Culture and MedicineScreening tools for depression inprimary careThe effects of culture, gender, and somatic symptoms on the detection of depression see also p 292,332

Depression is projected to become the leading cause ofdisability and the second leading contributor to the globalburden of disease by 2020.1 It is estimated that the dev-astation caused by depression—defined as the number ofyears lost to death or disability—by 2020 will be surpassedonly by heart disease.2

Primary care physicians treat more than 50% of pa-tients with mental disorders, and depressive disordersare accurately diagnosed in less than half of the patientswho are affected.3 A patient’s culture, gender, and/or pre-dominance of somatic symptoms can impede the de-tection of depression. This is reflected by biases found inself-reporting screening tools used to detect depression.In this article, we discuss the limitations of self-reportingscreening tools for depression with respect to culture, gen-der, and somatic symptoms and suggest ways to use theresults of screening tools to improve the detection of de-pressive disorders.

LITERATURE SEARCHWe conducted literature searches of the PubMed andPsychINFO databases (1990-2001) using the search termsBeck Depression Inventory, culture, and validity. Furthersearches of the PubMed database (1990-2001) includedthe additional search terms primary care, depression, Centerfor Epidemiological Studies Depression Scale, Patient HealthQuestionnaire, and General Health Questionnaire.

We chose articles with relevance to the practice of pri-mary care medicine, the use of depression screening toolsin different cultures and different demographic groups,gender biases associated with depression screening tools,and the relationship between depression and somaticsymptoms.

INFLUENCES OF CULTURE AND SEX ON THEIDENTIFICATION OF DEPRESSIONDepression screening is an essential part of the detection,treatment, and referral to mental health professionals ofpersons with depressive disorders. Worldwide, the BeckDepression Inventory is the most extensively used self-reporting tool.4 Developed in 1961, the inventory wasdesigned to assess the intensity of symptoms associatedwith psychoanalytic aspects of depression, such as sadness,feelings of failure, guilt, suicidal ideas, and social with-drawal (see box).5,6 But for certain demographic groupsand cultures, the Beck Depression Inventory has limited

Summary points

• Semantic differences between the terminology ofdepression screening tools and the language of somecultures may limit the diagnostic power of these tools

• Somatic symptoms may be more reliable indicators ofdepression than a patient’s emotional state

• Scores from depression screening tools should beused to indicate the need for further evaluation—notas a basis for diagnosis

• Despite their limitations, self-reported depressionscreening tools are useful for detecting depression inthe primary care setting

Beck Depression InventorySelf-Reporting Questionnaire

Organization• 21 questions• Questions scored on a scale from 0 to 3, with 3indicating severe

Question content1 Sadness2 Pessimism3 Sense of failure4 Dissatisfaction5 Guilt6 Expectation of punishment7 Self-dislike8 Self-accusations9 Suicidal ideas

10 Crying11 Irritability12 Social withdrawal13 Indecisiveness14 Body image change15 Work retardation16 Insomnia17 Fatigability18 Anorexia19 Weight loss20 Somatic preoccupation21 Loss of libido

Interpretation

• Score of 1-10: ups and downs are considered normal

• Score of 11-16: mild mood disturbance

• Score of 17-20: borderline clinical depression

• Score of 21-30: moderate depression

• Score of 31-40: severe depression• Score higher than 40: extreme depression

Laura K Kerr

Independent scholar267 Loucks AveLos Altos, CA 94022Len D Kerr Jr

PsychiatristGeorgetown, TX

Correspondence to:Dr Laura Kerr

uxmal@stanford.edu

Competing interests:None declared

West J Med2001;175:349-352 ..

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predictive power and validity because of the effects oftranslation from English to other languages, patients’ dif-ferent interpretations of its emotional terms, and variouscultural factors, such as perceptions of racial prejudice anda cultural group’s work ethic.6-9

These biases are observed with other screening toolsused in primary care, including the Center for Epidemio-logical Studies Depression scale, designed for diverse de-mographic groups, and the General Health Question-naire, which is used to identify short-term changes inmental health.8,9 Primary care physicians are expected torespond to the needs of a diverse population, and under-standing the reliability of self-reported screening tools canassist them in determining how tools contribute to theoverall recognition of depression in their patients.

Cross-cultural validity of the toolsOne shortcoming of the Beck Depression Inventory ariseswith linguistic translations of its questions. In their studyof the Spanish translation of the Beck Depression Inven-tory, Azocar and colleagues observed that although theinventory has internal consistency, it lacks cultural validityand applicability due to translations that ignore semanticdifferences between Spanish and English.7 The authorsobserved that Spanish-speaking Latinos, in contrast to En-glish-speaking US nationals, were more likely to endorse(ie, score 3 on) questions 6 (expectation of punishment),10 (crying), and 14 (body image change) and were lesslikely to endorse (ie, score 0 on) question 15 (work re-tardation) (see box). They identified several cultural biasesthat could affect Latinos’ interpretations of these questionsand that could lead to erroneous diagnoses of depression.In particular, the authors suggested the following:

• The high endorsement of question 6 could result fromthe central role of Catholicism in Latino culture andthe belief that suffering may be the result of Godpunishing you for your sins

• Question 10 might be highly endorsed because, inLatino culture, crying has symbolic value and is ap-propriate and often expected in certain circumstances

• The high endorsement of question 14 might be due toLatinos’ exclusion from stereotypic representations ofbeauty in Western society. Furthermore, Latino atti-tudes toward beauty, argued the authors, change dra-matically with age: in Latino culture, as a woman ages,beauty becomes associated with inner qualities ratherthan physical appearance

• Latinos’ strong work ethic might explain why theypredominantly score 0 on question 15. Latinos oftentake several jobs to support themselves, their familiesin America, and family members still in the countriesof their origin. Even limited absenteeism could have aprofound effect on themselves and their dependents

• This study is particularly relevant to primary care phy-sicians. Because of the stigma some Latino populationsassociate with visiting a mental health professional,they are more likely to see primary care physiciansthan mental health professionals for mental healthissues.7

Iwata and colleagues observed a similar effect with aJapanese translation of the General Health Questionnaire.8

In their study, Japanese consistently endorsed 2 questionsabout the loss of positive attitude, distorting the numberof persons who actually had depression. Cole and col-leagues, in their examination of question bias in the Cen-ter for Epidemiological Studies Depression scale, identi-fied the potential for biased scores in African Americansbecause of their positive responses to question 14, “peopleunfriendly,” and question 19, “people disliked me,” whichthey associated with their participants’ perceptions of racialprejudice rather than the presence of depression.9

Semantically different translations of depressionscreening questions may decrease the specificity of scoresand increase false-positive identifications of the presence ofdepression. Scores may give the impression that morepeople have depression than actually do, thereby limitingthe reliability of screening tools. Given these findings, it

Questions in a Spanish translation of the BeckDepression Inventory that bias Latinodepression scores

Highly likely to endorse (score 3)• Question 6

I don’t feel I am being punished (score 0)I feel I may be punished (score 1)I expect to be punished (score 2)I feel I am being punished (score 3)

• Question 10I don’t cry any more than usual (score 0)I cry more now than I used to (score 1)I cry all the time now (score 2)I used to be able to cry, but now I can’t cry eventhough I want to (score 3)

• Question 14I don’t feel that I look any worse than I used to(score 0)

I am worried that I am looking old or unattractive(score 1)

I feel that there are permanent changes in myappearance that make me look unattractive(score 2)

I believe that I look ugly (score 3)

Highly unlikely to endorse (score 0)• Question 15

I can work about as well as before (score 0)It takes an extra effort to get started at doingsomething (score 1)

I have to push myself very hard to do anything(score 2)

I can’t do any work at all (score 3)

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would be prudent for primary care physicians to use self-reporting depression screening tools to identify the needfor further evaluation rather than to actually diagnose de-pression itself.7

Gender bias in screening toolsIt is estimated that twice as many women as men arediagnosed with depressive disorders.10 Social norms forboth the expression and interpretation of depression arereflected in the Beck Depression Inventory’s terms, whichscreens for symptoms of depression stereotypically associ-ated with female gender norms rather than male gendernorms (eg, guilt, crying, indecisiveness, somatic preoccu-pation, and loss of libido). One outcome of this bias is ahigh rate of false-positive diagnoses for women.2,4 Thisgreater number of false-positives suggests that the inven-tory should be used primarily as an indicator of the needfor further clinical evaluation.

Social norms may contribute to the implicit prohibi-tion of certain self-descriptive terms depending on a pa-tient’s gender. This may influence whether a patient’ssymptoms will result in a diagnosis of depression. Menmay not perceive themselves, or be perceived, as depressedif their sex role prohibits them from using conventional

terms to describe emotional problems. This might be anobstacle to using standard screening methods for depres-sion in men.

DEPRESSION OCCURRING WITHSOMATIC COMPLAINTSPhysicians sometimes miss diagnosing depression whensomatic symptoms are the patient’s major complaints. So-matic complaints and psychological symptoms of de-pression often occur together. This relationship is not al-ways represented by the questions of depression screeningtools. Like the Beck Depression Inventory, most depres-sion questionnaires screen primarily for emotional symp-toms.11 When self-reporting tools screen for somaticcomplaints, they often identify nonspecific physical symp-toms that may also be found in patients who are notdepressed.3,5,7,12

Inaccurate measures may be attributed in part to howscreening tools are designed to test for major depressivedisorder. Depression is a syndrome with varied causes,some of which present with specific somatic complaints.Successful diagnosis and treatment (or referral) may bebest achieved in primary care through comprehensivescreening for all depressive disorders, rather than only formajor depressive disorder. Such a screening tool wouldmeasure comprehensively for depressive disorders listed inthe Diagnostic and Statistical Manual of Mental Disorders,4th Edition (DSM-IV) (see box).13 This tool would ex-pand the recognition of depressive disorders to includedepression that goes undetected because patients’ symp-toms are not typical of a major depressive disorder. Itwould also increase the recognition of depression in pa-tients who have few or no emotional symptoms but manysomatic ones (see box on next page).

The Patient Health Questionnaire could provide thefoundation for an examination of depression as a syn-drome, although further research is needed to determineits validity and reliability in cross-cultural settings.7 Thequestionnaire, derived from the clinician-administered

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Gender bias in screening tools may lead to overdiagnosis of depressionin women

Depressive disorders that should be picked up bya screening tool for depression

• Major depressive disorder

• Chronic depressive disorder

• Dysthymic disorder

• Adjustment disorder with depressed mood

• Adjustment disorder with anxiety and depressed mood

• Atypical depressive disorder

• Melancholia• Postpartum depressive disorder

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Primary Care Evaluation of Mental Disorders, was devel-oped to detect mental disorders in primary care patients.The long form of the questionnaire screens for 8 men-tal disorders, including major depressive disorder, an-xiety disorder, and depressive disorders not otherwisespecified.14 A short form is included in the DepressionManagement Kit available as part of the MacArthur Ini-tiative on Depression & Primary Care (www.depression-primarycare.org). By asking yes-or-no questions, primarycare physicians could elaborate on the results of the PatientHealth Questionnaire, thereby providing a more thor-ough examination for the presence of depression.

For example, consider the possibility of a patient whohas atypical depression. The DSM-IV gives the followingcriteria for atypical depression: significant weight gain orincrease in appetite, hypersomnia, leaden paralysis (ie,heavy, leaden feelings in arms or legs), and extreme sen-sitivity to perceived interpersonal rejection that often re-sults in angry outbursts. The following questions couldprovide the basis for an evaluation of atypical depressivedisorder: “Are you eating more but not really enjoyingyour food?” “Are you sleeping longer than usual?” “Doyour arms and your legs feel leaden and heavy?” “Haveyou become more sensitive to criticism?” “Do you havemore (than usual) displays of anger?”

CONCLUSIONComprehensive self-reporting tools are needed to help pri-mary care physicians screen for both the psychological andsomatic symptoms of depression. Ideally, such a screeningtool would be useful in the routine examination of allpatients, although whether it should be used on all pa-tients during every consultation remains unclear.12 Ques-tionnaire scores could contribute to the detection of de-pression and inform primary care physicians about thegeneral health of their patients. An ideal screening tool

would assess the possibility of depression even in a patientpresenting primarily with somatic symptoms.

The reliability of a depression screening tool is affectedby patients’ interpretation of its emotional terms and theircultural conception of depression. Primary care physi-cians’ familiarity with the terms that their patients use todescribe emotional problems, as well as how relevantquestions are in determining a patient’s mental state,could assist in the identification of depression in diversepopulations.

Regardless of the limitations of self-reported depres-sion screening tools, it is better to use them to screen fordepression than risk missing patients who are sufferingfrom a depressive disorder. Nevertheless, primary carephysicians should remember that diagnoses should notbe based solely on the findings of depression screeningquestionnaires.

Acknowledgment: Gus M Garmel assisted with research and providededitorial suggestions.

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References

1 World Health Organization. Mental Health and Brain Disorders: WhatIs Depression? www.who.int/mental_health/Topic_Depression/depression1.htm. Accessed August 10, 2001.

2 National DMDA anticipate health care trends. Newsletter of theNational Depressive and Manic Depressive Association 1998 Summer, p 1.

3 Callahan EJ, Bertakis KD, Azari R, Helms LJ, Robbins J, Miller J.Depression in primary care: patient factors that influence recognition.Fam Med 1997;29:172-176.

4 Richter P, Werner J, Heerlein A, Kraus A, Sauer H. On the validity ofthe Beck Depression Inventory: a review. Psychopathology1998;31:160-168.

5 Beck AT. Depression: Causes and Treatment. Philadelphia: University ofPennsylvania Press; 1967:333-335.

6 Leentjens AF, Verhey FR, Luijckx GJ, Troost J. The validity of theBeck Depression Inventory as a screening and diagnostic instrument fordepression in patients with Parkinson’s disease. Mov Disord2000;15:1221-1224.

7 Azocar F, Arean P, Miranda J, Munoz RF. Differential itemfunctioning in a Spanish translation of the Beck Depression Inventory.J Clin Psychol 2001;57:355-365.

8 Iwata N, Uno B, Suzuki T. Psychometric properties of the 30-itemversion general health questionnaire in Japanese. Jpn J Psychiatry Neurol1994;48:547-556.

9 Cole SR, Kawachi I, Maller SJ, Berkman LF. Test of item-response biasin the CES-D scale: experience from the New Haven EPESE Study. JClin Epidemiol 2000;53:285-289.

10 Juliano D. Depression: What Every Woman Should Know. Bethesda,MD: National Institute of Mental Health. NIH publication 95-3871.

11 Beck AT, Guth D, Steer RA, Ball R. Screening for major depressiondisorders in medical inpatients with the Beck Depression Inventory forPrimary Care. Behav Res Ther 1997;35:785-791.

12 Volk RJ, Nease DE Jr, Cass AR. Recognition of mental healthproblems in primary care practices. Fam Med 1997;29:182-183.

13 American Psychiatric Association. Diagnostic and Statistical Manual ofMental Disorders, 4th Edition. Washington, DC: American PsychiatricAssociation; 1994:317-391.

14 Spitzer RL, Kroenke K, Williams JBW. Validation and utility of aself-report version of PRIME-MD: the PHQ primary care study.Primary Care Evaluation of Mental Disorders. Patient HealthQuestionnaire. JAMA 1999;282:1737-1744.

Somatic symptoms that sometimes presentwith depression

• Headache, migraines

• Sexual dysfunction

• Appetite changes

• Menstrual-related symptoms

• Chronic pain• Chronic medical conditions (eg, diabetes, Parkinson’sdisease, alcoholism)

• Digestive problems (eg, diarrhea, constipation)

• Fatigue• Sleep disturbances

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