Validation of a Depression
Screening Measure for Stroke
Inpatients
Bruce Rybarczyk, Ph.D., David R. Winemiller, Ph.D.,
Lawrence W. Lazarus, M.D., Allyson Haut, Ph.D.,
Carolyn Hartman, M.D.
The Stroke Inpatient Depression Inventory (SID/) was
developed and tested on 50 stroke inpatients on a rehabilitation unit. The format and content of the SIDI questions were intended to improve on the limited validity of
the Center for Epidemiological Studies-Depression Scale
(CES-D) and other measures of depression with stroke
inpatients. The validity of the SIDI was supported by
higher correlations with a psychiatrist's rating of depression level (r = 0.70), SADS-C score (r = 0.68), and Hamilton Rating Scale for Depression score (r = O. 78)
compared with the CBS-D. Also, the SID] was more accurate than the CES-D in correct classification ofpatients
with regard to diagnosis of depression (86% us. 76%
correct). (American Journal of Geriatric Psychiatry 1996;
4:131-139)

S

tro ke is ranked among the 10 most
common admitting diagnoses for
acute care hospitals} and is the most common diagnosis for patients in rehabilitation hospttals.i A significant number of
these stroke patients become depressed
during the first few weeks after the stroke,
with estimates ranging between 29% and
64%.3-8Yet the data suggest that the majority of older adults with depression
secondary to any physical illness go undi-

agnosed and untreated in both acute care
and rehabilitation hospitals. 3,8- 10 Detection and treatment are particularly critical
for stroke patients, given the finding that
in-hospital levels of depression fredict
physical rehabilitation outcome, activities of daily living (ADL) functioning 2
years later,11 and to-year mortality.12
Existing depression scales have significant limitations for use with stroke
patients in the hospital setting.8,13 First,

Received December 28, 1994; revised March 16, 1995; accepted May 10, 1995. From the Department of
Psychology and Social Sciences, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL.Address correspondence to Dr, Rybarczyk, Dept. of Psychology and Social Sciences, Rush-Presbyterian-St. Luke's Medical Center,
1653 W. Congress Pkwy. Chicago, IL 60612.
Copyright © 1996 American Association for Geriatric Psychiatry
THE AMERICAN JOURNAL OF GERIATIUC PSYCHIATRY

131

Depression Screening and Stroke
because of the sudden onset) acute physical impairments) and subsequent hospitalization) the questions contained in
standard measures of depression are
often not appropriate for recent stroke
patients (e.g., "Have you dropped many
ofyour activities and interests?"). Second)
with the notable exception of the Geriatric Depression Scale (GDS) , 14 most depression inventories use a rating-scale
answer format) usually requiring respondents to rate how frequently they experience a symptom. This type of answer
format is often too complex and timeconsuming for patients who have either
some level of cognitive impairment)
language impairment, and/or fatigue secondary to the stroke. Pinally standard depression inventories often include
somatic-type symptoms that are common
to both the general older adult population and nondepressed stroke patients) in
particular. For example) two studies have
found that 4 of the 20 items of the Center
for Epidemiological Studies-Depression
scale (CES-D)15 correlate significantly
with the presence of physical disease, regardless of mood status (e.g., UI could not
get going. ") 16,17
Several self..report depression scales
have been validated for stroke outpatients. 7,15 The most widely studied scale
has been the CES-Dwhich, in general, has
demonstrated good criterion validity,
concurrent validity; and test-retest reliability with stroke outpatients.l' However)
when the CES-Dwas tested with a sample
of stroke inpatients, it lacked sufficient
concurrent and criterion validity'' For example) the CES-Dcorrelation with psychiatric diagnosis was 0.95 with outpatients
but only 0.53 with inpatients. Thus) the
limitations of general depression questionnaires for stroke inpatients may
diminish their validity with this population.
Given the large number of stroke patients on inpatient medical or rehabilitation units) the large percentage who have
132

concomitant depression, and the problems with existing depression questionnaires, a screening test tailored for an
inpatient population would address an
important need. Accordingly; we developed a 30-item, yes/no-format depression
scale, the Stroke Inpatient Depression Inventory (SIDI). Unlike general depression
measures, SIDI items address issues that
are unique to this population and refer
explicitly to the time period since the
patient had a stroke. To measure validity;
we compared scores obtained on the SIDI
with the results of an independent psychiatric evaluation of a group of stroke
inpatients on a rehabilitation unit. The
CES-D scale was also administered as a
comparison measure.

METHODS
Subjects

Over a period of 16 months) consecutive patients admitted to an inpatient rehabilitation service by two participating
physiatrists were screened for inclusion
in the study. Inclusion criteria were
voluntary consent (consent rate was approximately 80%); a recent cerebrovascular accident (CVA) verified by history;
physical exam, and CT scan or MRI; and a
combined score of 25 or more on the
abbreviated Neurobehavioral Cognitive
Screening Exam (NCSE; therebyeliminating patients with significant dysphasia) .
All 50 subjects included in the study
were inpatients on the 66-bed rehabilitation unit of a 900-bed urban hospital.
Subjects were an average of 71 ± 6.5
years old, with a mean of 11 ± 3.7 years
of formal education. In all, 23 were married, 14 widowed, 10 divorced) 2 never
married, and 1 separated; 56% of the subjects were black, and 44% were white;
56% of the CVAs were localized to the
right hemisphere, 35% to the left hemisphere, and the remainder were either
VOLUME 4 • NUMBER 2 • SPRING 1996

Rybarczyk et at.
FIGURE 1.

Items of the Stroke Inpatient Depression Inventory (SIDI)

STROKE INPATIENT DEPRESSION INVENTORY
INSTRUCTIONS: The foUowing questions address how you have adjusted since your stroke. You

must answer either "yes" or "no" for each question, whichever is the best answer.
ITEMS 1-15: SINCE YOUR STROKE .••
Y

1. have you found less

enjoyment in life's simple
pleasures that arc still
available to rou (e.g., W,
newspaper)'
2. have you been cheerful
most of the time?

3. arc you having more than

your usual troubles falling
asleep at night?
4. do other people get on
your nerves more easily?

Y

N

19. Are you worrying a great

deal about how you're
going to get by after you
leave the hospital?
20. Do you feci helpless the
way you are nowt

21. Compared to before your

5. have you of/ell felt like
crying?

22.

6. have you been worried
about your health much
more than usual?
7. are you getting more upset
over minor things?

23.

8. have you had your usual
zest for life?
9. have you been able to give
it your all when doing
exercises?
10. have you returned to
feeling like your "old self'
again?
11. have you been feeling
empty much of the time?

25.

12. do you find yourself
feeling downhearted
and blue?

N

18. Do you talk as much as
usual during visits from
family and friends?

24.

26.

stroke, arc you in as good
a mood when you get up
in the morning?
Compared to before your
stroke, arc you laughing
and smiling much less?
Have you been
discouraged by the
recovery process?
Even though you have
some disability from your
stroke, do you still find life
exciting?
Do you feel worthless the
way you are now?
Do you blame yourself for
the stroke?

27. Have you been bored most
of the time since being in
the hospital?
28. Do you feel that most
people are better off than
you arc?
29. If you stayed in the
condition you are in now,
do you feel like life would
be worth Iivin~?
30. Do you feel satisfiedwith the
lifeyou have lived thus fur?

13. has your interest in food
dropped off?,
14. have you had thoughts of
wanting to die?
15. have you felt full of
enerJW?
16. Currently, are you feeling
hopeful about your future?
17. During your hospital stay,
have you been in good
spirits most of the time?

SCORING:One point for each Uno" answer for
items 2, 8-10, 15-18, 21, 22, 24, 29, and 30. One
point for each "yes" answer for all other items.
TOTAL SCORE:

TliE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY

133

Depression Screening and Stroke
mixed or subcortical; 72% of the subjects
reported no previous eVA, 8 subjects had
one previous eVA, and 3 subjects had
three or more. The average length of time
between the recent CVA and the first day
of participation in the study was 23 ±20
days. Four patients reported a previous
history of depression. In each case, the
depression was not present at the time of
the stroke.

Procedure
Upon admission to the rehabilitation
unit, patients were screened for inclusion. Qualified patients who provided
consent were scheduled for testing. All
testing was conducted by staff psychologists, psychology residents, or psychology
graduate students trained in administration of the study instruments. Patients
first completed the abbreviated NCSE. If
they met criteria on this measure, they
were then administered both the CES-D
and SIDI on 2 consecutive days. Order of
testing was counterbalanced, with initial
order randomly selected. One of two geriatric psychiatrists, blind to the CES-D and
SIDI results, then conducted a standard
TABLE 1.

clinical interview and administered the
Hamilton Rating Scale for Depression
(Ham-D) and the Schedule for Affective
Disorders and Schizophrenia-Change
Form (SADS-C) interview rating scales
within several days of the administration
of the self-report scales (48 patients
within 4 days; 2 patients within 6 days;
mean = 2.6 days). The psychiatrist, using
the information obtained in the interview
and the rating scales, categorized the patients according to level of depression. To
facilitate comparison with other poststroke depression studies, three categories based on DSM-III criteria were
adopted from previous studies: 5-8 1) no
depression; 2) minor depression (at least
three of nine dysthymia symptoms, without the time criteria); and 3) major depression (five or more symptoms, with at
least one being depressed mood or
anhedonia).
Instruments

Stroke Inpatient Depression Inventory
(SID/). The 30 items of the SIDI were
selected from a pool of approximately 50

Comparison of criterion validity, concurrent validity, and reliability coefficients for the
SID] and CES-D
SIDI

Criterion validity
Psychiatrist rating of
no/minor/major depression
Concurrent validity
Ham ..
D
SADS-C Total Score
SADS-C Global Rating Scale
Reliability
24-hour test-retest
Cronbach's alpha

CES-D

0.70*

0.53*

0.78**
0.68**
-0.68**

0.66**
0.64**
-0.61**

0.92**
0.90

0.89**
0.87

Note: SIDI = Stroke Inpatient Depression Inventory; CES..D = Center for Epidemiological Studies
Depression Scale; Ham..D = Hamilton Rating Scale for Depression; SADS-C = Schedule for Affective
Disorders and Schizophrenia-Change Form.
*Spearman rho: P < 0.0001.
**Pcarson r: P < 0.0001.

134

VOLUME 4 • NUMBER 2 • SPRING 1996

Rybarczyk et al.
items written by a group offour psychologists and a psychiatrist (Figure 1). Items
were selected to match the major symptom areas covered in other self-report depression inventories. To accommodate
this particular population, the selected
items refer to activities that can be carried
out in the hospital, feelings and attitudes
about physical impairment, and unique
ways used by older adults to describe their
dysphoria (e.g., not feeling like "my old
self"). Nine items (#5, 7, 12, 15-17, 24,
25, 28) are modified questions from the
GDS. 14 The maximum score is 30, with
higher scores indicating more depressive
symptoms.

reliability, concurrent validity, and predictive validity in both nonmedical 15,19 and
medical populations. 7 ,16,17 Internal consistency, as measured by Cronbach's alpha, ranged from 0.84 to 0.90 in separate
samples. 19

Hamilton Rating Scale for Depression
(Ham-D). The Ham-D is a widely used
18-, 21-, or 24..item interview measure of
depression originally designed to assess
the severity of depression in patients already having a diagnosable depressive disorder. 20 A comprehensive review of the
Ham-D indicated that it has good criterion
validity, predictive validity, and reliability.21 A study with stroke outpatients
found that the Ham-D,was stronglycorrelated with the CES-D (r = 0.74), the GOS
(r = 0.77), and the Zung self-report scales
(r = 0.70).18 The 24-item version was
used in the present study.

Centerfor Epidemiologic Studies-Depression Scale (CBS-D). The CES-D is a 20item scale designed to assess the frequency of depressive symptomatol0f>: in
samples from community surveys.' Respondents indicate the frequency of each
symptom during the past 7 days on a
4-point scale: rarely or none of the time
(less than 1 day); some or little of the time
(1-2 days); occasionally or a moderate
amount of time (3-4 days); and most or
all of the time (5-7 days). To facilitate
recall of the four possible answers, patients were provided with a set of 511 x 8
cards with the responses printed in large
type. The CES-D has demonstrated good

Schedule of Affective Disorders and
Schizophrenia-Change Form (SADS-C).

The SADS-C is a 45-item, interview-based
rating scale developed for standardizing
the DSM-III diagnosis of depresslon.v'
The SADS-C has a seven-point response
format and includes a single-item Global
Rating Scale (GRS) that was a precursor to
Axis V of DSM-III-R. It has been widely
used in depression research and has dem-

t1

TABLE 2.

Agreement of SIDI and CES-D measures with psychlatrlst's diagnosis of depression/no
depression, %

Specificity

Sensitivity

Positive
Predictive Value

Correctly
Classified

SIDI

cutoff = 1,.1

94

71

86

86

18
S6

100
6S
6S

39

64
60
76

CES·D

cutoff= 17b
cutoff = 21c
cutoff = 263

82

44
6S

a Optimal cutoff score (l.e., highest percentage correctly classified).
b Cutoff score recommended in community studies of depression. 24
C

Cutoff score recommended in previous poststroke study.6

THE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY

13S

Depression Screening and Stroke
onstrated good concurrent validity and
interrater reliability.22 A single total score
obtained by summing all depression
items and the GRS were used in the present study.

Abbreviated Neurobebaoioral Cognitive
Screening Exam (NCSB). The NCSE was
developed as an expanded mental status
test that contains 10 subtests.v' It was
intended for patients with neurological
disorders and has demonstrated good reliability and predictive validity with this
population. Five subtests (Orientation, Attention, Comprehension, Memory, and Social Judgment) were selected for an
abbreviated version of the NCSE. These subtests represented cognitive functions that
were judged to be essential for answering a
self-report questionnaire.

tered by the psychiatrist.
The SIDI scores correlated highly
with Ham-D scores (r = 0.78), SADS-C total score (r = 0.68), and SADS-C Global
Rating Scale (r = - 0.68). Corresponding
CES-D correlations were lower, at r =
0.66, 0.64, and - 0.61, respectively (see
Table 1). The SIDI showed a correlation
of 0.77 with the CES-D.
Reliability was assessed by the correlation between identical tests administered 24 hours apart and the Cronbach
alpha measure of internal consistency
Test-retest reliability was 0.92 for the
SIDI and 0.89 for the CES-D. Cronbach's
alpha (equivalent to the average correlation of items with each other) was 0.90
for the SIDI and 0.87 for the CES-D (see
Table I)'.
To assess the accuracy of the SIDI and
CES-D as screening measures, a standard
meth odo1ogy61718 was used to measure
the level of agreement of the tests with
the psychiatrist's diagnosis. For the purpose of this analysis, minor depression
and major depression were combined
into a single diagnosis of depressive disorder.
Optimal cutoff scores were determined by the highest percentage of patients being correctly classified as
depressed or not depressed. The optimal
cutoff score of 17 for the SIDI resulted in
the correct classification of 86% of the
patients. The optimal cutoff of 26 for the
CES-D resulted in the correct classification of 76% of the patients.
Sensitivity (percentage of subjects diagnosed as depressed who had a score at
or above the cutoff), specificity (percentage of subjects diagnosed as not depressed who had a score below the
cutoff), and positive predictive value
(percentage of subjects with scores at or
above cutoff who received a depression
diagnosis) were calculated for the optimal cutoff scores as well as for two additional recommended cutoff scores for the
CES_D6 24 (see Table 2).
f

RESULTS
The breakdown ofdiagnoses according to
psychiatric classification was as follows:
33 patients with no depression (66%); 8
patients with minor depression (16%);
and 9 patients with major depression
(18%). When mild and major depression
were combined into one category, the
overall rate of depression was 34%. This
rate is in the lower end of the range reported by other studies. 3-8 However, it
should be noted that the present study
excluded dysphasic patients, a factor that
may account for the lower-than-average
rate of depression.
The standard used to assess criterion
validity was the psychiatrist's diagnosis of
level of depression (Le., no depression/minor/major depression). The SIDI
correlated 0.70 with depression level,
whereas the CES-D correlated 0.53 with
depression level.
Concurrent validity was assessed
by the correlation between the two
scales, the SIDI and the CES-D, and the
rating scales that had been adminis136

f

t

VOLUME 4

• NUMBER 2 • SPRING 1996

Rybarczyk et al.

DISCUSSION
The data presented in this paper indicate
that the SIDI is a valid and reliable screening instrument for poststroke depression.
In fact, the SIDI scored higher than the
widely used CES-D on all measures of
criterion validity, concurrent validity, and
reliability. For example, the SIDl correlated 0.70 with the criterion of the psychiatrist's diagnosis oflevel ofdepression,
compared with 0.53 for the CES-D. Also,
when minor and major depression were
combined into one category to allow for
sensitivity and specificity calculations, the
SIDI proved to be a more accurate screening instrument than the CES-D (86% vs.
76% correctly classified). The SIDI outperformed the CES-D by the largest margin
on specificity, which is a measure of false
positives (94% vs. 82%). These preliminary findings indicate that the SIDI has
advantages over the CES-D as both a measure for quantifying level of depression
and as a measure for screening for the
presence or absence of depressive
disorder.
A primary reason for developing and
testing the SIDI was the low level ofvalidity found for the CES-D when it was applied to 66 stroke inpatients enrolled in
the Stroke Data Bank study'' Interestingly;
the low correlation of the CES-D with
psychiatrist's diagnosis of depression in
this study (r = 0.53) was identical to the
correlation reported in the Stroke Data
Base study The studies used comparable
methods for psychiatric evaluation and
the same three categories of diagnosis.
However, the CES·D appears to have
a much higher level of validity for stroke
outpatients who are no longer in the
acute stages of recovery The Stroke Data
Base sample, which followed up patients
after discharge from the hospital over a
2-year period, showed a much higher correlation between patients' CES-D scores
and psychiatric diagnosis (0.95).6 A simiTHE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY

lar study found a moderately high correlation (0.73) between CES-D score and
psychiatric diagnosis among outpatients. I 8
Although a CES·D cutoff score of 16
has been suggested for use in the general
population, our analysis found that the
optimal cutoff for the present sample of
stroke patients was 26. This was even
higher than the optimal cutoff of 21 obtained in the Stroke Data Base study 6 This
difference is probably accounted for by
the fact that the Stroke Data Base study
primarily involved stroke outpatients.
Taken together, these studies suggest
that the period of acute care and rehabilitation immediately after a stroke is likely
to involve a greater number of false-positive answers to questions involving sleep
disturbance, fatigue, and other somatic
symptoms. Also, during the initial poststroke period some of the hallmarksymptoms of depression may be present as
part of the normal grief response without
the presence of a full depression. For example, one study using the Zung scale
found that crying and sadness items had
a very low correlation with total depression score among stroke patients in an
inpatient rehabilitation program. 25
Supplementary analyses of our data
did not support previous findings linking
the presence of poststroke depression
with gender,3,7 age,7 history of depression, 7 or hemisphere of lesion. 26 In our
sample, depressed patients did not differ
from nondepressed patients in terms of
gender, age, race, education, cognitive
status, prior history of strokes, history of
depression, or hemisphere of lesion.
The link with hemisphere of the lesion, in particular, has been a controversial issue in the literature.8 ,26 However, by
excluding individuals with significant dysphasia, we may have biased our sample
against finding a higher risk for depression in patients with left-hemisphere lesions. Also, we were unable to obtain a
sufficient number of completed measures
137

Depression Screening and Stroke
of physical functioning at the time of assessment to investigate the previously reported link between depression and
lower functional status."
A strength of the SIDI) and also a
limitation, is the reliance on items asking
the patient to compare current status to
the period before the stroke or hospitalization. This strategy could result in a patient not answering in the affirmative for
depressive symptoms that existed before
the stroke. In effect, this limits the SIDI to
the detection of depression secondary to
stroke or hospitalization.
One advantage of an instrument like
the SIDI, with a YeslNo format) is that it is
easier to administer and therefore less
time-consuming than open-ended questions. The development of user-friendly
screening instruments would contribute
to improving on the current low rate of
recognition and treatment observed for
cases of poststroke depression.'
The undertreatment of poststroke
depression is unfortunate, given the research showing that sttmulanr" and antidepressant medtcarionst'' are effective
with this population. Moreover, the issue
of early detection and treatment has become even more significant with the introduction of new antidepressant
medications (e.g., SSRIs) with fewer side
effects than tricyclics and improved efficacy in cases of less severe depressions
(e.g., minor depression) dysthymia). Although well-controlled studies have not
been conducted) it is reasonable to assume that amelioration of depression in

stroke patients facilitates the rehabilitation process and improves overall functioning.
In summary; this initial study indicates that the SIDI has good validity and
appears to have some advantages over the
CES-Dfor both clinical and research purposes. A study replicating the present
findings is needed to further support the
validity of the SlOt The modest sample
size of50 subjects and our reliance on the
clinical judgment of a single psychiatrist
for the validity criterion were limitations
of the present study that could be addressed in a replication stud}'. Combining
the current study with a replication study
would also allow for an item analysis and
the eventual elimination ofany items that
diminish the validity of the scale.
Finally; by substituting the word "hospitalization" for "stroke" throughout the
test (e.g., "since your hospltalization"),
the SIDI could be tested with hospitalized
older adults with any medical diagnosis.
Most of the problems outlined above
regarding assessment of poststroke depression (e.g., overlap of medical symptoms with depression symptoms) are
problems inherent in the assessment of
geriatric inpatients with any medical illness. Rates of depression among geriatric
medical inpatients) in general) are nearly
as high as those found among stroke inpatients (i.e., 34%-45%).9,10 Therefore) a
valid and reliable screening measure for
depression in medically ill elderly patients would also have considerable clinical utility

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