National Depression Screening Day (NDSD) is October 9, 2003.

The HANDS™ Depression Screening Tool

Impetus for Development of the HANDS^TM

Clinical depression is a highly prevalent illness. Studies indicate that between 17 and 20 million Americans may suffer from depression during the course of a year. ^1,2 Internationally, depression is an illness of tremendous cost. The World Health Organization’s Global Burden of Disease study revealed that clinical depression will be the second most burdensome illness in the world by the year 2020. ³ In addition to long-lasting disability, depression is associated with significant mortality through suicide, medical illness, and increased risk of accidental death.^4,5,6,7

Despite this tremendous prevalence, morbidity, and mortality, depression is underdiagnosed and undertreated. The reasons for this are varied and complex, but include stigma and denial, ignorance of symptomatology, uncertainty as to where or how to seek help, lack of insurance and/or treatment resources, lack of or miscommunication between patient and caregiver, and misdiagnosis. Public education campaigns, such as National Depression Screening Day^8,9 (initiated as part of the American Psychiatric Association’s Mental Illness Awareness Week), the National Institute of Mental Health’s Depression, Awareness, Recognition and Treatment (D/ART) program¹⁰ and the Campaign on Clinical Depression spearheaded by the National Mental Health Association, have worked to address some of these issues by providing accurate information about signs, symptoms, and treatments to both the public and health professionals. It is clear, however, that additional work needs to be done.

One area in which greater strides can be made is to increase the number of people screened for depression.

Purpose of the HANDS^TM

The HANDS is designed to be a brief, easy-to-score, self-report depression screening scale applicable to a variety of settings, that performs at least as well as longer, more complicated scales, and addresses the critical issues of sensitivity and specificity (probabilities of false-negatives and false-positives). The HANDS has been validated for detecting the likelihood of clinical depression based on criteria for a major depressive episode from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).¹¹

The HANDS addresses how likely the respondent is to be suffering from depression ranging from not likely to very likely. Comparisons with other scales, however, indicate that these categories are roughly equivalent to no symptomatology, mild to moderate symptomatology, and moderate to severe symptomatology.

Scale Development

The 10 items comprising the scale were derived from a pool of questions from a large number of existing rating scales for depression. The final items included in the HANDS were selected using the modern test construction method called “item response theory”¹² (IRT) which produces a unitary scale with the fewest necessary items.

Specifically, the HANDS was developed and tested in two studies of adults, ages 18-75. In Study 1, we wanted to recruit a general audience comprised of depressed and non-depressed people. We placed two ads, one recruiting depressed subjects, the other non-depressed subjects. We administered the Structured Clinical Interview for DSM-IV¹³ (SCID) to qualified respondents to confirm the presence or absence of major depressive episode. Those who answered the ‘depressed’ ad and were found to be depressed by SCID (N=40) and those who answered the ‘normal’ ad and were found not to be depressed by SCID (N=55) were accepted into the study. We administered a pool of 70 items, generated from a compilation of existing screening questionnaires, and were thus able to reduce our pool of items to 19 by eliminating harder-to- understand items and combining redundant items.

In Study 2, we wanted to simulate the self-selected population that attends National Depression Screening Day. We placed an ad with language similar to those ads used to publicize National Depression Screening Day and recruited 45 subjects. We administered the 19 items from Study 1, along with the 21-item Beck Depression Inventory, Second Edition (BDI-2)¹⁴, the 20-item Zung Self-Rating Depression Scale¹⁵, the 15-item Hopkins Symptom Checklist¹⁶, and the 25-item modified Composite International Diagnostic Interview (CIDI-Short Form)¹⁷ to all 45 subjects, without knowing whether or not any of these subjects truly were depressed by DSM-IV criteria. Later, 29 of these subjects were found to be depressed by SCID . Utilizing these results and guided by IRT analysis and clinical judgment, we then selected the 10-item scale which best identified depression in this self-selected group.¹²

We then retrospectively calculated a score for each subject in Study 1 on this 10-item scale (which we named the HANDS) and examined the validity statistics, which compared favorably with longer scales, and supported the HANDS utility in screening a general audience as well as a self-selected one.

Depending upon the population being assessed by the HANDS, the various cutoff scores have slightly different diagnostic implications, and can be used to maximize sensitivity or specificity, depending on the particular application. Sensitivity refers to the ability of the scale to correctly detect individuals who are truly depressed and to minimize the chance of incorrectly categorizing someone as not depressed (i.e., false-negatives). Specificity refers to the ability of the scale to rule out those individuals who are truly not depressed (i.e., false-positives).

Our statistical analysis found that a cutoff total score of 9 points or more performed well, both in a general and self-selected population.

These statistics indicate that for a general audience, a cutoff total score of 9 or more correctly detected 95% of those who met DSM-IV criteria for major depressive episode, and correctly ruled out 94% of those who did not meet criteria. For the self-selected population, a cutoff total score of 9 points or more correctly detected 93% of those who met DSM-IV criteria for major depressive episode, and correctly ruled out 64% of those who did not meet criteria. (This is because some of the individuals scoring above a cutoff total score of 9 points or more did not meet criteria for major depressive episode, but did meet criteria for one or more anxiety disorders with depressive features.) No other scale we tested had higher sensitivity or specificity in the self-selected sample of Study 2. If a clinician has a particular concern about specificity, in a desire to minimize false positives, a higher cutoff score is recommended. A score of 17 or greater on the HANDS improved specificity in Study 2 to 100%, but it decreased sensitivity to 41%.

The HANDS has good internal consistency, as shown by its coefficient Alpha of .87, and the median correlation of each item with the total score (minus that item) was .61, with a range of
0.37 (suicide item) to 0.83 (been feeling blue?).

For the purpose of validating this scale, the authors and consultants agreed on an operational definition of “clinical depression” as the presence of what is termed in the DSM-IV as a “major depressive episode.”¹¹ According to the DSM-IV, individuals who meet criteria for a major depressive episode are considered to have a major mood disorder, probably requiring treatment, regardless of whether the precise diagnosis is determined to be major depressive episode, bipolar depressive disorder, or depressive disorder caused by organic factors.

References

1. Regier D, Narrow W, Rae DS, et al. The de Facto US Mental and Addictive Disorders Service System: Epidemiologic Catchment Area Prospective 1-Year Prevalence Rates of Disorders and Services. Arch of Gen Psychiatry, 85-94.
2. Kessler RC, McGonagale KA, et al., Lifetime and 12-Month Prevalence of DSM-III-R Psychiatric Disorders in the United States: Results from the National Comorbidity Survey. Arch Gen Psychiatry, Jan., 1994, 8-19.
3. Murray CJ, Lopez AD. The Global Burden of Disease: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Harvard School of Public Health on behalf of the World Health Organization. Harvard University Press, Cambridge, MA.
4. Fawcett, J (1993). The morbidity and mortality of clinical depression. International Clinical Psychopharmacology, 8: 217-220.
5. Sims, ACP (1988). The mortality associated with depression. International Clinical Psychopharmacology, 3: 1-13.
6. Wells KB, Steward A, Hays, RD et al. (1989). The functioning and well-being of depressed patients. Results from the medical outcomes study. JAMA, 262: 914-919.
7. Murphy JM, Monson RR, Olivier DC, Sobol MA, Leighton AH: Affective disorders and mortality: a general population study. Arch Gen Psychiatry, 1987; 44:473-480.
8. Magruder KM, Norquist GS, et al. (1995). Who comes to a voluntary depression screening program? Am J Psychiatry, 152: 1615-1622.
9. Greenfield SF, Reizes JM, et al. (1997). Effectiveness of community-based screening for depression. Am J Psychiatry, 154: 1391-1397.
10. Regier DA, Hirschfeld R, et al. (1988). The NIMH depression awareness, recognition, and treatment program: structure, aims and scientific basis. Am J Psychiatry, 145: 1351-1357.
11. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association.
12. Baer L, Jacobs D, Blais M, et al (1998). Development of a brief screening instrument—the HANDS. Submitted manuscript.
13. First MB, Spitzer RL, Gibbon M, Williams JBW (1995). Structured Clinical Interview for DSM-IV Axis I Disorders – Patient Edition (SCID-I-P, Version 2.0). New York: Biometrics Research Dept., New York State Psychiatric Institute.
14. Beck AT, Steer RA, Brown GK (1996). Beck Depression Inventory -Second Edition: Manual. San Antonio, TX: The Psychological Corporation.
15. Zung WWK (1965). A self-rating depression scale. Arch Gen Psychiatry, 12: 63-70.
16. Derogatis LR, Lipman RS, Rickels K, Uhlenhuth EH, Covi L (1974). The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory. Behav Sci, 19:1-15.
17. World Health Organization (1990). Composite International Diagnostic Interview, Version 1.0. Geneva: World Health Organization.

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