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C HAP TE R 33 / Psychosocial Risk Factors: Assessment and Management Interventions 773

symptoms present at least more than half the days in the past
Table 33-2 ■ TWO-ITEM INSTRUMENT— 2 weeks: in addition, one of the symptoms has to be depressed
DEPRESSION SCREEN mood or anhedonia.
4. The Beck Depression Inventory: This frequently used, 21-
During the past month, have you often been bothered 104
by . . . question self-report scale has been recommended for epi-
1. Little interest or pleasure in doing things? Yes No demiological studies of CHD patients. 33 Response scores for
2. Feeling down, depressed, or hopeless? Yes No this first version, valid and reliable tool 105 can range from 0 to
63. A person who scores between 10 and 18 is considered
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Adapted from McManus, D., Pipkin, S. S., & Whooley, M. A. (2005). Screening for mildly depressed, between 19 and 29 moderately depressed, and
depression in patients with coronary heart disease. (Data from the Heart and Soul more than 30 severely depressed.
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Study.) American Journal of Cardiology, 96, 1076–1081.
Although there are some good choices for brief screening tools
available, a recent advisory statement by the American Heart As-
given their extensive contact with cardiac patients, are in a pivotal sociation has recommendations about the choice of screening in-
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role to recognize or screen for depression. Several brief and reliable struments for depression in CHD patients. Lichtman et al.
screening tools for clinical purposes can be used by nurses to iden- recommend the use of the two-item instrument followed by the
tify patients at high risk for depression: Patient Health Questionnaire-9, if one of the items on the two-
item instrument meets criteria for depression.
1. The two-item instrument: This screening tool (Table 33-2)
based on the Patient Health Questionnaire is a two-item in- Screening for Low-Perceived
strument about depressed mood and anhedonia with yes/no Social Support
responses and a higher sensitivity to identifying major depres-
sion. 100,101 The symptom duration is for a month. If no is the The ENRICHD Social Support Instrument, a seven-item, five-
response to both questions, a patient is unlikely to have major point Likert scale (Table 33-4), is based on several other social
depression. If yes is the answer to either question, a follow-up support scales that are predictive of mortality. 107,108 This self-
clinical interview is recommended. report instrument has items that assess for different types of sup-
2. The Patient Health Questionnaire-2: The Patient Health Ques- port including structural, instrumental, and emotional support
tionnaire-2 102 is a two-item depressive symptom subscale of a and takes about 5 minutes to complete. The criteria for low-per-
longer version, Patient Health Questionnaire-9 described be- ceived social support are based on five of the seven items (i.e.,
low (Table 33-3). The two items assess depressed mood and items 1, 2, 3, 5, and 6). The criteria are met if a score is less than
anhedonia. The symptom duration is for 2 weeks and the cut- or equal to 2 on at least two of the five items and a total score of
off score is 3 or more with a score range of 0 to 6. This is a very less than 18. This tool can also be used for further clarification
suitable tool for quick and reliable screening. about a patient’s social support system.
3. The Patient Health Questionnaire-9: The Patient Health Ques- Timing the assessment of social support is crucial. Most indi-
tionnaire-9 is a self-report instrument 103 of nine items based viduals who are admitted to the hospital experience an atypical
on DSM-IV criteria with four possible responses ranging from outpouring of support as family and friends respond to the crisis.
0 to 3 on each item (Table 33-3). The diagnosis of major de- Support can be more realistically assessed following discharge
pression is based on the presence of five or more of the nine from the hospital. 109 Because people with few social ties and little

Table 33-3 ■ PATIENT HEALTH QUESTIONNAIRE-9: DEPRESSION MODULE

More than Half Nearly
Over the Past 2 Weeks, how Often have you been Bothered Not at All Several Days the Days Every Day
by any of the Following Problems? 0 1 2 3
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself—or that you are a failure or have let yourself
or your family down
7. Trouble concentrating on things, such as reading the newspaper or
watching television
8. Moving or speaking so slowly that other people could have noticed; or
the opposite—being so fidgety or restless that you have been moving
around a lot more than usual
9. Thoughts that you would be better off dead or hurting yourself in some way
If you checked off any problems on this questionnaire so far, how difficult Not difficult Somewhat Very difficult Extremely
have these problems made it for you to complete your work, take care of difficult difficult
things at home, or get along with other people?

Permission obtained from Pfizer. Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal
Medicine, 16, 606–613.
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