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Detecting depressive disorders in drug abusers
Journal of Affective Disorders, 1 (1979) 255-267 @ Elsevier/North-Holland Biomedical Press
255
DETECTING DEPRESSIVE DISORDERS IN DRUG ABUSERS A Comparison of Screening Instruments
BRUCE J. ROUNSAVILLE PATRICIA H. ROSENBERGER HERBERT D. KLEBER ’
r, MYRNA
M. WEISSMAN ‘, 3, CHARLES H. WILBER
4 and
’ Assistant Professor, Yale University Department of Psychiatry and Director of Research, Substance Abuse Treatment Unit, Connecticut Mental Health Center; ’ Associate Professor of Psychiatry and Epidemiology, Yale University Department of Psychiatry and Director of Depression Research Unit, Connecticut Mental Health Center; 3 Research Associate with the Addiction-Prevention Treatment Foundation, Inc.; 4 Research Associate with the Addiction-Prevention Treatment Foundation, Inc.; s Professor of Psychiatry, Yale University Department of Psychiatry and Director of Substance Abuse Treatment Unit, Connecticut Mental Health Center, 100 Park Street, New Haven, CT 06511 (U.S.A.) (Received (Accepted
31 May, 1979) 7 June, 1979)
SUMMARY Previous investigators have reported a high prevalence of depressive symptoms in drugdependent patients. Given the responsiveness of depressive disorders to both psychological and pharmacological treatments, it is desirable to find an economical, efficient screening instrument to detect depressive disorders in this population. In this study, 6 depression symptom screening scales (Beck Depression Inventory, Hamilton Depression Scale, Raskin Depression Scale, Degree of Illness Rating, Symptom Checklist 90 Overall, and Depression Subscale) based on either clinician interview or patient self report, were compared according to their utility in detecting cases of depression among 64 applicants for treatment at a substance abuse treatment unit of a community mental health center. The criteria for a case of depression were the Research Diagnostic Criteria (RDC) which are specified and operationalized. Cases identified using previously described cutoff scores on the screening scales were compared to rates based on the RDC and sensitivity and specificity were determined. The results showed that: (1) although the sensitivity of the symptom scales was acceptable, ranging from 65-94%, the specificity was less impressive, ranging from 39-61%, and (2) the Beck Depression Inventory, a 13-item patient self report was the most sensitive and specific and is recommended for screening drug-dependent populations for depression.
This work was supported 271-77-3410. Please direct reprint requests
by
National
to Dr. Bruce
Institute Rounsaville.
of
Drug
Addiction
contract
No.
256 INTRODUCTION
The efficacy of both pharmacotherapy and psychological treatments has been demonstrated in several recent controlled clinical trials (Weissman 1978). These recent advances in the treatment of affective disorders underscore the importance of correctly diagnosing depression so that appropriate treatment can be indicated. Recent surveys have shown that a substantial proportion of drug abusers have high levels of dysphoria and depressive-like symptoms (Wieland and Sola 1970; Lehman and Deangellis 1972; Robbins 1974; Weissman et al. 1976; Steer et al. 1977), which may be clinical depression and may make them candidates for conventional treatments of depression. Before anti-depressant treatment is instituted, a thorough diagnostic evaluation is required since many patients who report mood disturbances are not clinically depressed and treatment would not be indicated. Routine diagnostic interviewing is time-consuming and expensive. However, the high prevalence of depressive symptoms in drug abuse makes it desirable to have routine, efficient means for screening for depression and detecting persons who are potential candidates for more vigorous treatment. In this paper, we will compare the utility of 5 depressive symptom scales as screening instruments for depression in drug-dependent clients. The results of relatively brief depression symptom rating scales based on either patient self report or clinician’s evaluation will be compared with diagnostic evaluation based on a relatively lengthy, structured clinical interview, the Schedule for Affective Disorders and Schizophrenia (SADS-L) (Spitzer and Endicott 1975), using operationalized research diagnostic criteria, RDC (Spitzer et al. 1975). The use of the RDC diagnosis of depression as a standard for evaluating symptom scales is based on the concept that an important distinction can be made between depressive symptoms and the syndrome of depression. Data based on out-patient and community samples indicate that, although most patients who meet the criteria for an RDC diagnosis of depression have a high level of depressive symptoms, a substantial number of those who complain of depressive symptoms do not meet the criteria for a diagnosis of depression either because symptoms are not of sufficient duration or because the symptoms have not led to impairment in occupational or social functioning (Weissman and Myers 1976). RDC criteria are of some practical importance in that they are nearly identical to those to be included in the forthcoming American Psychiatric Association’s DSM-III (American Psychiatric Association 1978). Moreover, it is unlikely that anti-depressant treatment would be justified for clients whose impairment is not sufficient to meet the criteria for an RDC diagnosis of a depressive disorder. The utility of the symptom scales as screening instruments will be evaluated according to the following standards: (a) sensitivity - ability to correctly identify those with depressive disorders, (b) specificity - ability to correctly identify those without a depressive disorder, (c) false positive rate - the extent to which the scale incorrectly identifies those without a
257
depressive disorder as depressed, and (d) false negative rate -the which the scale fails to detect depressive disorders when present.
extent
to
METHOD
Setting and sample Subjects for this study were applicants for treatment at the Screening and Evaluation section of the Drug Dependence Unit (DDU) of the Connecticut Mental Health Center, Yale University Department of Psychiatry, in New Haven, CT. This Unit serves an urban and suburban population of approximately 400,000 people. The Screening Unit is the mode of entry for several modalities of treatment offered to clients with a problem of drug abuse for any drug but alcohol. Following screening, clients may be be referred to (1) methadone maintenance program, (2) an inpatient detoxification unit, program, (4) a drug counseling program for poly drug ;3, a naltrexone abusers, (5) a residential adult therapeutic community, and (6) a residential adolescent therapeutic community. Sixty-four subjects were evaluated over a 2; -month period, comprising around one-half of the 134 clients initially seen at screening during this period. This was a sample of convenience. The evaluations, which took place in two sittings 1-3 days apart, were as follows: Day 1 - history, identifying information, sociodemographic data collected by intake counselors, and Day 2 - symptom rating scales and SADS-L interview completed by trained research assistants.
Rating scales Diagnostic assessment.
Information for making diagnostic judgments was collected on the Schedule for Affective Disorders and Schizophrenia (SADS). The SADS is a structured interview guide with an accompanying inventory of ratings scales and specific items. It records information on the subject’s functioning and symptomatology. Although the name of the instruments suggests that it only includes information on affective disorders and schizophrenia, in fact it is an overall mental status inventory and contains the information necessary for making diagnostic judgments for all major psychotic, neurotic, and personality disorders. This method has been shown to reduce the portion of variance in diagnosis due to differing interviewing styles and coverage. There are several versions of the SADS, depending on the time period assessed - current, past 5 years, or lifetime. We used the lifetime version (SADS-L) which includes an assessment of the subject’s current as well as lifetime mental status (Spitzer and Endicott 1978). Based on the information collected on the SADS, the subjects were classified on the Research Diagnostic Criteria (RDC) which is a set of operational diagnostic definitions with specific inclusion and exclusion criteria for a variety of nosological groups. These operational definitions were developed for reducing the variance due to differing criteria which has been shown to
258
account for the largest source of unreliability in making diagnoses (Spitzer et al. 1978). The RDC has evolved from a decade of research of diagnosis. The conditions included have the most evidence of validity in terms of clinical description, consistency over time, familial association, and response to treatment. Diagnoses on the RDC are made both for the current time period and for lifetime, with the exception of several diagnoses which are considered lifetime diagnoses only, regardless of whether or not the subject is currently manifesting symptoms of the disorder. These lifetime only disorders are the personality disorders (labile, cyclothymic, Briquet’s, antisocial) and bipolar disorders. Psychiatric disorders which cannot be categorized due to limitation of information or absence of diagnostic criteria are listed as ‘other’. All diagnoses can be classified as either ‘probable’ or ‘definite’. Symptom rating scales Clinician-rated symptom scales Hamilton Rating Scale (Hamilton 1960). The Hamilton Depression Scale is a widely used 17-item scale completed by a clinician and based on information elicited from a patient during an interview. The items are measured on a 3- or a 5-point scale. A total score is obtained by summing the scores of individual items. The total score range is from 0 to 62, a higher score indicating more impairment. Mean total scores in ambulatory depressed patients are usually about 20. The cutoff score for moderate to severe depression is 15 or above. Four factor scores have been derived which cover the dimensions of depression: sleep disturbance, somatization, anxiety-depression and apathy. Raskin Depression Scale (Raskin et al. 1969). The Raskin Depression Scale is the clinicians assessment of the patient made during an interview with the patient and covers three areas: the patient’s verbal report, behavior, and secondary symptoms of depression. Each area is rated on a 5-point scale and scores are summed to yield a total score of 3-15. A score of 7 or higher is considered a depression of sufficient severity to be treated with psychopharmacologic agents. Mean total pretreatment scores in acutely depressed ambulatory patients are about 10. Degree of illness rating. This rating is a single 7-point global scoring denoting the severity of the client’s depressive condition on the basis of the clinical interview from which the Raskin rating is made. A higher score denotes a greater degree of illness. Self report symptom scales Symptom Checklist. The symptom checklist (SCL 90) is a self report rating scale oriented toward the symptomatic behavior of psychiatric outpatients. It is derived from the Hopkins Symptom Checklist (Derogatis et al. 1974). It is composed of 90 items rated on a 5-point scale. The items reflect 9 primary symptom dimensions that are believed to underlie the majority of symptom behaviors observed in these patients: (1) somatization, (2) obses-
259
sive-compulsivity, (3) interpersonal sensitivity, (4) depression, (5) anxiety, (6) hostility, (7) phobic anxiety, (8) paranoid ideation, (9) psychoticism. Based on a community survey in New Haven (Weissman et al. 1975-76), a score of 0.7 or above on the depression factor was over 1 standard deviation above the mean. We will evaluate both the full scale and the depression subscale as methods of screening for depression. Beth Depression Inuentory. (Beck and Beck 1972) This is a 13-item self report of symptoms with items scores ranging from 0 to 3 and total score of O-39. The score was validated using comparisons with previously established methods of diagnosing depression and according to Beck (Beck et al. 1961) can discriminate between anxiety and depression. A total score of 8 or above has been identified as indicating a moderate level of depression.
Raters All evaluations were administered by two research assistants who received intensive training by a psychiatrist for 3 months in the use of instruments and were judged to be competent in their use. To determine inter-rater agreement for the SADS/RDC ratings, clinical evaluations were performed jointly on 16 subjects seen in screening and evaluation. One rater conducted the interview and one observed (alternately) and ratings were compared. In rating the presence of any current depressive disorders (major, minor, intermittent) 4 cases were detected with 100% agreement between the two raters. RESULTS
Sociodemographic
characteristics
The majority of clients single (56%), with a high social classes (71%).
Diagnostic
were young (81% were under 30), male (79%), school education or less (63%) and from lower
characteristics
The distribution of current and lifetime RDC diagnoses is shown in Table 1. In this system, multiple diagnoses are possible. Therefore, the N’s do not add up to 64 as one person could have multiple diagnoses. Depressive disorders were the most frequently diagnosed psychiatric disorder both currently and over a lifetime. A significant minority of clients were diagnosed as having anxiety and personality disorders. Combining major depression, minor depression, and intermittent depressive disorders, 19 clients (30%) were determined to have current depressive order, 21 (33%) were found to have past depressive disorders from which they had recovered, and only 24 (37%) clients had no history of a depressive disorder either currently or in the past. Primary drug of abuse is also presented in Table 1. Although many clients abused several classes of drugs, their classification denotes the drug of abuse for which the client sought treatment. Opiates were the most frequent (70%)
260 TABLE RDC
1
DIAGNOSES
OF DRUG
ABUSERS
Diagnoses
APPLYING
FOR
TREATMENT
(N = 64)
-__
Current N
Manic disorders Hypomanic disorder
%
1
2
7 0 13
11 0 20
12 10 2
19 16 3
45 15 4
70 23 7
Alcoholism
3
5
Otho Unspecified functional psychosis Other psychiatric disorder Schizotypal features
0 3 4
0 5 6
Depressive disorders Major depressive disorder Minor depressive disorder Intermittent depressive disorder Anxiety disorders Panic disorder Generalized anxiety disorder Obsessive compulsive disorder Phobic disorder Personality disorders Labile Antisocial Cyclothymic
(lifetime
only)
Primary drug of abuse Opiates Marijuana Barbiturates/cocaine/inhalants
drug of abuse. Marijuana users (23%) led to significant social impairment.
are those for whom use of this drug has
Identification of depression using symptom ratings Using the cutoff scores, which have been considered as indicative of being ‘a case’ in previous studies, the number of clients having at least a moderate level of symptoms ranged from 46% for the Global Degree of Illness to 70% for the SCL-90 Depression Factor (See Table 2). To note the relationship among rating instruments, correlations were examined among the 5 symptom rating scales and these were all moderately high with a range from 0.60 to 0.93 (Table 3). Correlations of the SCL-90, an overall symptom rating scale with 9 dimensions were comparable to
261 TABLE
2
CLASSIFICATION USING CUTOFF
OF DRUG ABUSERS SCORES ON DEPRESSION
Scale
AS DEPRESSED OR NOT DEPRESSED SYMPTOM RATING SCALES (N = 64) N
%
Clinician rating scales Hamilton Depression Scale Depressed (15 up) Not depressed (14 or less)
Raskin Depression Scale Depressed (7 up) Not depressed (6 or less)
Degree of illness 3 (mild) or higher Not depressed (2 or less)
34 30 -
53 47
64
100
38 26 -
59 41
64
100
29 34
46 54
63a
100
Self report scales SCL-90 Mean Depressed (0.7 or higher) Not depressed (less than 0.7) SCL-90 Depression Factor Depressed (0.7 or higher) Not depressed (less than 0.7) Beck Depression Inventory Depressed (8 up) Not depressed (7 or less)
41 23
64 36
64
100
45 19 64
70 30 100
36 28 -
56 44
64
100
a Data was missing on one client.
ratings among the scales which measured only depressive symptoms. In addition, correlations between self report scales and clinician rating scales were generally as high as correlations of self report with self report and clinician ratings with clinician ratings. Comparison of diagnostic evaluations and symptom ratings of depression We compared diagnostic assessments using the SADS/RDC and symptom ratings in two ways. First, means on symptom rating scales were compared on groups of clients who were determined to have current, past, and no depressive diagnosis according to the RDC. Those diagnoses included major,
262 TABLE
3
INTERCORRELATION
OF DEPRESSIVE
SYMPTOM
SCALES
IN DRUG
ABUSERS
(N =
64) Raskin
Clinician
Hamilton
Degree of illness
SCL 90 mean
SCL 90 depression
Beck Depression Inventory
0.84
0.76 a 0.68 a
0.71= 0.77 a
0.71 a 0.74 a
0.76 a 0.71 a
0.62 a
0.62 =
0.60 a
0.93 a
0.71 a 0.71 a
ratings
Raskin total Hamilton total Degree of illness
a
Self report scales SCL 90 mean SCL 90 (depression factor) Beck Depression Inventory a P < 0.001.
minor, and chronic intermittent depression. As displayed in Table 4, all symptom means are significantly different among these groups. It is noteworthy that a linear relationship was found so that clients with current depressive disorders had more symptoms than those who had recovered from previous episodes, and this group, in turn, had more depressive symptoms than those who had never had an episode of depression. TABLE
4
COMPARISON OF DEPRESSIVE SYMPTOM RATINGS ON DRUG ABUSERS CURRENT, PAST ONLY, OR NO RDC DIAGNOSES OF DEPRESSION (N = 64) Depressive measure
Clinician
RDC diagnosis depression
symptom
of
F tests
(a) Current
(b) Past only
(c) Never
Overall
18.9 9.0 3.0
15.8 7.4 2.5
10.0 5.5 1.8
1.6 2.1 13.0
1.1 1.4 10.1
0.7 0.8 6.0
(a) vs
WITH
(b)
(a) vs (c)
(b) vs (c)
7.4 b 13.1 c 7.3 b
1.6 5.3 a 2.8
13.9 c 25.8 c 14.2 c
6.5 a 8.3 b 4.9 a
10.3 c 12.8 ’ 7.1 b
5.9 7.1 b 2.2
20.5 c 25.5 = 13.7 c
4.7 a 6.1 a 5.3 a
rating scale
Hamilton total Raskin total Degree of illness
Self report scales SCL 90 mean SCL 90 (depression Beck total a P < 0.05,
factor)
bP < 0.01,
c P < 0.001.
263 TABLE
5
COMPARISON OF CLASSIFYING DRUG ABUSERS AS DEPRESSED DEPRESSED USING RDC CURRENT DIAGNOSES AND DEPRESSIVE SCALES AS CRITERIA (N = 64) Current RDC diagnosis
Clinician Rating Scale Hamilton Depressed (15 up) Not depressed (14 or less) Raskin Depressed (7 up) Not depressed (6 or less) Degree of illness 1 Depressed (3 up) Not depressed (2 or less) Self Report Scales SCL 90 mean Depressed (0.7 up) Not depressed (less than 0.7) SCL depression Depressed (0.7 up) Not depressed (less than 0.7) Beck Depression Inventory Depressed (8 up) Not depressed (7 or less)
AND NOT SYMPTOM
Sensitivity (a/a+c)
Specificity (d/b+d)
False+ (b/b+d)
False(c/a+c)
Yes
No
14 (a) 4 (c)
20 (b) 26 cd)
78%
57%
43%
22%
17 (a) 1 (c)
21 (b) 25 cd)
94%
54%
46%
6%
11 (a) 6 (C)
18 (b) 28 (d)
65%
61%
39%
35%
16 ca) 2 (c)
25 cb) 21 (d)
89%
46%
54%
11%
17 (a) 1 (c)
28 (b) 18 (d)
94%
39%
61%
6%
17 (a) 1 (c)
19 (b) 27 cd)
94%
59%
41%
6%
’ Missing data on one subject.
For a second comparison of diagnoses with symptom scales, ‘cases’ of depression were identified using cutoff scores traditionally used on each of the symptom rating scales. Using the RDC diagnostic categorization as the criterion, we assessed the specificity, sensitivity, false+ and false- rate obtained by using the rating scales as screening instruments. As noted in Table 5, the range of sensitivity was from 65 to 94%. However, specificity was much less impressive ranging from 39 to 59%. Although not tabulated here, a review of the false positives indicated that they largely consisted of
264 TABLE EFFECT SCORES
6 ON FOR
SPECIFICITY DETECTING
AND SENSITIVITY OF ADJUSTING THE CUTOFF CLINICAL DEPRESSION WITH SYMPTOM SCALES (N =
64) Scale
Sensitivity
Specificity
Hamilton total Depression = 15 up Depression = 16 up Depression = 17 up
78% 72% 61%
57% 57% 63%
Raskin total Depression Depression Depression
= 7 up = 8 up = 9 up
94% 72% 61%
54% 72% 76%
Degree of illness Depression = 2 up Depression = 3 up Depression = 4 up
100% 65% 35%
41% 61% 87%
89% 83% 78%
46% 50% 61%
94% 94% 94%
39% 41% 43%
94% 78% 78%
59% 61% 63%
SCL 90 mean Depression Depression Depression
= 0.7 up = 0.8 up = 0.9 up
SCL 90 (depression Depression = 0.7 Depression = 0.8 Depression = 0.9
sub-scale) up up up
Beck Depression Inventory Depression = 8 up Depression = 9 up Depression = 10 up
those who had past episodes of depression from which they had incompletely recovered. Considering both sensitivity and specificity together, the Beck Depression Inventory was the best overall screening purposes with the highest sensitivity and nearly the highest specificity. The more global degree of illness was least likely to detect depressive disorders although its specificity was the best. What is responsible for the large number of false+‘s? One possibility is that drug abusers, whether in depressive episodes or not, have a generally high number of depressive symptoms or have a response bias toward complaining of these symptoms, even if they are not severe. If this is the case, then the number of false+‘s might be reduced by elevating the cutoff scores used to identify ‘cases’ of depression. As noted in Table 6, when higher cutoff scores are used with the screening instruments, then specificity is increased but the sensitivity is reduced.
265 DISCUSSION
High prevalence
of depressive symptoms
A striking aspect of our findings was the large percentage of clients with a high level of depressive symptoms regardless of which symptom scale was used. The number was somewhat higher than that presented by other investigators who have reported that around one-third of clients had at least moderate levels of depressive symptoms or higher. Our findings may reflect sampling bias, in that a high number of clients coming to screening did not complete our evaluations and these may have been less depressed. However, even if all those who were not included in these figures were determined to be not depressed, the proportion of depressed patients in our sample would still be around one-third based on the symptom scales we used.
Depressive symptoms
in ‘recovered ’ depressives It was a surprising finding that addicts who have recovered from past episodes of depression scores are significantly more depressed on all symptom scales than those who had never experienced depressive episodes. This may reflect the chronicity of affective disturbances in the drug-dependent population that is described by psychodynamic theorists (Wurmser 1974; Khantzian 1977) who suggest that addicts have deficits in ego functioning which do not permit them to adequately regulate affective experiences. Thus, even if the depressive addict is not in a current episode of depression, he may not return to a normal level of mood but will continue to suffer from a reduced but significantly deviant level of dysphoria. Screening for clinical depression
The comparison of symptoms screening scales and diagnostic evaluations indicates that less than one-half of the clients who have a moderate level of depressive symptoms meet the criteria for a diagnosis of depression upon diagnostic evaluation. Others have reported similar findings with non-drugdependent population (Weissman and Myers 1976). With a more severely ill group, Strauss has reported that depression can be non-specific dimension of mental illness among patients with varying diagnoses (Strauss et al. 1978). However, in order to determine the appropriateness of specific treatments, it is critical to know if the symptoms fit a specific syndrome. Symptom screening scales provide only a relatively gross screening function and should be followed by more thorough clinical evaluation. Other studies reporting levels of depressive symptoms without diagnostic categorization must be reconsidered in light of our findings. Although there were substantial differences in the various symptom scales’ performance as screening devices, they correlated highly with one another. All the scales demonstrated discriminant validity in that mean scores for diagnosed depressives were significantly higher than scores of clients without a depressive diagnosis. Thus the scales were comparable in
266
distinguishing groups from one another but varied in their ability to accurately detect individual cases of a disorder. For epidemiological studies and for clinical purposes, the latter is the more important task. The purpose of a screening instrument is to detect those clients whose depression warrants further extensive clinical evaluation and some of the scales performed this function quite acceptably. Sensitivity is vital in order to insure that clients who have depression are adequately treated while specificity is less crucial, being important mainly to reduce the number of unnecessary evaluations that will be performed on clients without the disorder. In this study, 3 of the scales had acceptable sensitivity -the Raskin, the SCL 90 Depression Scale, and the Beck Depression Inventory. Of these the Beck Depression Inventory had the highest specificity. In that this scale is a quick, inexpensive, 13-item self report, it promises to be a valuable tool for screening this population for depression. If its performance in this study is representative, it would detect the great majority of depressives while saving further evaluation on 59% of those who are not depressed. Moreover, even among the false positives, many are clients who have had past episodes of depression, Given the recurring nature of this condition, detection of recovered depressives may also be of value. ACKNOWLEDGEMENT
We appreciate preparation.
the assistance
of Brigitte
Prusoff,
Ph.D.
in the data
analysis
REFERENCES Beck, A.T. and Beck, R.W. Screening depressed patients in family practices-A rapid technique, Postgrad. Med. 52 (1972) 1181-1185. Beck, A.T., Ward, C.H., Mendelson, M., et al., An inventory for measuring depression, Arch. Gen. Psychiat., 4 (1961) 461-471. checklist (HSCL) - A Derogatis, L., Lipman, R. and Rickels, K., The Hopkins symptom self-report symptom inventory, Behav. Sci., 19 (1974) l-16. Assoc., Washington, Diagnostic and Statistical Manual, Draft, 3rd ed., Amer. Psychiat. D.C., 1978. Endicott, J. and Spitzer, R.L. A diagnostic interview-The schedule for affective disorders and schizophrenia, Arch. Gen. Psychiat., 37 (1978) 837-844. Hamilton, M., A rating scale for depression, J. Neurol. Neurosurg. Psychiat., 23 (1960) 56-62. Khantzian, E.J. The ego, the self, and opiate addiction - Theoretical and treatment considerations. In: J.D. Blaine and D.A. Julius (Eds.), Psychodynamics of Drug Dependence, N.I.D.A. Monograph 12,1977, pp. 101-117. methadone and psychotherapeutic Lehman, W.X. and Deangellis, G.G., Adolescents, agents. In: Proceedings of the 4th National Conference on Methadone Treatment, 1972, pp. 55-58. Raskin, A., Schulterbrandt, J., Reatig, N., et al., Replication of factors of psychopathology in interview, ward behavior, and self-report ratings of hospitalized depressives, J.
267 Nerv. Ment. Robbins, P.R.,
Dis., 148 (1969) 87-98. Depression and drug addiction,
Psychiat.
Q., 48 (1974)
374-386.
Spitzer, R.L. and Endicott, J., Schedule for affective disorder and schizophrenia, Biometrics Research, New York State Department Mental Hygiene, New York, 1975. Spitzer, R.L., Endicott, J. and Robins, E., The research diagnostic criteria, Biometrics Research, New York State Department Mental Hygiene, New York, 1975. Spitzer, R.L., Endicott, J. and Robins, E., Research diagnostic criteria - Rationale and reliability, Arch. Gen. Psychiat., 35 (1978) 773-789. Steer, R.A., Kovacs, M. and Beck, A.T., Incidence of clinical depression in heroin addicts, Paper presented at the National Drug Abuse Conference, Seattle, Washington, 3-8 April, 1978. Strauss, J.S., Kokes, R.F., Ritzler, B.A., Handen, D.W. and Van Ord, A., Patterns of disorder in first admission psychiatric patients, J. Nerv. Ment. Dis., 166 (1978) 611-625. Wriland, W.F. and Sola, S. Depression in opiate addicts measured by objective tests. In: Proceedings of the 3rd National Conference on Methadone Treatment, 1970, pp. 75-79, Weissman, M.M., Psychotherapy and its relevance to the pharmacotherapy of affective disorders-From ideology to evidence. In: M. Lipton, A. DiMascio and K. Killam (Eds.) Psychopharmacology - A Generation of Progress, Raven Press, New York, 1978, pp. 1313-1321. Weissman, M.M. and Myers, J.K., The New Haven Community Survey 1967-75 Depressive symptoms and diagnosis. In: S.B. Sells, R. Crandall, M. Roff, J.S. Strauss and W. Pollin (Eds.), Human Functions in Longitudinal Perspective - Studies of Normal and Psychopathological Populations, Williams and Wilkins, Baltimore, 1979, In press. Weissman, M.M., Myers, J.K. and Harding, P.S., Psychiatric disorders in a U.S. urban community: 1975-76, Amer. J. Psychiat., 135 (1978) 459-462. Weissman, M.M., Slobetz, F., Prusoff, B., Mezritz, M. and Howard, P., Clinical depression among narcotic addicts maintained on methadone in the community, Amer. J. Psychiat., 133 (1976) 1434-1438. Wurmser, L. Psychoanalytic consideration in the etiology of compulsive drug use, J. Amer. Psychoanal. Ass., 22 (1974) 820-843.
255
DETECTING DEPRESSIVE DISORDERS IN DRUG ABUSERS A Comparison of Screening Instruments
BRUCE J. ROUNSAVILLE PATRICIA H. ROSENBERGER HERBERT D. KLEBER ’
r, MYRNA
M. WEISSMAN ‘, 3, CHARLES H. WILBER
4 and
’ Assistant Professor, Yale University Department of Psychiatry and Director of Research, Substance Abuse Treatment Unit, Connecticut Mental Health Center; ’ Associate Professor of Psychiatry and Epidemiology, Yale University Department of Psychiatry and Director of Depression Research Unit, Connecticut Mental Health Center; 3 Research Associate with the Addiction-Prevention Treatment Foundation, Inc.; 4 Research Associate with the Addiction-Prevention Treatment Foundation, Inc.; s Professor of Psychiatry, Yale University Department of Psychiatry and Director of Substance Abuse Treatment Unit, Connecticut Mental Health Center, 100 Park Street, New Haven, CT 06511 (U.S.A.) (Received (Accepted
31 May, 1979) 7 June, 1979)
SUMMARY Previous investigators have reported a high prevalence of depressive symptoms in drugdependent patients. Given the responsiveness of depressive disorders to both psychological and pharmacological treatments, it is desirable to find an economical, efficient screening instrument to detect depressive disorders in this population. In this study, 6 depression symptom screening scales (Beck Depression Inventory, Hamilton Depression Scale, Raskin Depression Scale, Degree of Illness Rating, Symptom Checklist 90 Overall, and Depression Subscale) based on either clinician interview or patient self report, were compared according to their utility in detecting cases of depression among 64 applicants for treatment at a substance abuse treatment unit of a community mental health center. The criteria for a case of depression were the Research Diagnostic Criteria (RDC) which are specified and operationalized. Cases identified using previously described cutoff scores on the screening scales were compared to rates based on the RDC and sensitivity and specificity were determined. The results showed that: (1) although the sensitivity of the symptom scales was acceptable, ranging from 65-94%, the specificity was less impressive, ranging from 39-61%, and (2) the Beck Depression Inventory, a 13-item patient self report was the most sensitive and specific and is recommended for screening drug-dependent populations for depression.
This work was supported 271-77-3410. Please direct reprint requests
by
National
to Dr. Bruce
Institute Rounsaville.
of
Drug
Addiction
contract
No.
256 INTRODUCTION
The efficacy of both pharmacotherapy and psychological treatments has been demonstrated in several recent controlled clinical trials (Weissman 1978). These recent advances in the treatment of affective disorders underscore the importance of correctly diagnosing depression so that appropriate treatment can be indicated. Recent surveys have shown that a substantial proportion of drug abusers have high levels of dysphoria and depressive-like symptoms (Wieland and Sola 1970; Lehman and Deangellis 1972; Robbins 1974; Weissman et al. 1976; Steer et al. 1977), which may be clinical depression and may make them candidates for conventional treatments of depression. Before anti-depressant treatment is instituted, a thorough diagnostic evaluation is required since many patients who report mood disturbances are not clinically depressed and treatment would not be indicated. Routine diagnostic interviewing is time-consuming and expensive. However, the high prevalence of depressive symptoms in drug abuse makes it desirable to have routine, efficient means for screening for depression and detecting persons who are potential candidates for more vigorous treatment. In this paper, we will compare the utility of 5 depressive symptom scales as screening instruments for depression in drug-dependent clients. The results of relatively brief depression symptom rating scales based on either patient self report or clinician’s evaluation will be compared with diagnostic evaluation based on a relatively lengthy, structured clinical interview, the Schedule for Affective Disorders and Schizophrenia (SADS-L) (Spitzer and Endicott 1975), using operationalized research diagnostic criteria, RDC (Spitzer et al. 1975). The use of the RDC diagnosis of depression as a standard for evaluating symptom scales is based on the concept that an important distinction can be made between depressive symptoms and the syndrome of depression. Data based on out-patient and community samples indicate that, although most patients who meet the criteria for an RDC diagnosis of depression have a high level of depressive symptoms, a substantial number of those who complain of depressive symptoms do not meet the criteria for a diagnosis of depression either because symptoms are not of sufficient duration or because the symptoms have not led to impairment in occupational or social functioning (Weissman and Myers 1976). RDC criteria are of some practical importance in that they are nearly identical to those to be included in the forthcoming American Psychiatric Association’s DSM-III (American Psychiatric Association 1978). Moreover, it is unlikely that anti-depressant treatment would be justified for clients whose impairment is not sufficient to meet the criteria for an RDC diagnosis of a depressive disorder. The utility of the symptom scales as screening instruments will be evaluated according to the following standards: (a) sensitivity - ability to correctly identify those with depressive disorders, (b) specificity - ability to correctly identify those without a depressive disorder, (c) false positive rate - the extent to which the scale incorrectly identifies those without a
257
depressive disorder as depressed, and (d) false negative rate -the which the scale fails to detect depressive disorders when present.
extent
to
METHOD
Setting and sample Subjects for this study were applicants for treatment at the Screening and Evaluation section of the Drug Dependence Unit (DDU) of the Connecticut Mental Health Center, Yale University Department of Psychiatry, in New Haven, CT. This Unit serves an urban and suburban population of approximately 400,000 people. The Screening Unit is the mode of entry for several modalities of treatment offered to clients with a problem of drug abuse for any drug but alcohol. Following screening, clients may be be referred to (1) methadone maintenance program, (2) an inpatient detoxification unit, program, (4) a drug counseling program for poly drug ;3, a naltrexone abusers, (5) a residential adult therapeutic community, and (6) a residential adolescent therapeutic community. Sixty-four subjects were evaluated over a 2; -month period, comprising around one-half of the 134 clients initially seen at screening during this period. This was a sample of convenience. The evaluations, which took place in two sittings 1-3 days apart, were as follows: Day 1 - history, identifying information, sociodemographic data collected by intake counselors, and Day 2 - symptom rating scales and SADS-L interview completed by trained research assistants.
Rating scales Diagnostic assessment.
Information for making diagnostic judgments was collected on the Schedule for Affective Disorders and Schizophrenia (SADS). The SADS is a structured interview guide with an accompanying inventory of ratings scales and specific items. It records information on the subject’s functioning and symptomatology. Although the name of the instruments suggests that it only includes information on affective disorders and schizophrenia, in fact it is an overall mental status inventory and contains the information necessary for making diagnostic judgments for all major psychotic, neurotic, and personality disorders. This method has been shown to reduce the portion of variance in diagnosis due to differing interviewing styles and coverage. There are several versions of the SADS, depending on the time period assessed - current, past 5 years, or lifetime. We used the lifetime version (SADS-L) which includes an assessment of the subject’s current as well as lifetime mental status (Spitzer and Endicott 1978). Based on the information collected on the SADS, the subjects were classified on the Research Diagnostic Criteria (RDC) which is a set of operational diagnostic definitions with specific inclusion and exclusion criteria for a variety of nosological groups. These operational definitions were developed for reducing the variance due to differing criteria which has been shown to
258
account for the largest source of unreliability in making diagnoses (Spitzer et al. 1978). The RDC has evolved from a decade of research of diagnosis. The conditions included have the most evidence of validity in terms of clinical description, consistency over time, familial association, and response to treatment. Diagnoses on the RDC are made both for the current time period and for lifetime, with the exception of several diagnoses which are considered lifetime diagnoses only, regardless of whether or not the subject is currently manifesting symptoms of the disorder. These lifetime only disorders are the personality disorders (labile, cyclothymic, Briquet’s, antisocial) and bipolar disorders. Psychiatric disorders which cannot be categorized due to limitation of information or absence of diagnostic criteria are listed as ‘other’. All diagnoses can be classified as either ‘probable’ or ‘definite’. Symptom rating scales Clinician-rated symptom scales Hamilton Rating Scale (Hamilton 1960). The Hamilton Depression Scale is a widely used 17-item scale completed by a clinician and based on information elicited from a patient during an interview. The items are measured on a 3- or a 5-point scale. A total score is obtained by summing the scores of individual items. The total score range is from 0 to 62, a higher score indicating more impairment. Mean total scores in ambulatory depressed patients are usually about 20. The cutoff score for moderate to severe depression is 15 or above. Four factor scores have been derived which cover the dimensions of depression: sleep disturbance, somatization, anxiety-depression and apathy. Raskin Depression Scale (Raskin et al. 1969). The Raskin Depression Scale is the clinicians assessment of the patient made during an interview with the patient and covers three areas: the patient’s verbal report, behavior, and secondary symptoms of depression. Each area is rated on a 5-point scale and scores are summed to yield a total score of 3-15. A score of 7 or higher is considered a depression of sufficient severity to be treated with psychopharmacologic agents. Mean total pretreatment scores in acutely depressed ambulatory patients are about 10. Degree of illness rating. This rating is a single 7-point global scoring denoting the severity of the client’s depressive condition on the basis of the clinical interview from which the Raskin rating is made. A higher score denotes a greater degree of illness. Self report symptom scales Symptom Checklist. The symptom checklist (SCL 90) is a self report rating scale oriented toward the symptomatic behavior of psychiatric outpatients. It is derived from the Hopkins Symptom Checklist (Derogatis et al. 1974). It is composed of 90 items rated on a 5-point scale. The items reflect 9 primary symptom dimensions that are believed to underlie the majority of symptom behaviors observed in these patients: (1) somatization, (2) obses-
259
sive-compulsivity, (3) interpersonal sensitivity, (4) depression, (5) anxiety, (6) hostility, (7) phobic anxiety, (8) paranoid ideation, (9) psychoticism. Based on a community survey in New Haven (Weissman et al. 1975-76), a score of 0.7 or above on the depression factor was over 1 standard deviation above the mean. We will evaluate both the full scale and the depression subscale as methods of screening for depression. Beth Depression Inuentory. (Beck and Beck 1972) This is a 13-item self report of symptoms with items scores ranging from 0 to 3 and total score of O-39. The score was validated using comparisons with previously established methods of diagnosing depression and according to Beck (Beck et al. 1961) can discriminate between anxiety and depression. A total score of 8 or above has been identified as indicating a moderate level of depression.
Raters All evaluations were administered by two research assistants who received intensive training by a psychiatrist for 3 months in the use of instruments and were judged to be competent in their use. To determine inter-rater agreement for the SADS/RDC ratings, clinical evaluations were performed jointly on 16 subjects seen in screening and evaluation. One rater conducted the interview and one observed (alternately) and ratings were compared. In rating the presence of any current depressive disorders (major, minor, intermittent) 4 cases were detected with 100% agreement between the two raters. RESULTS
Sociodemographic
characteristics
The majority of clients single (56%), with a high social classes (71%).
Diagnostic
were young (81% were under 30), male (79%), school education or less (63%) and from lower
characteristics
The distribution of current and lifetime RDC diagnoses is shown in Table 1. In this system, multiple diagnoses are possible. Therefore, the N’s do not add up to 64 as one person could have multiple diagnoses. Depressive disorders were the most frequently diagnosed psychiatric disorder both currently and over a lifetime. A significant minority of clients were diagnosed as having anxiety and personality disorders. Combining major depression, minor depression, and intermittent depressive disorders, 19 clients (30%) were determined to have current depressive order, 21 (33%) were found to have past depressive disorders from which they had recovered, and only 24 (37%) clients had no history of a depressive disorder either currently or in the past. Primary drug of abuse is also presented in Table 1. Although many clients abused several classes of drugs, their classification denotes the drug of abuse for which the client sought treatment. Opiates were the most frequent (70%)
260 TABLE RDC
1
DIAGNOSES
OF DRUG
ABUSERS
Diagnoses
APPLYING
FOR
TREATMENT
(N = 64)
-__
Current N
Manic disorders Hypomanic disorder
%
1
2
7 0 13
11 0 20
12 10 2
19 16 3
45 15 4
70 23 7
Alcoholism
3
5
Otho Unspecified functional psychosis Other psychiatric disorder Schizotypal features
0 3 4
0 5 6
Depressive disorders Major depressive disorder Minor depressive disorder Intermittent depressive disorder Anxiety disorders Panic disorder Generalized anxiety disorder Obsessive compulsive disorder Phobic disorder Personality disorders Labile Antisocial Cyclothymic
(lifetime
only)
Primary drug of abuse Opiates Marijuana Barbiturates/cocaine/inhalants
drug of abuse. Marijuana users (23%) led to significant social impairment.
are those for whom use of this drug has
Identification of depression using symptom ratings Using the cutoff scores, which have been considered as indicative of being ‘a case’ in previous studies, the number of clients having at least a moderate level of symptoms ranged from 46% for the Global Degree of Illness to 70% for the SCL-90 Depression Factor (See Table 2). To note the relationship among rating instruments, correlations were examined among the 5 symptom rating scales and these were all moderately high with a range from 0.60 to 0.93 (Table 3). Correlations of the SCL-90, an overall symptom rating scale with 9 dimensions were comparable to
261 TABLE
2
CLASSIFICATION USING CUTOFF
OF DRUG ABUSERS SCORES ON DEPRESSION
Scale
AS DEPRESSED OR NOT DEPRESSED SYMPTOM RATING SCALES (N = 64) N
%
Clinician rating scales Hamilton Depression Scale Depressed (15 up) Not depressed (14 or less)
Raskin Depression Scale Depressed (7 up) Not depressed (6 or less)
Degree of illness 3 (mild) or higher Not depressed (2 or less)
34 30 -
53 47
64
100
38 26 -
59 41
64
100
29 34
46 54
63a
100
Self report scales SCL-90 Mean Depressed (0.7 or higher) Not depressed (less than 0.7) SCL-90 Depression Factor Depressed (0.7 or higher) Not depressed (less than 0.7) Beck Depression Inventory Depressed (8 up) Not depressed (7 or less)
41 23
64 36
64
100
45 19 64
70 30 100
36 28 -
56 44
64
100
a Data was missing on one client.
ratings among the scales which measured only depressive symptoms. In addition, correlations between self report scales and clinician rating scales were generally as high as correlations of self report with self report and clinician ratings with clinician ratings. Comparison of diagnostic evaluations and symptom ratings of depression We compared diagnostic assessments using the SADS/RDC and symptom ratings in two ways. First, means on symptom rating scales were compared on groups of clients who were determined to have current, past, and no depressive diagnosis according to the RDC. Those diagnoses included major,
262 TABLE
3
INTERCORRELATION
OF DEPRESSIVE
SYMPTOM
SCALES
IN DRUG
ABUSERS
(N =
64) Raskin
Clinician
Hamilton
Degree of illness
SCL 90 mean
SCL 90 depression
Beck Depression Inventory
0.84
0.76 a 0.68 a
0.71= 0.77 a
0.71 a 0.74 a
0.76 a 0.71 a
0.62 a
0.62 =
0.60 a
0.93 a
0.71 a 0.71 a
ratings
Raskin total Hamilton total Degree of illness
a
Self report scales SCL 90 mean SCL 90 (depression factor) Beck Depression Inventory a P < 0.001.
minor, and chronic intermittent depression. As displayed in Table 4, all symptom means are significantly different among these groups. It is noteworthy that a linear relationship was found so that clients with current depressive disorders had more symptoms than those who had recovered from previous episodes, and this group, in turn, had more depressive symptoms than those who had never had an episode of depression. TABLE
4
COMPARISON OF DEPRESSIVE SYMPTOM RATINGS ON DRUG ABUSERS CURRENT, PAST ONLY, OR NO RDC DIAGNOSES OF DEPRESSION (N = 64) Depressive measure
Clinician
RDC diagnosis depression
symptom
of
F tests
(a) Current
(b) Past only
(c) Never
Overall
18.9 9.0 3.0
15.8 7.4 2.5
10.0 5.5 1.8
1.6 2.1 13.0
1.1 1.4 10.1
0.7 0.8 6.0
(a) vs
WITH
(b)
(a) vs (c)
(b) vs (c)
7.4 b 13.1 c 7.3 b
1.6 5.3 a 2.8
13.9 c 25.8 c 14.2 c
6.5 a 8.3 b 4.9 a
10.3 c 12.8 ’ 7.1 b
5.9 7.1 b 2.2
20.5 c 25.5 = 13.7 c
4.7 a 6.1 a 5.3 a
rating scale
Hamilton total Raskin total Degree of illness
Self report scales SCL 90 mean SCL 90 (depression Beck total a P < 0.05,
factor)
bP < 0.01,
c P < 0.001.
263 TABLE
5
COMPARISON OF CLASSIFYING DRUG ABUSERS AS DEPRESSED DEPRESSED USING RDC CURRENT DIAGNOSES AND DEPRESSIVE SCALES AS CRITERIA (N = 64) Current RDC diagnosis
Clinician Rating Scale Hamilton Depressed (15 up) Not depressed (14 or less) Raskin Depressed (7 up) Not depressed (6 or less) Degree of illness 1 Depressed (3 up) Not depressed (2 or less) Self Report Scales SCL 90 mean Depressed (0.7 up) Not depressed (less than 0.7) SCL depression Depressed (0.7 up) Not depressed (less than 0.7) Beck Depression Inventory Depressed (8 up) Not depressed (7 or less)
AND NOT SYMPTOM
Sensitivity (a/a+c)
Specificity (d/b+d)
False+ (b/b+d)
False(c/a+c)
Yes
No
14 (a) 4 (c)
20 (b) 26 cd)
78%
57%
43%
22%
17 (a) 1 (c)
21 (b) 25 cd)
94%
54%
46%
6%
11 (a) 6 (C)
18 (b) 28 (d)
65%
61%
39%
35%
16 ca) 2 (c)
25 cb) 21 (d)
89%
46%
54%
11%
17 (a) 1 (c)
28 (b) 18 (d)
94%
39%
61%
6%
17 (a) 1 (c)
19 (b) 27 cd)
94%
59%
41%
6%
’ Missing data on one subject.
For a second comparison of diagnoses with symptom scales, ‘cases’ of depression were identified using cutoff scores traditionally used on each of the symptom rating scales. Using the RDC diagnostic categorization as the criterion, we assessed the specificity, sensitivity, false+ and false- rate obtained by using the rating scales as screening instruments. As noted in Table 5, the range of sensitivity was from 65 to 94%. However, specificity was much less impressive ranging from 39 to 59%. Although not tabulated here, a review of the false positives indicated that they largely consisted of
264 TABLE EFFECT SCORES
6 ON FOR
SPECIFICITY DETECTING
AND SENSITIVITY OF ADJUSTING THE CUTOFF CLINICAL DEPRESSION WITH SYMPTOM SCALES (N =
64) Scale
Sensitivity
Specificity
Hamilton total Depression = 15 up Depression = 16 up Depression = 17 up
78% 72% 61%
57% 57% 63%
Raskin total Depression Depression Depression
= 7 up = 8 up = 9 up
94% 72% 61%
54% 72% 76%
Degree of illness Depression = 2 up Depression = 3 up Depression = 4 up
100% 65% 35%
41% 61% 87%
89% 83% 78%
46% 50% 61%
94% 94% 94%
39% 41% 43%
94% 78% 78%
59% 61% 63%
SCL 90 mean Depression Depression Depression
= 0.7 up = 0.8 up = 0.9 up
SCL 90 (depression Depression = 0.7 Depression = 0.8 Depression = 0.9
sub-scale) up up up
Beck Depression Inventory Depression = 8 up Depression = 9 up Depression = 10 up
those who had past episodes of depression from which they had incompletely recovered. Considering both sensitivity and specificity together, the Beck Depression Inventory was the best overall screening purposes with the highest sensitivity and nearly the highest specificity. The more global degree of illness was least likely to detect depressive disorders although its specificity was the best. What is responsible for the large number of false+‘s? One possibility is that drug abusers, whether in depressive episodes or not, have a generally high number of depressive symptoms or have a response bias toward complaining of these symptoms, even if they are not severe. If this is the case, then the number of false+‘s might be reduced by elevating the cutoff scores used to identify ‘cases’ of depression. As noted in Table 6, when higher cutoff scores are used with the screening instruments, then specificity is increased but the sensitivity is reduced.
265 DISCUSSION
High prevalence
of depressive symptoms
A striking aspect of our findings was the large percentage of clients with a high level of depressive symptoms regardless of which symptom scale was used. The number was somewhat higher than that presented by other investigators who have reported that around one-third of clients had at least moderate levels of depressive symptoms or higher. Our findings may reflect sampling bias, in that a high number of clients coming to screening did not complete our evaluations and these may have been less depressed. However, even if all those who were not included in these figures were determined to be not depressed, the proportion of depressed patients in our sample would still be around one-third based on the symptom scales we used.
Depressive symptoms
in ‘recovered ’ depressives It was a surprising finding that addicts who have recovered from past episodes of depression scores are significantly more depressed on all symptom scales than those who had never experienced depressive episodes. This may reflect the chronicity of affective disturbances in the drug-dependent population that is described by psychodynamic theorists (Wurmser 1974; Khantzian 1977) who suggest that addicts have deficits in ego functioning which do not permit them to adequately regulate affective experiences. Thus, even if the depressive addict is not in a current episode of depression, he may not return to a normal level of mood but will continue to suffer from a reduced but significantly deviant level of dysphoria. Screening for clinical depression
The comparison of symptoms screening scales and diagnostic evaluations indicates that less than one-half of the clients who have a moderate level of depressive symptoms meet the criteria for a diagnosis of depression upon diagnostic evaluation. Others have reported similar findings with non-drugdependent population (Weissman and Myers 1976). With a more severely ill group, Strauss has reported that depression can be non-specific dimension of mental illness among patients with varying diagnoses (Strauss et al. 1978). However, in order to determine the appropriateness of specific treatments, it is critical to know if the symptoms fit a specific syndrome. Symptom screening scales provide only a relatively gross screening function and should be followed by more thorough clinical evaluation. Other studies reporting levels of depressive symptoms without diagnostic categorization must be reconsidered in light of our findings. Although there were substantial differences in the various symptom scales’ performance as screening devices, they correlated highly with one another. All the scales demonstrated discriminant validity in that mean scores for diagnosed depressives were significantly higher than scores of clients without a depressive diagnosis. Thus the scales were comparable in
266
distinguishing groups from one another but varied in their ability to accurately detect individual cases of a disorder. For epidemiological studies and for clinical purposes, the latter is the more important task. The purpose of a screening instrument is to detect those clients whose depression warrants further extensive clinical evaluation and some of the scales performed this function quite acceptably. Sensitivity is vital in order to insure that clients who have depression are adequately treated while specificity is less crucial, being important mainly to reduce the number of unnecessary evaluations that will be performed on clients without the disorder. In this study, 3 of the scales had acceptable sensitivity -the Raskin, the SCL 90 Depression Scale, and the Beck Depression Inventory. Of these the Beck Depression Inventory had the highest specificity. In that this scale is a quick, inexpensive, 13-item self report, it promises to be a valuable tool for screening this population for depression. If its performance in this study is representative, it would detect the great majority of depressives while saving further evaluation on 59% of those who are not depressed. Moreover, even among the false positives, many are clients who have had past episodes of depression, Given the recurring nature of this condition, detection of recovered depressives may also be of value. ACKNOWLEDGEMENT
We appreciate preparation.
the assistance
of Brigitte
Prusoff,
Ph.D.
in the data
analysis
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