Validity and Reliability of Screening Measures for Depression and Anxiety Disorders in Rheumatoid Arthritis

Abstract

Objective: To test the validity and reliability of screening instruments for depression and anxiety in rheumatoid arthritis (RA).

Methods: Participants with RA completed the Patient Health Questionnaire (PHQ-2 or PHQ-9), the Patient Reported Outcomes Measurement Information System depression short form 8a and anxiety short form 8a, the Hospital Anxiety and Depression Scale anxiety score (HADS-A) and depression score (HADS-D), the Overall Anxiety Severity and Impairment Scale, the Generalized Anxiety Disorder 2- and 7-item scales, and the Kessler-6 scale. Clinical depression and anxiety disorders were confirmed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I Disorders (SCID-1) research version. We reported sensitivity, specificity, positive predictive value, and negative predictive value using SCID-1 diagnoses as the criterion standard. Test-retest reliability was assessed with the intraclass correlation coefficient.

Results: Of 150 participants, 11.3% had SCID-1-diagnosed depression, 7.3% had SCID-1-diagnosed generalized anxiety disorder, and 19.3% had any SCID-1-diagnosed anxiety disorder. For depression, sensitivity ranged from HADS-D (cut point 11; 35%) to PHQ-2 (88%) and PHQ-9 (87%). Specificity ranged from PHQ-9 (77%) and PHQ-2 (84%) to HADS-D (cut point 11; 94%). Positive predictive value ranged from 30% to 43%. Negative predictive value ranged from 92% to 98%. For generalized anxiety disorder, sensitivity ranged from HADS-A (cut point 11; 45%) to HADS-A (cut point 8; 91%). Specificity ranged from 81% to 89% for all measures except the HADS-A (cut point 8; 63%). Intraclass correlation coefficient estimates ranging from 0.69 to 0.88 confirmed good test-retest reliability.

Conclusion: Depression screening instruments had good diagnostic performance; anxiety instruments were more variable. Identified depression and anxiety require clinical confirmation.

Figure 1

Receiver operating characteristic curves for screening measures as compared to the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I Disorders. A, Depression; B, Generalized anxiety disorder. PHQ‐2 = Patient Health Questionnaire 2; AUC = area under the curve; PROMIS = Patient Reported Outcomes Measurement Information System; Kessler‐6 = Kessler‐6 scale (a measure of general psychologic distress); HADS‐D = Hospital Anxiety and Depression Scale depression score; OASIS = Overall Anxiety and Severity Impairment Scale; GAD‐2 = Generalized Anxiety Disorder 2; HADS‐A = HADS anxiety score.