Hemodialysis International 2012; 16:207213

Beck Depression Inventory-Fast Screen

(BDI-FS): An efcient tool for depression
screening in patients with end-stage
renal disease
Andrea NEITZER,1 Sumi SUN,1 Sheila DOSS,1 John MORAN,1,2 Brigitte SCHILLER1,2
1

Satellite Healthcare, San Jose, California, USA; 2Division of Nephrology, Stanford University School of
Medicine, Palo Alto, California, USA

Abstract
Depression is common in patients suffering from end-stage renal disease (ESRD). Various screening
tools for depression in ESRD patients are available. This study aimed to validate the Beck Depression Inventory-Fast Screen (BDI-FS) with the Beck Depression Inventory-II (BDI-II) as depression
screening tool in conventional hemodialysis (CHD) patients. One hundred sixty two CHD patients
were studied with both screening questionnaires. We used the Pearson Correlation Coefcient to
measure the agreement between BDI-II and BDI-FS scores from 134 patients who responded to both
questionnaires. Receiver operating characteristics curve and area under the curve were constructed
to determine a valid BDI-FS cutoff score to identify ESRD patients at risk for depression. BDI-II and
BDI-FS scores strongly correlated (Pearson r = 0.85, p < 0.0001). At a BDI-II cutoff 16, receiver
operating characteristics showed the best balance between sensitivity and specicity for the BDI-FS
cutoff value of 4 with a sensitivity of 97.2% (95% condence interval [CI]: 85.5%, 99.9%) and a
specicity of 91.8% (95% CI: 84.5%, 96.4%). When applying the above cutoff scores, prevalence of
depressive symptoms in all completed questionnaires was found to be 28.7% (BDI-II) and 30.1%
(BDI-FS), respectively. The BDI-FS was found to be an efcient and effective tool for depression
screening in ESRD patients which can be easily implemented in routine dialysis care.
Key words: Depression screening, end-stage renal disease, hemodialysis, Beck Depression
Inventory

INTRODUCTION
Depression has been recognized to be among the most
common psychological disorders in end-stage renal
disease (ESRD) patients.1,2 Recent investigations suggest
that 2030% of the maintenance dialysis population in
the United States and Europe is affected by depression.35
Depressive symptoms and the psychological effects of
Correspondence to: A. Neitzer, MSD, Satellite Healthcare,
300 Santana Row, Suite 300, San Jose, CA 95128, USA.
E-mail: neitzera@satellitehealth.com

depression are strongly associated with increased hospitalization rates, impaired medical outcomes, and
mortality.68
Prevalence estimates vary depending on the populations under investigation and/or the different depression
screening tools applied. This paper focuses on the latter
and attempts to make a recommendation for a routine
depression screening tool in ESRD patients, based on the
comparison of two commonly used tools.
An instrument frequently used to screen for depression
in ESRD patients is the Beck Depression Inventory-Second
Edition (BDI-II). Previous studies on depressive disorders

2012 Satellite Healthcare, Inc.

Hemodialysis International 2012 International Society for Hemodialysis
DOI:10.1111/j.1542-4758.2012.00663.x

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Neitzer et al.

in this patient population have validated a cutoff score of

16 or greater.9,10 The BDI-II is a 21-item self-report instrument that screens for the severity of depression corresponding to psychological and somatic symptoms.11
However, uremia and other symptoms of inadequate
dialysis such as anorexia, sleep disturbance, fatigue, gastrointestinal disorder, and pain can overlap with the
somatic symptoms of depression.12 This can complicate
the diagnosis of major depression in ESRD patients, and
BDI-II results should be interpreted with caution.2
To measure the severity of depression that corresponds
to nonsomatic criteria, the Beck Depression Inventory
Fast-Screen for Medical Patients (BDI-FS), formerly
known as the Beck Depression Inventory for Primary
Care, was developed.13 It extracts the seven nonsomatic
symptoms from the BDI-II (sadness, pessimism, fast
failure, loss of pleasure, self-dislike, self-criticalness, and
suicidal thoughts or wishes) and reduces patient burden
because of its faster administration. Previous research has
tested the BDI-FS in multiple sclerosis,14 geriatric
primary-care patients,15 and compared the BDI-FS to the
BDI-II in patients with chronic pain.16 However, to date
the BDI-FS has not been validated as a screen for depression in patients with chronic kidney disease (CKD) or
ESRD, and the question for the appropriate cutoff score
for a renal population remains open. The objectives of our
study were to measure the prevalence of depressive symptoms in our in-center hemodialysis (HD) patients with
both the BDI-II and the BDI-FS, to test the agreement
between both depression screening tools, and to determine a reliable BDI-FS cutoff score for patients with
ESRD.

MATERIALS AND METHODS

A cross-sectional sample of 317 patients on conventional
hemodialysis (CHD) in 20 outpatient units (15 in California, five in Texas) was approached for this study. Patients
were English or Spanish speaking, at least 18 years old,
and were due in April to June 2009 for their 90 days or
yearly Kidney Disease Quality Of Life-36 (KDQOL-SF36)
assessment required by the new Conditions for Coverage.
All patients were invited to complete the BDI-II and the
BDI-FS during their HD treatment. Order of completion
was not specified. Questionnaires with 50% or more of the
questions left blank were considered incomplete and
excluded.
The BDI-II is a 21-item self-report case-finding screening tool assessing various degrees of depressive symptoms.11 It was developed for the evaluation of symptoms
corresponding to criteria for diagnosing depressive dis-

208

orders listed in the American Psychiatric Associations

Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, DSM-IV.17 Each item is rated on a 4-point
scale from 0 to 3, with a maximum total score of 63.
Higher scores indicate more severe depressive symptoms.
It takes 510 minutes to complete, and has been widely
used to screen for depression in patients with CKD
and ESRD. Based on previous studies, we classified
patients with a BDI-II score 16 as being in risk for
depression.9,10
The BDI-FS is an extract from the 21-item BDI-II13 with
only seven items and requires less than 5 minutes for
completion. Scoring is similar to the BDI-II. The BDI-FS
was developed specifically for evaluating depression in
patients whose behavioral and somatic symptoms are
attributable to biological, medical, alcohol, and/or substance abuse problems that may confound the diagnosis of
depression. It was constructed to reduce the number of
false positives for depression in patients with these problems, and measures the degree of depressive symptoms
that corresponds to the psychological or nonsomatic criteria for diagnosing major depression disorders as listed in
the DSM-IV.

Statistical methods
Patient information on gender, race, diabetic status, and
length of time on dialysis was retrieved from our internal
patient database. All other information was collected from
the completed survey tools. Patient demographics and
score on the BDI-II and BDI-FS were described by proportion (percentage) and mean (standard deviation,
SD). The Pearson correlation coefficient was used to
measure the agreement between BDI-II and BDI-FS scores.
The BDI-FS was validated against the BDI-II cutoff score
16 as the standard. In order to determine a BDI-FS
cutoff score valid for identifying ESRD patients at risk for
depression, the receiver operating characteristic (ROC)
curve and area under the curve (AUC) was constructed.
We further calculated the concordance and discordance
between the score results of both BDIs. T-test and chisquare test were used to compare means and proportions,
respectively. For all analysis two-tailed P value < 0.05 was
considered significant. SAS version 9.1 (SAS Institute,
Cary, NC, or http://www.sas.com) was used to conduct the
statistical analyses.

RESULTS
A total of 162 CHD patients returned at least one of the
BDIs, the remaining 155 patients did not answer any of

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Depression screening in dialysis

Table 1 Patient characteristics (n = 134)

Characteristics
Male, %
52
Mean age, y (SD)
59.1 14.7
Race, %
White
60
Black
22
Asian
13
Other
4
Years on dialysis, %
<1
10
15
71
610
16
>10
3
Median time on dialysis, months (range) 27.5 (2.9252.2)

the two questionnaires. Of those 162 patients, 150

patients answered the BDI-II, and 146 answered the BDIFS. Both survey tools were returned by 134 patients,
resulting in a response rate of 42%. Demographic data
from those 134 patients were as follows: The participants
ages ranged from 21 to 87 years (mean: 59.1 14.7). The
majority (52%) was diabetic, and 98.5% of our patient
sample was on dialysis for 90 days or longer. Other patient
characteristics are summarized in Table 1. Average scores
for the BDI-II (n = 150) and the BDI-FS (n = 146) were
12.3 10.8 and 2.7 3.4, respectively. Total BDI-II and

BDI-FS scores demonstrated a strong positive linear

correlation (Pearson r = 0.85, p < 0.0001, (n = 134) as
shown in Figure 1.
The ROC analysis with a BDI-II cutoff 16 as the gold
standard revealed the best balance between sensitivity
(true positive rate) and specificity (true negative rate) for
the BDI-FS at a cutoff value of 4 (Figure 2). At this
cutoff, BDI-FS results had a sensitivity of 97.2% (95% CI:
85.5%, 99.9%) and a specificity of 91.8% (95% CI:
84.5%, 96.4%). The positive predictive value (PPV) was
81.4%, and the negative predictive value (NPV) was
98.9%. Concordance for both BDIs was found to be
93.3% (125/134 patients), while discordance was only
6.7% (9/134 patients), summarized in Table 2. We calculated the AUC as 0.982, indicating that the BDI-FS had a
high predictive accuracy vs. the gold standard to correctly
classify patients with and without the prevalence of
depressive symptoms.
BDI-II scores 16 and BDI-FS scores 4 were found
in 28.7% and 30.1% of our study participants, respectively. These patients were significantly younger compared to patients not classified as being at risk for
depression. Except for age, no significant differences for
gender, race, vintage, or prevalence of diabetes were
found between these groups (Table 3). Of note was the
observation that, of those patients who completed the
BDI-FS but did not answer at least half of the questions
on the BDI-II, over 80% missed the questions on the

Figure 1 Correlation between BDI-II and BDI-FS total scores.

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Neitzer et al.

Figure 2 Receiver/Responder Operating Characteristic (ROC) curve to assess a reliable cutoff value for BDI-FS (with BDIII 16 as standard).

reverse side of the BDI-II but answered the majority or all

of the questions on the front side. These patients were
significantly older (p < 0.05) compared to patients who
answered the complete BDI-II. Patients who did not

complete the BDI-FS but had answered the BDI-II were

significantly younger (p < 0.001). Table 4 shows the
mean age for patients who completed and those who did
not complete the BDIs.

Table 2 Agreement between BDI-II (cutoff 16) and BDI-FS (cutoff 4)

BDI-II
16

<16

Total (n)

35 (26.1%)

8 (6.0%)

43 (32.1%)

<4

1 (0.7%)

90 (67.2%)

91 (67.9%)

36 (26.9%)
Sensitivity = 35/36 (97.2%)

98 (73.1%)
Specificity = 90/98 (91.8%)

BDI-FS

Total

Positive predictive
value = 35/43 (81.4%)
Negative predictive
value = 90/91 (98.9%)

Table 3 Patient characteristics according to depression indicators

BDI-II
Mean age, y (SD)
Male, %
Race, %
White
Black
Asian
Others
Diabetic, %
Mean time on dialysis, months (SD)

BDI-FS

<16 (n = 107)

16 (n = 43)

<4 (n = 102)

4 (n = 44)

60.4 15.0
55.1

50.4 13.8
58.1

62.1 14.5
52.0

54.4 14.0b
61.4

59.8
18.7
15.0
6.5
55.1
44.8 43.6

69.8
23.3
2.3
4.7
39.5
44.9 33.8

56.9
20.6
16.7
5.9
54.9
43.4 44.3

68.2
22.7
4.6
4.6
47.7
44.0 33.1

p < 0.001, bp < 0.01.

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Depression screening in dialysis

Table 4 Mean age (years) of patients who completed and those who did not complete the BDI depression screening tools

Questionnaires

Completed

Not completed

Mean age, y (SD), range

Mean age, y (SD), range

57.5 (15.3), 2187

59.8 (14.8), 2187

67.8 (13.8)a, 4287

44.5 (14.2)b, 2472

BDI-II
BDI-FS

BDI-II completed (n = 150), BDI-II not completed (n = 12); BDI-FS completed (n = 146), BDI-FS not completed (n = 16).
a
p < 0.05, bp < 0.001.

DISCUSSION
We found a strong correlation between BDI-II and BDI-FS
questionnaires in the evaluation for depression when
administering both questionnaires simultaneously to
patients undergoing HD.
Our data suggest that a BDI-FS cutoff 4 identifies
ESRD patients at risk for depression. Applying this cutoff
to our patient sample reveals a prevalence of depressive
symptoms of about 30%. This confirms prior data for the
estimated prevalence of depression and depressive symptoms in patients on dialysis in the Unites States and
Europe.35 In agreement with previous research,18 we also
found dialysis patients at risk for depression to be younger
than those patients without depressive symptoms. Concerns that in ESRD patients the BDI-II may overestimate
the risk of depression due to various questions related to
somatic symptoms frequently seen in patients undergoing
HD including fatigue, insomnia, and loss of appetite were
not confirmed in our study.
However, screening for depression needs to be distinguished from diagnosing depression, and it is a limitation of this study that we did not perform psychological
interviews with those patients at risk of depression in
order to confirm or reject the diagnosis. Also the response
bias of self-report inventories needs consideration. While
these tools reflect subjective perception of the patients
well-being, they contain valuable information and metrics
for patient assessment, however without a clear diagnosis.
Hedayati et al.5,19 confirmed that self-report questionnaires such as the BDI-II should not be used for a clinical
diagnosis of depression in CKD or ESRD patients but that
they performed well as screening tools.
The implementation of a framework for systematic
depression screening in a dialysis facility and a depression
treatment algorithm for ESRD patients has been advocated
but has also proven to be challenging.20 Nephrologists
might correctly argue that the therapy of depression is not
part of their area of expertise, and they often do not feel
comfortable treating depression. Furthermore, it is not
known whether treatment of depression impacts the outcomes of ESRD patients as randomized clinical trials are

Hemodialysis International 2012; 16:207213

missing. Although the prevalence of depressive symptoms

was found to be very common in the incident dialysis
patient,21 there are no data available indicating when to
start screening patients with ESRD for depression.
However, considering the high prevalence of depression
in ESRD patients and the negative impact on medical
outcomes, hospitalization rate, and mortality in this population, including depression screening in routine ESRD
patient care is likely to add benefits and should therefore
lead to more insistent effort also from the nephrologists
side. Data from the Following Rehabilitation, Economics
and Everyday-Dialysis Outcomes Measurements study
recently revealed a significant improvement in BDI-II
scores in patients treated with daily (six times per week)
home HD over 12 months.22 Moreover, the Frequent
Hemodialysis Network trial comparing more frequent
center dialysis therapy to conventional thrice-weekly
dialysis showed a decrease in the BDI-II score from
12.6 8.7 to 10.4 8.5 in the daily group after 12
months. Although not statistically significant this is a
notable finding given the extra burden of dialysis with
daily therapy.23
From a patients perspective, a diagnosis of depression
is often still understood as a stigma, and affected patients
might tend to deny depression-related symptoms. Kleinman has shown that many depressed Chinese patients
found a diagnosis of depression morally unacceptable.24
Furthermore, resistance to the diagnosis of depression is
evident from studies showing that 55% of PD patients
suggested by the BDI-II as being depressed refused
further assessment to confirm or rule out the diagnosis of
major depression. Of those patients diagnosed with
major depression by psychological evaluation, only half
successfully completed 12 weeks of pharmacologic
therapy.4 Patients need to be educated to understand that
depression is a serious medical illness that impairs
quality of life and even survival, and therefore should be
seriously considered to be part of a patient-centered
ESRD care approach. With ESRD patients affected by
depression being younger than patients without depressive symptoms, attention to symptoms appears even
more critical, as ESRD and the burden of dialysis may

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present a greater disruption of work and social life in

younger patients.25
We conclude that a routine depression screening
program in ESRD patients needs to be efficient and costeffective in order to have chances of success. It should be
well accepted by ESRD patients, practical, and easily
administered for the caretakers considering the growing
demands in dialysis units because of the increasingly older
and multi-morbid population. In this regard, the BDI-FS
is a promising tool. It is one-sided, without risk of patients
accidentally skipping questions on the reverse side of the
questionnaire. Our study showed that patients with an
incomplete questionnaire were significantly older, suggesting that the BDI-FS would be more suitable for these
patients. Its completion takes less than 5 minutes and
therefore causes little burden for the patients to complete
and for the staff to evaluate. Furthermore, it focuses on
nonsomatic indicators rather than on physical symptoms
that might overlap with complaints due to uremia or
dialysis-associated adverse events. Although administration and scoring may be easy, it is recommended that the
BDI-FS should be interpreted only by professionals with
appropriate clinical training and experience.13
With the BDI-FS in hand, ESRD patients could systematically be screened for depression with an easy and reproducible questionnaire, allowing for trending over time. In
accordance with the increasing focus on quality of life as a
metric for outcome in ESRD, this tool will allow the multidisciplinary care team to focus on patients at risk who
will likely benefit from psychosocial intervention. Moreover, it may help to develop algorithms for the more
integrated ESRD care model of the future and to increase
the patients quality of life.
Manuscript received September 2011; revised November
2011.

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