioral and psychological symptoms of dementia in a pilot psychogeriatric unit: management and outcomes

Background

Behavioral and psychological symptoms in dementia (BPSD) are a major concern. The French government gave a consensual definition of reinforced intermediate-term care units for BPSD within the project “Plan Alzheimer 2008/2012”.

Objective

Our aim was to report one of the first experiences of this unit in France.

Results

Fifty-two patients (38 females, 14 males) were included, mean age 82.07 ± 7.84 (73-97). About 80% of patients were improved and there was a high discharge rate to home of about 30%. Night-time behaviors, aberrant motor behaviors and agitation were the most frequent symptoms.

Conclusion

Our study confirms that demented elderly patients greatly benefit from a specific BPSD care unit in agreement with the objective of Plan Alzheimer 2008/2012.     

A prospective study of the impact of smoking on outcomes in bipolar and schizoaffective disorder

Background

Tobacco smoking is more prevalent among people with mental illnesses, including bipolar disorder, than in the general community. Most data are cross-sectional, and there are no prospective trials examining the relationship of smoking to outcome in bipolar disorder. The impact of tobacco smoking on mental health outcomes was investigated in a 24-month, naturalistic, longitudinal study of 240 people with bipolar disorder or schizoaffective disorder.

Method

Participants were interviewed and data recorded by trained study clinicians at 9 interviews during the study period.

Results

Comparisons were made between participants who smoked daily (n = 122) and the remaining study participants (n = 117). During the 24-month study period, the daily smokers had poorer scores on the Clinical Global Impressions-Depression (P = .034) and Clinical Global Impressions-Overall Bipolar (P = .026) scales and had lengthier stays in hospital (P = .012), compared with nonsmokers.

Limitations

Smoking status was determined by self-report. Nicotine dependence was not measured.

Conclusion

These findings suggest that smoking is associated with poorer mental health outcomes in bipolar and schizoaffective disorder.     

Social phobia and depression: Prevalence and comorbidity

Background

Social phobia may seriously impair the functioning of affected individuals. It is frequently associated with other mental disorders.

Aims

To estimate the co-occurrence of social phobia with major depressive disorder (MDD) and to analyze their interaction.

Method

Subjects were 18,980 individuals, aged 15 years or older, representative of the general population of the United Kingdom, Germany, Italy, Spain and Portugal, who were interviewed by telephone. DSM-IV diagnoses were made with the Sleep-EVAL system.

Results

The point prevalence for social phobia was 4.4% (95% confidence interval: 4.1-4.7%) of the sample. It was higher in women (odds ratio: 1.6) and decreased with age. MDDs were found in 19.5% of participants with social phobia. Co-occurrence of another anxiety disorder was high and increased when a MDD was present (65.2%). The odds of developing a major depressive episode 2 years after the appearance of the social phobia was of 5.74.

Conclusions

Social phobia is highly prevalent in the general population. It increases the risk of developing a MDD and has a high comorbidity with other mental disorders. Social phobia is often present in the course of depression, more obviously during remission period of MDD. Physicians must explore and treat more systematically this frequent pathology.     

Screening for anxiety and depression after stroke: Comparison of the Hospital Anxiety and Depression Scale and the Montgomery and Åsberg Depression Rating Scale

Objective

Anxiety and depression after stroke are frequent, but are often overlooked and not assessed. The aims of the study were to (1) assess the prevalence of anxiety and depression and (2) compare the performance of the Hospital Anxiety and Depression Scale (HADS) and Montgomery and Åsberg Depression Rating Scale (MADRS) as screening instruments for anxiety and depression disorders 4 months after stroke.

Methods

Stroke patients, consecutively admitted to a stroke unit, were assessed with HADS and MADRS 4 months after stroke (n=104). Depression and anxiety disorders were diagnosed using the Structured Clinical Interview for DSM-IV (SCID). Measures were compared in terms of correlations, sensitivity, specificity, positive and negative predictive value, overall agreement, kappa, and ROC curves, using DSM-IV diagnoses of “at least one current significant anxiety disorder” (Anxiety) and “any current depression” (Depression), as the clinical criteria.

Results

Anxiety occurred in 23% of patients and Depression in 19% (13% major depression, 3% minor depression, 4% dysthymia). For Anxiety, the optimal screening cut-off was 4 for HADS-A and 6 for HADS-total; for Depression, optimal cut-offs were 4 for HADS-D, 11 for HADS-total, and 8 for MADRS. At cut-offs commonly used in clinical practice for depression screening (HADS-D: 8, MADRS: 12), the MADRS performed marginally better than the HADS.

Conclusion

Anxiety is as prevalent as depression 4 months after stroke. MADRS and HADS-D perform acceptably as screening instruments for depression, and HADS-A for anxiety after stroke. However, lower HADS cut-offs than recommended for the general population should be considered for stroke patients.     

Patients’ subjective initial response and the outcome of inpatient and day hospital treatment

Objective

This study aimed to establish whether psychiatric patients’ subjective initial response (SIR) to hospital and day hospital treatment predicts outcomes over a one-year follow-up period.

Method

We analysed data from 765 patients who were randomised to acute psychiatric treatment in a hospital or day hospital. SIR was assessed on day 3 after admission. Outcomes were psychiatric symptom levels and social disability at discharge, and at 3 and 12 months after discharge.

Results

After controlling for socio-demographic and clinical characteristics, a more positive SIR was significantly associated with lower symptom levels at discharge and 3 months after discharge and lower social disability at 3 months and 12 months after discharge.

Conclusion

SIR can predict outcomes of complex interventions over a one-year period. Patients’ initial views of acute hospital and day treatment should be elicited and considered as important.     

Health outcomes and self-labeling as a victim of workplace bullying

Objective

This study investigated the extent to which self-labeling as a victim of workplace bullying mediates or moderates the relationship between exposure to bullying and the target's health outcomes.

Methods

Data were collected by means of anonymous self-report questionnaires. A total of 1024 employees in a transport organization participated in the study, among whom 116 self-labeled victims were identified. Exposure to bullying was measured by a short version of the Negative Acts Questionnaire, while the respondents' health outcomes were measured by the Bergen Health Checklist.

Results

The findings showed that self-labeling both moderated and partially mediated the relationship between exposure to bullying and the targets' health. However, the moderator analyses indicate that self-labeling only acts as moderator in cases of low exposure. Intense exposure to bullying behaviors is related to increased levels of health complaints regardless of the target's subjective appraisal of being a victim or not.

Conclusion

Self-labeling as a victim plays an important role in the victimizing process, although persistent exposure to workplace bullying seems to have considerable harmful effects on the target's health independently of whether the experience is labeled as bullying or not.     

P11 expression and PET in bipolar disorders

Background

Bipolar disorder (BD) is a common mental disorder, subdivided into BD-I and BD-II. Currently, few biomarkers differentiate BD-I from BD-II. However, it is suggested that peripheral blood mononuclear cell (PBMC) mRNA levels of p11 and positron emission tomography (PET) might be potential biomarkers for BD.

Methods

Healthy controls (HCs), BD-I, and BD-II patients in remission (n = 20 in each group) underwent a resting PET study with the radiotracer [¹⁸F]-2-deoxy-2-fluoro-d-glucose (¹⁸F-FDG). PBMC p11 mRNA levels were determined by quantitative real-time PCR.

Results

Comparing BD patients to HCs, normalized glucose metabolism (NGM) was higher in the hippocampus, parahippocampus, and amygdala, but lower in the anterior cingulate cortex (aCC), medial prefrontal cortex (mPFC), dorsolateral prefrontal cortex (dlPFC), insula and thalamus. Compared to BD-II, BD-I had hypometabolism of glucose in the aCC, bilateral middle and inferior gyrus, insula and striatum, and hypermetabolism of glucose in the left parahippocampus. PBMC p11 mRNA was over-expressed in both BD-I and BD-II, although there was no significant difference in its expression levels between BD-I and B-II patients. Further, there were significant positive correlations between PBMC p11 mRNA and NGM in the mPFC, aCC, left insula, bilateral orbitofrontal cortex (OFC), and left middle, inferior and superior temporal gyri. Also, PBMC p11 mRNA was positively correlated to the number of depressive episodes in BD patients, especially in BD-I patients.

Discussion

This study demonstrates that PBMC p11 mRNA expression is associated with neural activation in the brain of BD patients and warrants a larger translational study to determine its clinical utility.     

Parsing the familiality of oppositional defiant disorder from that of conduct disorder: a familial risk analysis

Background

Family risk analysis can provide an improved understanding of the association between attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), attending to the comorbidity with conduct disorder (CD).

Methods

We compared rates of psychiatric disorders in relatives of 78 control probands without ODD and CD (Control, N = 265), relatives of 10 control probands with ODD and without CD (ODD, N = 37), relatives of 19 ADHD probands without ODD and CD (ADHD, N = 71), relatives of 38 ADHD probands with ODD and without CD (ADHD + ODD, N = 130), and relatives of 50 ADHD probands with ODD and CD (ADHD + ODD + CD, N = 170).

Results

Rates of ADHD were significantly higher in all three ADHD groups compared to the Control group, while rates of ODD were significantly higher in all three ODD groups compared to the Control group. Evidence for co-segregation was found in the ADHD + ODD group. Rates of mood disorders, anxiety disorders, and addictions in the relatives were significantly elevated only in the ADHD + ODD + CD group.

Conclusions

ADHD and ODD are familial disorders, and ADHD plus ODD outside the context of CD may mark a familial subtype of ADHD. ODD and CD confer different familial risks, providing further support for the hypothesis that ODD and CD are separate disorders.     

Detection of endogenous tissue factor levels in plasma using the calibrated automated thrombogram assay

Background

The calibrated automated thrombogram (CAT) assay measures thrombin generation in plasma.

Objective

Use the CAT assay to detect endogenous tissue factor (TF) in recalcified platelet-rich plasma (PRP) and platelet-free plasma (PFP).

Methods

Blood from healthy volunteers was collected into citrate and incubated at 37 °C with or without lipopolysaccharide (LPS) for 5 hours. PRP and PFP were prepared and clotting was initiated by recalcification. Thrombin generation was measured using the CAT assay.

Results

The lag time (LT) was significantly shortened in PRP prepared from LPS-treated blood compared with untreated blood (10 ± 3 min versus 20 ± 6 min), and this change was reversed by the addition of inactivated human factor VIIa. LPS stimulation did not change the peak thrombin. Similar results were observed in PFP (21 ± 4 min versus 35 ± 5 min). LPS stimulation also significantly reduced the LT of PRP and PFP derived from blood containing citrate and a factor XIIa inhibitor. Finally, a low concentration of exogenous TF shortened the LT of PFP prepared from unstimulated, citrated blood without affecting the peak thrombin.

Conclusion

Changes in LT in the CAT assay can be used to monitor levels of endogenous TF in citrated plasma.     

A confirmatory factor analysis of the Beck Depression Inventory-II in end-stage renal disease patients

Objective

We sought to examine several competing factor structures of the Beck Depression Inventory-II (BDI) in a sample of patients with End-Stage Renal Disease (ESRD), in which setting the factor structure is poorly defined, though depression symptoms are common. In addition, demographic and clinical correlates of the identified factors were examined.

Methods

The BDI was administered to clinical sample of 460 ESRD patients attending 4 UK renal centres. Competing models of the factor structure of the BDI were evaluated using confirmatory factor analysis.

Results

The best fitting model consisted of general depression factor that accounted for 81% of the common variance between all items along with orthogonal cognitive and somatic factors (G-S-C model, CFI = .983, TLI = .979, RMSEA = .037), which explained 8% and 9% of the common variance, respectively. Age, diabetes, and ethnicity were significantly related to the cognitive factor, whereas albumin, dialysis adequacy, and ethnicity were related to the somatic factor. No demographic or clinical variable was associated with the general factor.

Conclusion

The general-factor model provides the best fitting and conceptually most acceptable interpretation of the BDI. Furthermore, the cognitive and somatic factors appear to be related to specific demographic and clinical factors.     

Response to tryptophan depletion in major depression treated with either cognitive therapy or selective serotonin reuptake inhibitor antidepressants

Background

Mood sensitivity to rapid tryptophan depletion (RTD) has been demonstrated in patients treated with antidepressants that act preferentially on the serotonergic system. Depressed patients treated with bright-light therapy also show sensitivity to RTD, but those treated with electroconvulsive therapy or total sleep deprivation do not. Patients treated with an empirically supported psychotherapy have not been investigated for sensitivity to tryptophan depletion. This study compares the effects of RTD in patients treated with either selective serotonin re-uptake inhibitors (SSRIs) or cognitive therapy (CT).

Methods

Twenty patients treated with either SSRIs or CT underwent both rapid tryptophan depletion and sham-depletion using a blinded crossover design. Depressive symptoms were assessed using a modified Hamilton Depression Rating Scale (HDRS) and the Beck Depression Inventory (BDI). The differential change in depression scores across procedures between the groups was compared, and effect sizes were calculated.

Results

The differential worsening of mood for the SSRI group compared with the CT group was significant on the BDI. The effect size of the differential change was 1.6 for the BDI and .8 for the HDRS. Furthermore, the SSRI group experienced significant mood worsening during depletion compared with sham on both the HDRS and the BDI, whereas the CT group did not.

Conclusions

The CT group was resistant to the effects of tryptophan depletion, but the SSRI group was not.     

Prospective associations of early-onset Axis I disorders with developing eating disorders

Objective

The purpose of this study is to analyze the developmental relationships of adolescent-onset Axis I mental disorders and eating disorders (EDs).

Method

One thousand three hundred eighteen adolescent twins born from 1983 to 1987 completed a professionally administered semistructured psychiatric interview at the age of 14 years and a questionnaire follow-up at the age of 17.5 years.

Results

Eating disorders at the age of 17.5 years were significantly predicted by major depressive disorder (odds ratio, 5.9; 95% confidence interval, 2.6-15.3) and generalized anxiety disorder (GAD) (odds ratio, 4.7; 95% confidence interval, 1.8-15.6) at the age of 14 years, when baseline EDs were excluded. Early-onset major depressive disorder in combination with GAD increased the likelihood of developing EDs compared with either mood or anxiety disorders alone. Similar risks and trends were evident in within-family analyses of twin pairs discordant for baseline predictors and ED outcome.

Conclusions

Depressive disorder and GAD that manifest at that age of 14 years predict future EDs. Analysis of discordant twins suggested that early-onset depressive disorder and GAD prospectively relate to EDs in adolescence, even after familial factors are taken into account.     

Interictal alterations of cytokines and leukocytes in patients with active epilepsy

Background

Involvement of the innate immune system in the pathogenesis of epilepsies has been suggested but possible interactions between the immune system and human epilepsy remain unclear. We analyzed the interictal immuno-phenotype of leukocyte subsets and proinflammatory cytokine profiles in epileptic patients and correlated them with the epilepsy syndrome.

Methods

101 patients with active focal or generalized epilepsy were prospectively included and compared to 36 healthy controls. Immuno-phenotype of leukocyte subsets and cytokines IL-1β, IL-6 and tnfα were measured in peripheral blood. Multivariate analyses were performed to test group differences.

Results

As compared to controls, the patients showed an elevated percentage of monocytes (18.06 ± 7.08% vs. 12.68 ± 4.55%, p < 0.001), NK cells (14.88 ± 7.08% vs. 11.43 ± 5.41%, p = 0.019) and IL-6 concentration (3.33 ± 3.11 pg/ml vs. 1.5 ± 1.36 pg/ml, p = 0.002). This remained true when focal epilepsies or generalized epilepsies were compared separately to controls but only focal epilepsies showed additionally a decrease in B lymphocyts (8.16 ± 3.76% vs. 11.54 ± 4.2%, p < 0.001). Treatment with lamotrigine was associated with a higher percentage of B lymphocytes and valproate with an increased percentage of CD4⁺ T lymphocytes. Therapy with levetiracetam showed a trend towards decreased CD8⁺ T cell counts. No significant differences were seen between focal and generalized epilepsies and between temporal and extratemporal lobe epilepsies.

Conclusion

Patients with active epilepsy revealed interictal alterations of the immune system which varied among specific syndromes and were influenced by antiepileptic drug treatment.     

Training primary care staff to deliver a computer-assisted cognitive-behavioral therapy program for anxiety disorders

Objectives

This paper describes the training approach used with primary care staff to deliver an evidence-based computer-assisted cognitive-behavioral therapy (CBT) program for anxiety disorders within a collaborative care treatment delivery model.

Methods

We describe the training and proficiency evaluation procedures utilized in the Coordinated Anxiety Learning and Management (CALM) study, a large multisite study of collaborative care for anxiety disorders in primary care. Training incorporated readings, didactic presentations, video demonstrations of CBT skills, role-plays, computer-assisted practice, CBT training cases and ongoing group supervision provided by study psychologists.

Results

Proficiency training case data from 15 clinicians are presented. The anxiety clinical specialists (ACSs) were highly proficient at delivering the CBT component of the CALM intervention. The ACSs also provided Likert-scale ratings and open-ended responses about their experiences with the training. Overall, the training was rated very positively and was described as very thorough, indicating a high level of acceptability to clinicians. Recommendations for future training are described.

Conclusions

Primary care staff with none or minimal prior CBT experience can be trained to deliver a computer-assisted, evidence-based treatment for anxiety disorders. The implications for dissemination and transportability of evidenced-based interventions are discussed.     

Sensitivity and specificity of the Beck Depression Inventory in cardiologic inpatients: How useful is the conventional cut-off score?

Objective

The Beck Depression Inventory (BDI) is widely used for depression screening in various patient populations. However, there are still insufficient data about its sensitivity and specificity in nonpsychiatric patients. Furthermore, some research suggests that somatic BDI items heighten its sum score artificially in physically ill patients.The aim of the present study was to validate the conventional BDI cut-off score by examination of its sensitivity and specificity in a mixed sample of cardiac inpatients and compare it to a modified “cognitive-emotional” BDI (BDI_c/e) after exclusion of somatic items.

Methods

A total of 126 cardiologic inpatients were assessed. Receiver operating characteristic curves (ROC) were calculated for total BDI (BDI_t) and BDI_c/e. Screening performance of cut-off scores was evaluated using the Youden Index (Y).

Results

With the application of the conventional BDI cut-off score, ROC analysis revealed a moderate overall screening performance with Y=52.6 and an area under the curve (AUC) of 0.83. In contrast, Y improved to 57.5 at a cut-off score of >9, but screening performance was still not optimal. BDI_c/e showed also a moderate screening performance (AUC=.82); Y was maximized at a cut-off score of >8 (Y=0.53.5). Again, no cut-off score provided optimal screening performance.

Conclusion

The BDI cannot be recommended as a formal screening instrument in cardiac inpatients since no cut-off score for either BDI_t or BDI_c/e combined both sufficiently high sensitivity and specificity. However, the shorter BDI_c/e could be used as alternative to BDI_t which may be confounded in physically ill patients. Generally, researchers should consider using alternative screening instruments (e.g., the Hospital Anxiety and Depression Scale) instead.