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AMBULATORY ANESTHESIOLOGY

An Efficient Screening Tool for Preoperative Depression: The Geriatric Depression Scale-Short Form

Diana S. Bass, BS^*, Deborah K. Attix, PhD, ABPP/ABCN^*, Barbara Phillips-Bute, PhD, and Terri G. Monk, MD, ABA

From the *Division of Neurology, Division of Medical Psychology, Duke University Medical Center, Department of Anesthesiology, Duke University Medical Center, and Department of Anesthesiology, Durham Veterans Affairs Medical Center, Durham, North Carolina.

Address correspondence and reprint requests to Deborah K. Attix, PhD, ABPP/ABCN, Box 3333 Duke University Medical Center, Durham, NC 27705. Address e-mail to koltai{at}duke.edu.

Abstract

BACKGROUND: Depression is highly prevalent in patients before surgery, and it has been widely shown to have a serious impact on their postoperative outcomes. It would therefore be desirable for physicians to obtain a quick, simple screen to evaluate depression to consider treatment of symptomatology and potentially optimize postoperative outcomes.

METHODS: In this study, we investigated the prevalence of depression in a presurgical inpatient sample undergoing major, noncardiac surgery. In addition, we sought to establish the Geriatric Depression Scale-Short Form (GDS-SF) as a valid screening tool for depression by examining its relationship to the Beck Depression inventory (BDI) by age and gender.

RESULTS: In our sample of 1043 presurgical candidates, prevalence of depression as established by the BDI was significantly higher than rates consistently found in healthy community samples. Depression was more common in women than in men (P = 0.02), and depression rates were lower in elders relative to middle-aged and younger groups (P = 0.003 and 0.003, respectively). In addition, we found that there was a high correlation between the BDI and the GDS-SF within each of the age groups.

CONCLUSIONS: These data further support the need for depression screens in presurgical populations and establish the validity of the GDS-SF as a valid quick assessment alternative available to physicians.

Depression has been associated with poor health care utilization and heath status, as well as poor outcomes after many types of major surgery.1–3 For instance, research has demonstrated worsened outcomes after coronary artery bypass (CAB) and vascular surgeries.4,5 The prevalence of preoperative depression in these populations is as high as 47% before CAB and 36% before vascular surgery, as opposed to only a 2%–4% prevalence in normal community samples.4–6 Despite these prevalence estimates, treatment of depression in presurgical populations is often limited, possibly because some physicians consider psychological disorders as less clinically relevant than physical ailments.1

Depression before CAB independently predicts the need for cardiac hospitalization after CAB as well as continued surgical pain and failure to return to preoperative activity in the first 6 mo after surgery.4 Cherr et al.5 also demonstrated that patients who exhibit depression before peripheral vascular surgery have an increased risk of recurrent symptomatic peripheral arterial disease and failure of graft patency after their surgery. For this reason, depression screening ideally should be included in the presurgical workup of patients scheduled for cardiovascular surgical procedures.

Less is known about prevalence rates across various noncardiovascular surgical populations, but several noncardiac surgical studies have also shown that prognosis for depressed, ill patients is greatly affected by their depression.3,7 These patients show less adherence to treatment plans and health maintenance, amplified physical symptoms of existing conditions, greater health care utilization, as well as higher levels of mortality than their nondepressed counterparts.8 Therefore, all surgical populations may be at higher risk for problematic outcomes because of comorbid depression. Given the known impact of depression on health care status and health care utilization,1 early identification and treatment through screening may lead to implementation of effective methods to favorably influence quality of life and health care outcomes. Indeed, some evidence has been offered suggesting improved clinical outcomes resulting from treatment for depression.9

There are several measures which allow clinicians to screen for depression. Most screens consist of brief questionnaires that ask patients about common symptoms of depression. Two of the most widely used depression screens are the Beck Depression Inventory (BDI) and the Geriatric Depression Scale (GDS). These two instruments have been found to have high reliability and validity for identifying depressed patients across age groups, sexes, and cultures.10–16 In addition, they have been found to have high correlations (e.g., 0.78, 0.84, 0.73) with each other in psychiatric, alcoholic, and young normal populations.10,11,13 The GDS-Short Form (GDS-SF) is also effective for evaluating depression, as well as offering a shorter and more manageable format.17

In the present study, we investigated the prevalence of depression in noncardiac presurgical inpatients undergoing major surgery. We further sought to establish the relationship between the BDI and GDS-SF in these patients, and to determine whether this relationship varied by age or gender. Finally, we wanted to determine whether the GDS-SF, an efficient and cost-effective method of screening for depression, was a valid alternative to the BDI as a preoperative screening tool for depression.

METHODS

Subjects
This study received IRB approval and each participant provided written informed consent. All of these patients were enrolled in a study evaluating long-term outcomes after surgery.18 Primary findings of that work include identification of age and education as strong predictors of postoperative cognitive decline; depression was not an independent predictor of such decline.18 Eligible patients were those aged 18 yr or older presenting for major noncardiac surgery under general anesthesia and scheduled to be admitted to the hospital after surgery. Exclusion criteria were preoperative Mini-Mental State Examination score of 23 or less before surgery; preoperative disease of the central nervous system (including but not limited to infections, metabolic disorders, tumors, major head trauma, neurodegenerative diseases, and Parkinson's disease); scheduled surgical procedures known to affect postoperative cognitive function (carotid surgery, neurosurgical, and cardiopulmonary bypass procedures); current alcoholism or drug dependence; severe visual or auditory handicaps; inability to comprehend or follow directions; previous enrollment in the study; or refusal to give informed consent for the study. Importantly, surgical patients with current or past major depression or psychosis requiring electroconvulsive therapy or psychiatric care, or current use of tranquilizers or antidepressants were also excluded.

Patients were classified as young (18–39 yr), middle-aged (40–59 yr), or elderly (60 yr or older) in this study. Preoperative clinical information was recorded from the patient's medical history. Comorbidity was quantified using the Charlson Comorbidity Score.19 Patients underwent minimally invasive, intraabdominal/thoracic, or orthopedic surgeries. Subjects completed an abbreviated neuropsychological testing battery designed to assess cognition and mood preoperatively (within 14 days of surgery), and again at 1 wk and 3 mo after the surgery. As part of this evaluation, subjects completed the BDI and GDS-SF during the preoperative visit. All data were immediately checked for compatibility and completeness on entry into a dedicated computer program; staff training ensured consistency and reliability of data collection.

One-thousand and sixty-four patients were enrolled, and 1043 had complete data for analysis. The clinical and demographic characteristics of the study population are shown in Table 1.

Instruments
BDI20
The BDI is a 21-item questionnaire that uses a multiple-choice format to address many of the psychological and physical complaints associated with a diagnosis of depression. The BDI has been widely used in clinical populations and has been well established as an effective screening measure for depression.21 In fact, this instrument has been found to be one of the top 10 measures used in psychological clinical practice.22

GDS-SF (Appendix)23
The original GDS was developed for an elderly population, but has been shown to be valid for all age groups.10 This 30-question screen is advantageous because it uses a simple YES/NO format and also eliminates many of the somatic questions found in the BDI, which often lead to false positives in medically ill populations. A short form of the GDS was developed for ease of administration. This 15-item form has been found to significantly correlate with the original screen as well as clinician-diagnosed depression.24–26 This shorter form eases the burden on especially ill patients, and is also more efficient for use by medical professionals.

Statistical Methods
Using the cut-off of scores >13 on the BDI, baseline depression prevalence was established by age group and gender. This cut point has been shown to have adequate sensitivity and specificity (0.82% and 0.89%, respectively).27 Depressive symptoms were compared across age and gender categories with ² tests of general association.

The association between BDI and GDS-SF was assessed for the whole group using Spearman correlations. This relationship was also examined within age categories.

RESULTS

Mean BDI scores for young, middle, and elderly age groups were 7.09 (sd 7.0), 7.68 (sd 7.3), and 5.87 (sd 5.1), respectively. Depression rates as captured by scores >13 on the BDI for men and women in each age group are presented in Table 2. The rate of depression was significantly higher in women than in men (P = 0.02). Although depression rates within the young and middle-aged groups did not differ significantly (P = 0.99), elders demonstrated a statistically lower rate of depression than both the young and middle-aged groups (P = 0.003 and 0.003, respectively).

Spearman correlation coefficients revealed highly significant correlations between the BDI and GDS-SF in this presurgical sample. This association was confirmed within each of the age groups (Table 3). Figure 1 illustrates the association between measures for the sample.

View larger version (11K): [in this window] [in a new window]   Figure 1. Scatterplot of Beck Depression Inventory (BDI) and Geriatric Depression Scale-Short Form (GDS-SF) scores preoperatively.

DISCUSSION

The rates of depression in our preoperative surgical sample were considerably higher than those consistently found in healthy community samples.6 These rates suggested that in our sample, across most of our age groups, approximately 1 of every 10 patients exhibited considerable preoperative depressive symptoms. This is notable, given that patients requiring psychiatric care or using antidepressants or tranquilizers were excluded. Previous research has shown that both female gender and younger age are associated with a higher prevalence of depression.6 Our work supports this, with males and elders demonstrating less depression, even in a presurgical population.

Our study adds to the body of information that has established that depression is highly prevalent in presurgical patient populations. Depression is a treatable disorder, and its potential adverse affects on surgical treatment outcomes for these patients should not be underestimated. Depression has been found to be associated with poorer prognosis, longer recovery times, and increased health care utilization.4,5 It is, therefore, important that the symptoms of depression in these patients be recognized by their physicians in order for them to receive proper perioperative care. To identify these symptoms, physicians need a fast, simple screen so as to quickly and efficiently identify patients who may be depressed.

The robust correlation between the BDI and GDS-SF (Table 3, Fig. 1) establishes the validity of the GDS-SF as a screening instrument for preoperative depression in this sample. Although the BDI is more commonly used in the medical field as a screen for depression, the GDS-SF, unlike the BDI, is in the public domain and can be reproduced inexpensively and without formal authorization, making it ideal for widespread clinical use. In addition, the GDS-SF may be better suited to presurgical populations because it eliminates the somatic items contained in the BDI that could lead to an increased rate of false-positive depression diagnoses in ill populations. The GDS-SF also simplifies administration by using a YES/NO format and can be completed in approximately 5 min. The GDS-SF has also been found to identify depression as well as its longer counterpart. More importantly, because this shorter form simplifies the screening tool, and thus reduces patient burden, even severely ill individuals can be screened. Overall, the GDS-SF is an ideal measure that offers numerous advantages for efficient, cost-effective, and valid depression screening.

Using the BDI as the "gold standard," the scores of both measures can be reviewed to estimate corresponding cut-off points. In our sample, 12.6% scored at the cut-off of >13 on the BDI. Review of the distribution of GDS-SF scores to establish a cut-score capturing a similar proportion of the sample reveals that 12.7% of the sample scored >6. Of course, additional studies with clinically diagnosed depression will be needed to establish GDS-SF cut-off scores with adequate sensitivity and specificity and to determine the rates of over- and under-diagnosis.

Despite the comprehensive nature of this instrumentation study, there are variables which could be examined in future studies to build upon these findings. We did not distinguish major from minor depression based on BDI scores but, rather, used a commonly applied cut-off indicating the presence of clinical symptoms with good sensitivity and specificity. Examination of the relationship of depression to specific types of noncardiac surgery would be of interest and could be the focus of another study. To this end, depression rates were not examined in relationship to medical variables, as we sought to focus on the sensitivity of these measures to depression and their validity rather than the source of distress. We did observe that while the Charlson Comorbidity Score revealed increasing health issues across the age groups, this was not paralleled by increasing depression with age. However, more in-depth studies examining the relationship of depression to medical variables, such as preoperative disease, medications, or other comorbid disorders, are warranted. Also, additional studies using healthy nonsurgical subjects would augment our understanding of the relationship between depression and functional outcomes. In addition, although considerable data have been collected on the GDS, data about the psychometric properties (i.e., reliability, validity) and its sensitivity in specific patient populations of the GDS-SF are just now emerging.

In conclusion, our findings demonstrate that the GDS-SF is a valid screening tool for depression in the preoperative setting. With our current level of knowledge, it is now apparent that "excess disability," or greater than warranted incapacity due to treatable factors such as depression, is not only unnecessary but also may negatively impact patient outcomes. Given the impact of depression on outcomes, health care utilization, and basic quality of life, it is clearly advantageous for clinicians to have a practical and efficient means of screening for depression. Therefore, preoperative identification and treatment of these psychological factors should be considered. We have demonstrated the use of the GDS-SF to identify depression in patients scheduled for high-risk surgery.

Appendix

Footnotes

Accepted for publication November 19, 2007.

Supported by the National Institute on Aging (Grant K01-AG19214); Anesthesia Patient Safety Foundation; and I. Heermann Anesthesia Foundation, Inc.

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