The Edmonton Symptom Assessment System: Poor performance as screener for major depression in patients with incurable cancer

Elisabeth Brenne (Corresponding Author), Jon H Loge, Hanne Lie, Marianne J Hjermstad, Peter Fayers, Stein Kaasa

Research output: Contribution to journalArticle

4 Citations (Scopus)


Depressive symptoms are prevalent in patients with advanced cancer, sometimes of a severity that fulfil the criteria for a major depressive episode.

The aim of this study was to investigate how the item on depression in the Edmonton Symptom Assessment System with a 0–10 Numerical Rating Scale performed as a screener for major depressive episode. A possible improved performance by adding the Edmonton Symptom Assessment System-Anxiety item was also examined.

An international cross-sectional study including patients with incurable cancer was conducted. The Edmonton Symptom Assessment System score was compared against major depressive episode as assessed by the Patient Health Questionnaire-9. Screening performance was examined by sensitivity, specificity and the kappa coefficient.

Patients with incurable cancer (n = 969), median age 63 years and from eight nationalities provided report. Median Karnofsky Performance Status was 70. Median survival was 229 days (205–255 days).

Patient Health Questionnaire-9 major depressive episode was present in 133 of 969 patients (13.7%). Edmonton Symptom Assessment System-Depression screening ability for Patient Health Questionnaire-9 major depressive episode was limited. Area under the receiver operating characteristic curve was 0.71 (0.66–0.76). Valid detection or exclusion of Patient Health Questionnaire-9 major depressive episode could not be concluded at any Edmonton Symptom Assessment System-Depression cut-off; by the cut-off Numerical Rating Scale ⩾ 2, sensitivity was 0.69 and specificity was 0.60. By the cut-off Numerical Rating Scale ⩾ 4, sensitivity was 0.51 and specificity was 0.82. Combined mean ratings by Edmonton Symptom Assessment System-Depression and Edmonton Symptom Assessment System-Anxiety revealed similar limited screening ability.

The depression and anxiety items of the Edmonton Symptom Assessment System, a frequently used assessment tool in palliative care settings, seem to measure a construct other than major depressive episode as assessed by the Patient Health Questionnaire-9 instrument.
Original languageEnglish
Pages (from-to)587-598
Number of pages12
JournalPalliative Medicine
Issue number6
Early online date13 Jan 2016
Publication statusPublished - 30 Jun 2016



  • Palliative care
  • Neoplasms
  • depression
  • Depressive disorder
  • symptom assessment

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