Detecting depression in patients with coronary heart disease: a diagnostic evaluation of the PHQ-9 and HADS-D in primary care, findings from the UPBEAT-UK study
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OBJECTIVE: People with coronary heart disease (CHD) are at heightened risk of depression, and this co-occurrence of conditions is associated with poorer outcomes including raised mortality. This study compares the diagnostic accuracy of two depression case finding instruments in CHD patients relative to a diagnostic standard, the revised Clinical Interview Schedule (CIS-R). METHODS: The Patient Health Questionnaire (PHQ-9), the Hospital Anxiety and Depression Scale depression subscale (HADS-D) and the CIS-R depression module were administered to 803 patients identified from the CHD registers of GP practices in Greater London. RESULTS: Of 730 recruited patients without previously identified depression, 32 (4.4%) met ICD-10 depressive episode criteria according to the CIS-R. For the PHQ-9 and HADS-D lower cut-points than those routinely recommended were associated with improved case identifying properties. The PHQ-9 appeared the superior instrument using a cut-point of ≥8 (sensitivity=94%; specificity=84%). Using categorical scoring the PHQ-9 was 59% sensitive and 95% specific. For the HADS-D using cut-point ≥5, sensitivity was 81% and specificity was 77%. Areas under the curves (AUC) (standard error) were 0.95 (0.01) and 0.88 (0.02) for the PHQ-9 and HADS-D, and 0.91 (0.02) for PHQ-9 using the categorical algorithm. Statistically significant differences between AUCs of the PHQ-9 and the HADS-D favoured the former. Severity ratings compared across measures indicated inconsistency between recommended bandings: the PHQ-9 categorised a larger proportion of participants with mild and moderate depression. CONCLUSION: This is the first large-scale investigation of the accuracy of these commonly used measures within a primary care CHD population. Our results suggest that although both scales have acceptable abilities and can be used as case identification instruments for depression in patients with CHD, the PHQ-9 appeared diagnostically superior. Importantly, optimal cut-off points for depression identification in this population appear to differ from standard values, and severity ratings differ between these measures.
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The Hospital Anxiety and Depression Scale (HADS) has good psychometric properties and is widely used on patients with somatic diseases, including cardiology patients.
“HADS has good psychometric properties and is widely used on patients with somatic diseases (36, 37), including cardiology patients (38, 39).”
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- Authors
- Haddad, M., Walters, P., Phillips, R., Tsakok, J., Williams, P., Mann, A., & Tylee, A.
- Affiliations
- City, University of London (GB)
- King's College London (GB)
- Venue
- PLoS ONE
- Publisher
- Public Library of Science (PLoS)
- Published
- 2013-10-10
- Volume
- 8
- Issue
- 10
- Pages
- e78493
- ISSN
- 1932-6203 (ISSN-L)
- PMC
- PMC3795055
- OpenAlex
- W2159522765
- Cited by
- 109
- References
- 49
- Citations by year
- 2026: 3 · 2025: 11 · 2024: 9 · 2023: 9 · 2022: 8 · 2021: 10 · 2020: 17 · 2019: 16 · 2018: 4 · 2017: 5 · 2016: 6 · 2015: 7 · 2014: 4
- FWCI
- 3.85
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- PLoS ONE (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Research Portal (King's College London) (publishedVersion, other-oa)
- City Research Online (City University London) (acceptedVersion)
- RePEc: Research Papers in Economics (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Figshare (submittedVersion, cc-by)
- Spiral (Imperial College London) (submittedVersion, other-oa)
- Funders
- National Institute for Health and Care Research (RP-PG-0606-1048, MET-08-08-101)
- Programme Grants for Applied Research
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Keywords
- depression, coronary artery disease, PHQ-9, Hospital Anxiety and Depression Scale, case finding, diagnostic accuracy, cut-off values, depression severity, primary care, comorbidities
- MeSH terms
- Aged, Aged, 80 and over, Coronary Disease, Cross-Sectional Studies, Depressive Disorder, Female, United Kingdom, Humans, Male, Middle Aged, Primary Health Care, Psychometrics, Surveys and Questionnaires
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