Letters to the Editor
Using Depression Inventories: Not a Replacement for Clinical Judgment
The Children’s Depression Inventory (1) is one of the most common psychometric tools used in assessing childhood depression (2). It is a self-report questionnaire that is considered to have a high internal consistency and a satisfactory reliability. Despite the fact that Kovacs never intended for the CDI to be used to diagnose depression and that its ability to discriminate between children with and without depression is questionable (3), there are many instances when the CDI has been employed to do just this (1).
Case Report
Allan, aged 11 years, was referred for psychiatric assessment of depressive symptoms. His presenting symptoms of fatigue, initial insomnia, hyperphagia, and decreased concentration had been ongoing for 1 year. His teachers had begun to report a decline in his academic and social functioning at school; however, his parents said that his presenting symptoms did not seem to interfere with their son’s functioning when the task at hand was of interest to Allan. At the time of assessment, Allan denied experiencing any suicidal ideation or a history of suicide attempts, but he reported vague thoughts that life was no longer worth living. Neither he nor his parents were able to identify any recent stressors, but there was a long-standing history of bullying by peers regarding his obesity. The provisional diagnosis after initial psychiatric interview was adjustment disorder with depressed mood. Psychometric testing revealed Allan to have average to superior abilities but a large discrepancy between verbal and performance IQ. On the Children’s Depression Inventory (CDI), Allan endorsed several depressive symptoms, including suicidal ideation, with a total raw score of 27. This prompted an immediate risk assessment by the urgent care psychiatrist who failed to identify the patient as being at risk. That psychiatrist’s clinical impression was adjustment disorder with depressed mood, with the significant stressor being bullying at school.
In this case, a child with depressive symptoms but no suicidal ideation on clinical exam received a nondepression diagnosis from 2 independent psychiatrists. Conversely, assessment using the CDI rated this boy as very much above average for depressive symptoms and as experiencing suicidal ideation. This case suggests that the CDI may be an indicator of distress but not necessarily of depressive illness. It further supports the use of psychometric tools (in this case, the CDI) as adjuncts to clinical diagnosis. While such tools are valuable in assessment, they should not be considered a reliable substitute for the clinical interviewing process in determining diagnosis or suicidal risk.
References
1. Kovacs M. The Children’s Depression Inventory. North Tonawanda (NY): Mental Health Systems; 1992.
2. Fristad MA, Emery BL, Beck SJ. Use and abuse of the children’s depression inventory. J Consult Clin Psychol 1997;65:699–702.
3. Leblanc JC, Almudevar A, Brooks SJ, Kutcher S. Screening for adolescent depression: comparison of the Kutcher Adolescent Depression Scale with the Beck Depression Inventory. J Child Adolesc Psychopharmacol 2002;12:113–26.
Cherie Jones-Hiscock, MD, FRCPC
Kingston, Ontario
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