Diagnostic evaluation of the hospital depression scale (HADS) and the Beck depression inventory II (BDI-II) in adults with congenital heart disease using a structured clinical interview: Impact of depression severity

Eur J Prev Cardiol. 2020 Mar;27(4):381-390. doi: 10.1177/2047487319865055. Epub 2019 Jul 26.


Objective: The purpose of this study was the diagnostic evaluation of the hospital anxiety and depression scale total score, its depression subscale and the Beck depression inventory II in adults with congenital heart disease.

Methods: This cross-sectional study evaluated 206 patients with congenital heart disease (mean age 35.3 ± 11.7 years; 58.3% men). Major depressive disorder was diagnosed by a structured clinical interview for the Diagnostic and Statistical Manual of Mental Disorders IV and disease severity with the Montgomery-Åsberg depression rating scale. Receiver operating characteristics provided assessment of diagnostic accuracy. Youden's J statistic identified optimal cut-off points.

Results: Fifty-three participants (25.7%) presented with major depressive disorder. Of these, 28 (52.8%) had mild and 25 (47.2%) had moderate to severe symptoms. In the total cohort, the optimal cut-off of values was >11 in the Beck depression inventory II, >11 in the hospital anxiety and depression scale and >5 in the depression subscale. Optimal cut-off points for moderate to severe major depressive disorder were similar. The cut-offs for mild major depressive disorder were lower (Beck depression inventory II >4; hospital anxiety and depression scale >8; >2 in its depression subscale). In the total cohort the calculated area under the curve varied between 0.906 (hospital anxiety and depression scale) and 0.93 (Beck depression inventory II). Detection of moderate to severe major depressive disorder (area under the curve 0.965-0.98) was excellent; detection of mild major depressive disorder (area under the curve 0.851-0.885) was limited. Patients with major depressive disorder had a significantly lower quality of life, even when they had mild symptoms.

Conclusion: All scales were excellent for detecting moderate to severe major depressive disorder. Classification of mild major depressive disorder, representing 50% of cases, was limited. Therapy necessitating loss of quality of life is already present in major depressive disorder with mild symptoms. Established cut-off points may still be too high to identify patients with major depressive disorder requiring therapy. External validation is needed to confirm our data.

Keywords: Depression; adult congenital heart disease; self-rating scale; validation.

Publication types

  • Comparative Study

MeSH terms

  • Adult
  • Affect*
  • Depressive Disorder, Major / diagnosis*
  • Depressive Disorder, Major / etiology
  • Depressive Disorder, Major / psychology
  • Female
  • Heart Defects, Congenital / complications*
  • Heart Defects, Congenital / diagnosis
  • Heart Defects, Congenital / psychology
  • Humans
  • Interview, Psychological*
  • Male
  • Middle Aged
  • Predictive Value of Tests
  • Psychiatric Status Rating Scales*
  • Reproducibility of Results
  • Severity of Illness Index
  • Young Adult