A variety of screening tools is available and most have good sensitivity, with scores in the .8 to .9 range. Specificity is typically adequate but not as accurate, with scores ranging from .70 to .85. The results of the USPSTF investigations into appropriate tools found that “There is little evidence to recommend one screening method over another, so clinicians should use the method that best suits their personal preference, the patient population served and the practice setting.”22 In fact, a two-question screen known as the Patient Health Questionnaire 2 (PHQ-2) is as effective as longer tools.
An issue in the selection of appropriate screening tools for healthcare providers caring for people who are ill—and especially for those with arthritis—is the number of questions that ask about somatic symptoms that overlap with symptoms of illness and arthritis. Such a tool would give a high false-positive rate. The Beck Depression Index (BDI) is the most frequently used screening tool worldwide. Other frequently used patient self-report screenings include the:
- Hospital Anxiety and Depression Scale (HADS);
- Center for Epidemiological Studies–Depression (CES-D);
- Patient Health Questionnaire (PHQ-9);
- PHQ-2; and
- Two questions from the PRIME MD.
All of these will be discussed below.
The Tools
The BDI was developed by Aaron Beck in 1961, and revised in 1996 with the newer version known as the BDI-II. The test consists of 21 items that are scored from 0 (not present) to 3 (present to a significant degree). It is typically given to the patient to self-complete or can be read aloud to a patient with a verbal response. It depends on a fifth- or sixth-grade reading level and was validated on a white, middle-class population, so its usefulness in minority patients is uncertain. The BDI and BDI-II ask for the cardinal signs of depression, including indicators of mood, cognition and somatic symptoms. This last category is problematic for use in a medical setting. Therefore, the BDI for Primary Care (BDI-PC) was developed for use in settings in which patients might be expected to have physical symptoms that overlap depression.23 The BDI-PC contains no questions relative to somatic symptoms, but includes questions that assess such symptoms as sadness, pessimism, past failures, loss of pleasure and thoughts of suicide.
