Burnand, Bernard

Büla, Christophe J.

Wietlisbach, Vincent

Yersin, Bertrand

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Does a single item question identifyelderly medical inpatients who reportsignificant depressive symptoms?SIR—Several studies have shown that elderly medicalinpatients frequently report significant depressive symp-toms, defined as six or more symptoms using the 15-itemGeriatric Depression Scale (GDS) [1–3]. Although thesepatients might not all meet the criteria-based diagnosis ofmajor depression (e.g. ICD10 or DSMIV), several studiessuggest that even minor and subsyndromal depressionthat do not meet these criteria are associated withsubstantial functional and medical morbidity, and couldLetters to the Editor231benefit from therapeutic interventions [4, 5]. In previousstudies we observed that these subjects with depressivesymptoms were more likely to be readmitted, had higherservice utilisation during a 6-month follow-up period,and were more likely to spend inappropriate days inthe acute care setting [6, 7]. We also observed thatonly 16.7% of these subjects were identified as havingdepressive symptoms [3].Because routine screening for depression is difficultto implement in the busy acute care setting, even withshort instruments such as the 15-item GDS, we wantedto evaluate whether a single question could be analternative to the GDS in detecting significant depressivesymptoms in these elderly medical inpatients. Weassessed the agreement between the single item screen-ing question ‘Do you often feel sad or depressed?’ andthe GDS.Population selection and methods have beendescribed in detail previously [6]. Briefly, 401 patientsaged 75 years and older consecutively admitted over6 months to the internal medicine service of an academichospital were enrolled. In addition to affective statusassessment, data on demographics, medical, physical,social and mental status were collected upon admission.Subjects’ mean age was 82.4 years, 60.9% werewomen. Overall, 90 patients (22.4%) had depressivesymptoms (GDS score 06). In a first step, we assessedwhether reporting a depressed mood by the singlequestion predicted the presence of depressive symptoms.In a stepwise multivariate regression analysis that con-trolled for demographic, medical and functional charac-teristics, subjects reporting a depressed mood by thesingle question had about 8 times higher odds (adjustedOR 8.4, 95% CI 4.2–16.8) of reporting depressiveFigure 1. Distribution of the score at the Geriatric Depression Scale according to gender and presence of depressedmood by the single question.Letters to the Editor232symptoms at the GDS compared to subjects withoutdepressed mood. However, the agreement betweenthe single question and the GDS was only moderate(80.3%, k 0.48, P-0.001). This is further shownwhen considering the GDS as if it were the criterionstandard. Using different GDS cut-off scores (6 or more,8 or more, and 10 or more) to define the presenceof significant depressive symptoms, sensitivity and speci-ficity remained low, ranging from 70.0 to 86.4%, andfrom 83.3 to 74.7%, respectively. Corresponding nega-tive predictive values ranged from 9.4 to 1.0%. Subgroupanalyses of discordant results between the singlequestion and GDS showed that this single questionperformed better in men (agreement 86.0%, k 0.61,sensitivity 74.3%, specificity 89.3%, negative predictivevalue 7.6%) than in women (agreement 76.6%, k 0.41,sensitivity 67.3%, specificity 79.4%, negative predictivevalue 10.7%). In the analysis predicting the presenceof significant depressive symptoms using the GDS, asignificant interaction was found between gender andthe answer to the single question. Results indicated thatwhen men and women reported a depressed mood bythe single question, men were about three times morelikely (adjusted OR 3.3, 95% CI 1.0–11.1, P = 0.048)than women to also report significant depressivesymptoms with the GDS (see Figure 1), even thoughthe proportion of men and women with abnormal GDSwas similar (22.3 and 22.5%, respectively). Despite theapparent better agreement in men, the concordancewith GDS remained moderate, and up to 25.7% of menwith significant depressive symptoms were not identifiedby the single question alone. This proportion seems toohigh when considering the adverse outcomes such asincreased mortality or hospital readmission previouslyobserved in subjects with high GDS scores [1–3].The moderate agreement between the single question‘Do you often feel sad or depressed?’ and the GDS resultprecludes the use of this question as an alternative to theGDS in similar samples of elderly hospitalized persons.Interestingly, this single question performed differentlyin men and women. According to our results, while menwere less likely to disclose having a depressed mood,once doing so, they were much more likely to also reportsignificant depressive symptoms with the GDS. Thisfinding is interesting and requires further investigationas most studies testing single or one-item instrumentsin middle-aged or older populations have includedprimarily male patients.One obvious limitation to this analysis is the absenceof a true gold standard such as a structured psychiatricassessment to determine whether these elderly subjectswho reported significant depressive symptoms with theGDS suffered from major depression, minor depression,dysthymia, or other mood disorders. We are thereforeunable to draw firm conclusions regarding the usefulnessof this single question in detecting major depressiveepisodes. However, as others [8], we think thatdepression exists along a continuum in elderly persons,and even though an abnormal GDS score is notequivalent to a diagnosis of major depressive episode,it identifies subjects with affective conditions severeenough to warrant further intervention [1–3].In conclusion, we believe that these results contributeto a better understanding of a simple screening test inhospitalized older persons and add to the currentknowledge in showing that performance on a singlequestion might differ depending on patient gender.CHRISTOPHE J. BU¨LA1,2, VINCENT WIETLISBACH4,BERTRAND YERSIN2,3, BERNARD BURNAND41Division of Geriatric Medicine and Geriatric Rehabilitation,2Department of Internal Medicine,3Department of Emergency Medicine, Centre HospitalierUniversitaire Vaudois (CHUV), Lausanne, Switzerland4Institute of Social and Preventive Medicine,University of Lausanne, SwitzerlandAddress correspondence to: C. J. Bu¨la, CUTR Sylvana,Ch de Sylvana #10, 1066 Epalinges,SwitzerlandFax: (q11) 41 21 314 3858Email: Christophe.Bula@chuv.hospvd.ch1. Whooley MA, Browner WS. Association between depres-sive symptoms and mortality in older women. Arch Intern Med1998; 158: 2129–35.2. Covinsky KE, Kahana E, Chin MH, Palmer RM, Fortinsky RH,Landefeld CS. Depressive symptoms and 3-year mortality inolder hospitalized medical patients. Ann Intern Med 1999;130: 563–9.3. Pouget R, Yersin B, Wietlisbach V, Burnand B,Bu¨la CJ. Depressed mood in a cohort of elderly medicalinpatients: prevalence, clinical correlates, and recognition rate.Aging Clin Exp Res 2000; 12: 301–7.4. Lyness JM, King DA, Cox C, Yoediono Z, Caine ED.The importance of subsyndromal depression in older primarycare patients: prevalence and associated functional disability.J Am Geriatr Soc 1999; 47: 647–52.5. Williams JW, Barrett J, Oxman T et al. Treatmentof dysthymia and minor depression in primary care. arandomized controlled trial in older adults. JAMA 2000;284: 1519–26.6. Bu¨la CJ, Wietlisbach V, Burnand B, Yersin B. Depressivesymptoms as a predictor of 6-month outcomes and servicesutilization in elderly medical inpatients. Arch Intern Med 2001;161: 2609–15.7. Ingold B, Yersin B, Wietlisbach V, Burnand B, Bu¨la CJ.Characteristics associated with inappropriate hospital use inelderly patients admitted to a general internal medicine service.Aging Clin Exp Res 2000; 12: 430–8.8. Hybels CF, Blazer D, Pieper CF. Toward a threshold forsubthreshold depression: an analysis of correlates of depres-sion by severity of symptoms using data from an elderlycommunity sample. Gerontologist 2001; 41: 357–65.Letters to the Editor233

Does a single item question identify elderly medical inpatients who report significant depressive symptoms?

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