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Detecting depression

MADRS can detect depression in pre-op patients

The positive acceptance of the short scale by the users, both patients and overloaded clinicians, can increase the cost-effectiveness of assessment for inexpensive implementation in bariatric clinics

A Brazilian study assessing 10-item and 5-item version of Montgomery-Åsberg Depression Rating Scale (MADRS) to determine pre-operative bariatric evaluation of depression, has concluded that whilst both are effective, the 5-item scale enhanced perioperative evaluations of patients with obesity and improved treatment outcomes. The study researchers from University of São Paulo Medical School, São Paulo, Brazil, reported their findings, ‘Clinical utility of the Montgomery-Åsberg Depression Rating Scale for the detection of depression among bariatric surgery candidates’, in BMC Psychiatry.

Clinical assessment of depression is an important part of pre-surgical assessment among individuals with morbid obesity. However, there is no agreed-upon instrument to identify mood psychopathology in this population. We examined the reliability and criterion validity of the clinician-administered Montgomery-Åsberg Depression Rating Scale (MADRS) and the utility of a short version for bariatric surgery candidates.

“Systematic assessment with short version of MADRS to detect depression, coordinated screening of patient's weight and metabolic indicators are pivotal to enhance perioperative evaluations of patients with obesity and improve their treatment outcome.”

According to the authors, MADRS has a limited number of somatic symptoms and captures the construct of depression among patient samples, with empirical evidence of psychometric robustness and cost-effectiveness. Therefore, they investigated the applicability of the MADRS for a sample of pre-surgical patients in the waiting list of a bariatric clinic.

“The MADRS has never been applied to preoperative bariatric candidates and incorporates a structured interview embedded in a brief 10-item scale,” they write. “We aimed to determine the accuracy of the scale (a) to estimate its reliability and validity for assessing depression, and (b) to test whether it is possible to develop a short version of instrument without somatic-cognitive symptoms.”

Study

The 374 study participants were recruited from a University-based bariatric centre in Brazil, the majority were women (79), half were married/cohabiting (50.8 %), one-quarter was single (25.4 %), the remaining was separated/divorced (16.8 %) or widowed (7.0 %). The mean age was 43.0 years (SD 11.6) and the mean BMI was 47.0 (SD 7.1; range 31.2–92.1).

They assessed patients with MADRS, which investigates the presence of affective, somatic, cognitive and behavioural symptoms of depression. In this, ten symptoms are rated on a 0–6 scale, along the possible scores of 0–60. The total score classifies the patients in levels of severity: normal or absent 0–6; mild 7–19; moderate 20–34; and severe 35–60 [30]. The raters were clinical psychologists with experience in bariatric patients, whose scores were calibrated in three consensus meetings.

In addition, from 2010 to 2012, participants were randomly assigned to Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I), a standardised semi-structured interview (face-to-face assessment by trained psychologists with previous experience in obesity and bariatric surgery.

Outcomes

Of the 374 participants, 7% (n=26) met the criteria for major depressive episode and 27.5% (n=103) lifetime major depression in accordance with SCID-I/DSM-IV criteria. The mean total score of MADRS was 7.73 (SD 11.33, range 0–58, CV 1.47). The highest item endorsement rates (mean score around 1.0) were observed for ‘apparent sadness’, ‘reduced sleep’, ‘reported sadness’ and ‘inner tension’. The lowest endorsement rates (mean < 0.75) were ‘suicidal thoughts’, ‘reduced appetite’, ‘pessimistic thoughts’ and ‘concentration difficulties’.

The items with the highest dispersion (CV > 2.0) were ‘suicidal thoughts’, ‘reduced appetite’ and ‘pessimistic thoughts’, indicating sizable response bias of score precision (Table 1). Although women scored higher than men (8.08 vs. 6.33), the authors note that high data dispersion has cancelled the statistical difference between sexes (p=0.23).

Table 2 Mean, standard deviation (SD), coefficient of variation (CV) of the Montgomery-Åsberg Depression Rating Scale (MADRS) for severely obese patients (N = 374). Item-total correlation and commonalities

For the 10-item scale, the Cronbach’s alpha coefficient was 0.93, showing adequate homogeneity. For 10-item MADRS, the best trade-off threshold between sensitivity and specificity was 13/14, yielding sensitivity 0.85 and specificity 0.81. Further analysis showed that 23.8% of participants scored above 13 points with mean score of 24.96 (25.1% women and 18.7% men).

The 5-item version showed comparable performance with 10-item version, in terms of sensitivity and specificity. For the best threshold of 10/11, 19.0% of the sample scored above ten points (19.4% women and 17.3% men).

The authors commented that the positive acceptance of the short scale by the users, both patients and overloaded clinicians, can increase the cost-effectiveness of assessment for inexpensive implementation in bariatric clinics.

“The forecast that both obesity and depression are epidemic conditions that will rise exponentially in next decades challenges their proper identification as a medical task of utmost interest…” the authors conclude. “Systematic assessment with short version of MADRS to detect depression, coordinated screening of patient's weight and metabolic indicators are pivotal to enhance perioperative evaluations of patients with obesity and improve their treatment outcome.

To access the paper, please click here

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