LETTER TO THE EDITOR
Influence of age, gender, and race on depression in heart failure patients
Ronald Freudenberger, MD*,
Stacey C. Cahn, PhD and
Christine Skotzko, MD, FAPM
* 125 Paterson Street, Suite 6100, New Brunswick, NJ 08903 (Email: freuders{at}umdnj.edu).
We applaud Gottlieb and colleagues for devoting attention to depression and quality of life in heart failure (HF) patients (1). We are concerned, however, with the investigators' use of: 1) the Beck Depression Inventory (BDI) (2) as a sole measure of depression, and 2) the Medical Outcomes Study, Short Form Health Survey-36 (SF-36) (3) as a measure of quality of life in HF patients.
Although there is precedent for using the BDI to screen for depression in HF patients (4,5), we are concerned that the BDI may be inadequate as a single index of depression in this medically ill population. Because the BDI was not designed to diagnose or assess depression in medically ill patient samples, fully one-third of the scale's items are somatic in focus, assessing fatigue, appetite, libido, sleep habits, somatic worry, functional ability, and weight change—all symptoms consistent with HF. Previous studies of major depression in HF have used the BDI as a screening instrument before using a diagnostic interview such as the Diagnostic Interview Survey (DIS) (6) to diagnose major depression (4,5). Without a diagnostic interview for depression and/or a concurrent, nonsomatic measure of depression (e.g., the Hospital Anxiety and Depression Scale) (7), using only the BDI to assess depression poses a potential threat to construct validity in these symptomatic HF patients. In their study, Gottlieb et al. (1) further operationalized depression as a BDI score  10. Whereas Beck et al. (2) categorize BDI scores of 4 to 10 as normal, and scores of 11 to 16 as indicative of mild depression, these cut-off points represent norms established in a nonmedically ill population. Thus, classifying stage II to IV HF patients with BDI scores 10 as depressed, in the absence of a secondary diagnostic or nonsomatic measure of depression, may potentially serve to overestimate the prevalence of depression in this, by definition, symptomatic sample.
Additionally, the SF-36 used by the researchers as an index of quality of life is, like the BDI, comprised of both mood and somatic items. The investigators report a significant correlation between the BDI and the SF-36; thus, they conclude that depression is associated with lower quality of life in HF patients. The overlapping domain items in the BDI and SF-36, however, may potentially confound this correlation, as the statistical association might, at least in part, reflect the degree to which the scales themselves correlate.
Depression and quality of life in patients with HF are significant public health issues that clearly warrant further investigation. As scientists, we must successfully grapple with the thorny issues of construct and scale validity within this population (e.g., "what is the nature of depression in HF?" "what is a validated measure of depression in HF?") if our research is to advance both the science and the standard of care for HF.
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References
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1. Gottlieb SS, Khatta M, Friedmann E, et al. The influence of age, gender, and race on the prevalence of depression in heart failure patients J Am Coll Cardiol 2004;43:1542-1549.[Abstract/Free Full Text]
2. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression Arch Gen Psychiatry 1961;4:561-571.[Abstract/Free Full Text]
3. Ware JE, Sherbourne CD. The MOS 36-Item Short Form Health Survey (SF-36) IConceptual framework and item selection. Med Care 1992;30:473-483.[Medline]
4. Freedland KE, Rich MW, Skala JA, Carney RM, Davila-Roman VG, Jaffe AS. Prevalence of depression in hospitalized patients with congestive heart failure Psychosom Med 2003;65:119-128.[Abstract/Free Full Text]
5. Jiang W, Alexander J, Christopher E, et al. Relationship of depression to increased risk of mortality and rehospitalization in patients with congestive heart failure Arch Intern Med 2001;161:1849-1856.[Abstract/Free Full Text]
6. Robins LN, Cottler LB, Bucholz KK, Compton III WM. Diagnostic interview schedule for DSM-IV (DIS-IV)St. Louis, MO: National Institute of Mental Health; 1995.
7. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale Acta Psychiatr Scand 1983;67:361-370.[Medline]
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