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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2006  |  Volume : 17  |  Issue : 4  |  Page : 503-510
The Diagnostic Utility of Self-Reporting Questionnaire (SRQ) as a Screening Tool for Major Depression in Hemodialysis Patients


1 Department of Nephrology, King Saud University, Riyadh, Saudi Arabia
2 Department of Psychiatry, King Saud University, Riyadh, Saudi Arabia

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   Abstract 

There is overwhelming evidence that individuals with Major Depressive Disorder (MDD) are being seriously under diagnosed and under treated. The Self-Reporting Questionnaire (SRQ) is a good screening instrument for the detection of psychiatric disorders. However, the clinical significance of SRQ as a screening test for MDD in patients on hemodialysis (HD) has yet to be elucidated. The purpose of this study was to evaluate the diagnostic utility of the SRQ in detecting MDD in a cohort of patients with end-stage renal disease (ESRD) on maintenance HD. Twenty-six patients on maintenance HD were randomly recruited and were asked to complete the SRQ. The participants were, in addition, interviewed by a psychiatrist, who had been blinded to the SRQ score. We examined the ability of SRQ to detect patients who were diagnosed to have MDD based on psychiatric assessment. Among the 26 patients assessed, four patients were diagnosed to have MDD based on current diagnostic criteria. Logistic regression analysis showed that SRQ could predict patients with MDD with adjusted odds ratio of 1.9 (CI, 1.06- 3.42). Being a female was the most important variable for having a high SRQ (F=16.9, P=0.0004). The limitations of this study include a relatively small sample size and a high rate of somatic symptoms reported in the non-depressed population that limited the positive predictive value of the SRQ. Thus, although the SRQ has a high sensitivity, the positive predictive value of the SRQ is poor at low cut offs. In conclusion, our study suggests that an ideal screening tool in patients on HD should have minimal emphasis on the somatic symptoms of MDD. Until such a tool is available, clinical assessment remains the best screening tool for MDD.

Keywords: Self-Reporting Questionnaire, Hemodialysis, Depression.

How to cite this article:
Alsuwaida A, Alwahhabi F. The Diagnostic Utility of Self-Reporting Questionnaire (SRQ) as a Screening Tool for Major Depression in Hemodialysis Patients. Saudi J Kidney Dis Transpl 2006;17:503-10

How to cite this URL:
Alsuwaida A, Alwahhabi F. The Diagnostic Utility of Self-Reporting Questionnaire (SRQ) as a Screening Tool for Major Depression in Hemodialysis Patients. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2019 Nov 12];17:503-10. Available from: http://www.sjkdt.org/text.asp?2006/17/4/503/32487

   Introduction Top


Psychiatric illness is common among patients with chronic disorders, particularly in those with end-stage renal disease (ESRD). [1] One of the early studies in this field showed that psychiatric disorders among dialysis patients had a point prevalence of 31%, using a standardized semi-structured interview. [2] In a study of approximately 175,000 dialysis patients, nine percent were hospitalized with a mental disorder during a one-year period. [1] The one-year incidence rate of three psychiatric disorders, namely, dementia, delirium, and major depression was 10.6% in a similar population of variable ages. [3] Major Depressive Disorder (MDD) is the most commonly studied psychiatric disorder in this population. MDD among dialysis patients may adversely affect mortality, possibly independent of dialysis adequacy. [4],[5],[6],[7] It is the most common psychiatric disorder requiring hospitalization in this patient population, and can usually be success­fully treated by the judicious use of medications, with or without counseling.

The exact incidence of depression in dialysis patients is widely variable, ranging from 10 to 66%. [5],[8],[9],[10],[11] This wide variation is based in part upon the different criteria utilized for assessing mood disturbances. In addition, some patients may over-emphasize their somatic symptoms, and may deny any mood distur­bance or other symptoms directly attributable to depression. [12] Although many self-report scales have been used to assess mood state in ESRD patients, few depression scales have been validated in Arabic speaking population and none had been formally validated in Arabic speaking ESRD population. For example, the Hospital Anxiety and Depression Rating Scale (HADRS) had been validated among Arabic-speaking population in a primary health care setting. [13] The Center for Epide­miological Studies-Depression Scale (CES­D) was validated in non-clinical sample of young Arabic females. [14] However, neither has been tested in patients on hemodialysis (HD). Recently, Lopes et al., as part of the Dialysis Outcomes Quality Initiative, showed that a patient's self-reported positive response to two questions on the Kidney Disease Quality of Life Instrument Short Form (KDQOL-SF); "Have you felt downhearted and blue?" and "Have you felt so down in the dumps that nothing could cheer you?", were associated with increased risk of mortality and hospitalization in a cohort of patients on HD. [15] However, the kappa index of agreement between depression diagnosed by the physician and by the "so down in the dumps" and "down hearted and blue" questions were 0.16 and 0.17, respectively. This poor agreement will limit the utility of these two questions by themselves in diagnosing depression. The Self-Reporting Questionnaire (SRQ), although not designed specifically to detect MDD, was able to detect all true cases of MDD in the study that esta­blished its validity in an Arabic population. [16] In addition, the sample tested composed of medical patients in which somatic symptoms predominate, similar to ESRD patients.

The impact of demographic and social correlates on the prevalence of MDD among ESRD patients is poorly studied. Until recently, the relationship between age, ethnicity, marital status and satisfaction on the one hand, and perception of quality of life and level of depressive affect and diagnosis of depression and medical outcomes on the other, have not been determined in patients with renal disease. [17] More recent studies give conflicting reports. For example, in one study that exa­mined 53 ESRD patients on HD, men had higher scores on the Beck Depression Inventory (BDI) and perceived lower social support, compared to women. [18] In another study of HD patients, no correlation was found between Hospital Anxiety and Depression (HAD) scale versus age, and no gender difference was observed. [19] To our knowledge, such interaction has not been studied in Arabic-speaking ESRD population.

The primary goal of this study was to determine the validity and reliability of the Arabic version of the SRQ in detecting MDD in a cohort of ESRD patients in comparison to physician-based diagnosis. Accomplishing this goal will facilitate the detection of ESRD patients with possible MDD, who would likely benefit from psychiatric intervention. Other goals include exploring the influence of various demographic and laboratory variables on the prevalence of depression in patients on HD.

The study was in compliance with the Second Declaration of Helsinki and approved by the ethics committee of the King Khaled University Hospital (KKUH), Riyadh, Saudi Arabia.


   Methods Top


The basic design was a single center, cross sectional study. Patients were included if they had ESRD and were on maintenance HD for at least three months duration, and were 18 years of age or older. The exclusion criteria were: inability to participate in psy­chiatric interview, acute renal failure and delirium. Also, patients who were diagnosed with psychiatric disorders other than MDD, based on psychiatric interviewing, were ex­cluded. All patients fulfilling the inclusion criteria and coming for regular HD at the KKUH were entered. A single psychiatrist interviewed all the study subjects. They were screened for mood, anxiety and somatoform disorders based on the DSM-IV diagnostic criteria. [20] In addition, participants were asked to complete the Arabic version of SRQ, a valid and reliable screening tool of psychiatric disorders, consisting of 20 items. The Arabic version of SRQ had been validated previously. [16] The instrument is composed of 25 questions that require yes or no as answer. The questions inquire about a variety of psychiatric symptoms. Questions 1 to 21 focus on non-psychotic symptoms while questions 22-25 focus on psychotic symptoms.

Fourteen questions are directly related to DSM-IV diagnostic criteria of a major de­pressive episode such as sad mood, presence of death wishes, inability to experience pleasure, disturbed sleep, and fatigability. For the purpose of this study, only responses to the questions 1-21 were considered. It takes approximately eight to 10 minutes to complete the question­naire and yields a score that correlates with the presence or absence of psychiatric dis­orders. The participants filled the question­naires within a week of the interview by the psychiatrist. During the study period, no changes were made in their medications, including psychotropics. The results of the SRQ were not revealed to the psychiatrist.


   Statistical Analysis Top


Data analyses were performed using the statistical software package, SAS Version 8. Baseline characteristics of the cohort were described using the appropriate parametric and non-parametric methods respectively for continuous and categorical variables. Correlations between baseline SRQ and each of the explanatory variables, and among the explanatory variables, were calculated using Chi-Square/Fisher's Exact tests and Wilcoxon rank sum tests for categorical variables as appropriate. Factors that have been shown in various studies to be associated with depression in dialysis patients include age, duration on dialysis, gender, adequacy of dialysis, Body Mass Index (BMI) and co­ morbidities (e.g., diabetes). [21],[22],[23],[24] Those variables which are found to be significantly associated with baseline Score at α < 0.05 were entered into separate stepwise multivariable regression models to estimate adjusted associations between baseline patient characteristics and the score. In all analyses, we additionally assessed for interactions between each of the explanatory variables and our measure of SRQ. SAS Proc REG was used to perform baseline regression modelling. Logistic re­gression was used to assess the adjusted predictive value of the SRQ, while the clinical judgment by psychiatrist with dichotomous outcome (Depressed or Not Depressed) was used as the gold standard.


   Results Top


Patient characteristics

Of the 34 patients considered initially as participants in the study, 26 were included. The reasons for exclusion of the eight patients were: refusal to participate (three patients), severe dementia (two patients), acute renal failure (two patients) and presence of other psychiatric illnesses (one patient with gene­ralized anxiety disorder). [Table - 1] presents the baseline characteristics of the 26 parti­cipants in the study. The mean age was 48.1 years and there were 15 males (58%) and 11 females (42%).

Demographic Characteristics of Patients with Depression Based on Clinical Assessment

Among the 26 patients assessed by a psy­chiatrist, four patients were diagnosed to have current major depressive episode. [Table - 2] presents the demographic differences bet­ween the patients with and without MDD. There were no statistically significant differences in the demographic or laboratory features between the two groups. However, there was a trend for more females to be depressed, as three out of four patients with MDD were female.

Important predictors of SRQ total score

Our first step was to determine the most important variables which are to be included in a model that would best represent the data, and is most valuable for prediction of high score on the SRQ. Multiple regression analysis was carried out with forward selection for important predictors. The model with gender, BMI, age, URR, diabetes and duration on HD was tested. Only gender was a signi­ficant predictor for SRQ. Being a female was the most important variable for having a high SRQ (F=16.9, P=0.0004) [Figure - 1].

Diagnostic utility of the SRQ scale

Logistic regression analysis was done to test the hypothesis that SRQ can predict patients with or without MDD, the diagnosis being based on physician assessment. Backward selections were done with SRQ, gender, BMI, diabetes, URR and duration on HD. Only SRQ met statistical significance with adjusted odds ratio of 1.9 (CI, 1.06- 3.42). [Table - 3] shows the different diagnostic parameters for SRQ at various cutoffs. [Figure - 2] shows ROC curve for SRQ scale with estimated area under the curve of 0.96. Although the SRQ has a high sensitivity, the positive predictive value of the SRQ is poor at low cutoffs. The reason for low predictive value for the SRQ is the relatively high score reported by the non-depressed patients.


   Discussion Top


Chronic medical illness such as ESRD is consistently associated with an increased prevalence of depressive symptoms and dis­orders. [20] There is overwhelming evidence that individuals with depression are being seriously under diagnosed and under treated for a variety of reasons. [25] Providers may not look beyond a chronic medical illness to explain non-specific symptoms. In addition, psychiatric symptomatology may be mimicked by symptoms of the chronic renal failure. Any ideal screening test should be brief, simple, and inexpensive. The SRQ has the potential of being a good screening test for MDD in HD patients. In the study reported by Alsubaie et al, a cut off point between six and seven yielded high sensitivity (93%) and reasonably good specificity (70%) in detecting psychiatric co-morbidity among patients referred for gastroscopy. Our study revealed that such cut off obviously could not be generalized to patients with ESRD. Although usage of these cut offs of SRQ in HD patients has a very high sensitivity, the specificity is low at 18%. Patients with ESRD are more likely to experience physical symptoms such as fatigue and sleep disturbance that would decrease the diagnostic validity of some SRQ items related to such symptoms. Raising the cut off to 13 or more will give a more acceptable specificity level of 82% without compromising the sensitivity. Unlike the sensitivity and specificity of the SRQ, which are considered the main characteristics of any test, the positive predictive value of the test is affected by the following factors: the prevalence of the disorder, its infrequency as well as the specificity of the test being used. This clearly explains the low predictive value of the SRQ in our study, as the preva­lence was relatively low and the specificity was poor at low cut offs.

Duration on dialysis and younger age were not associated with high SRQ score in a statistically significant manner. This is in contrast to the work done by Craven et al [26] who had shown that all these factors in addi­tion to a history of previous major depressive episode were all predictors of current MDD.

The reason for the large difference in the prevalence of MDD between males and females with ESRD based on SRQ score, and their likelihood of being diagnosed with MDD based on psychiatric assessment, is unclear and is in contrast with the study by Patel et al. [18] However, our observation with regard to gender difference could represent a reflection of the well-known increased prevalence of mood disorders among females. Also, the kidney normally plays an important role in the metabolism, degradation, and ex­cretion of several hormones, which include cortisol, thyroxin and catecholamines. It is not surprising therefore, that impairment in kidney function leads to disturbed hormonal physiology. The clinical importance of these hormonal disturbances in increasing risk of MDD in patients with ESRD is not known. However, females tend to be more susce­ptible to various dysregulations than males, which may contribute to an increased susceptibility to MDD. [27],[28]

The limitations of this study include a relatively small sample size, single center approach, use of semi-structured interview and a high rate of somatic symptoms reported in the non-depressed population that limited the positive predictive value of the SRQ.

Future studies are needed to adjust this scale, as well as other scales used in ESRD setting, to improve the predictive value.

We conclude that an ideal screening tool for MDD in patients on HD should have minimal emphasis on the somatic symptoms of MDD. Until such tool is available, clinical assessment remains the best screening tool for MDD.

 
   References Top

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15.Lopes AA, Bragg J, Young E, et al. Dialysis Outcomes and Practice Patterns Study (DOPPS). Depression as a predictor of mortality and hospitalization among hemodialysis patients in the United States and Europe. Kidney Int 2002;62:199-207.  Back to cited text no. 15    
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Correspondence Address:
Fahad Alwahhabi
Department of Psychiatry, King Saud University, P.O. Box 231657, Riyadh 11321
Saudi Arabia
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