Use of brief depression screening tools in primary care: consideration of heterogeneity in performance in different patient groups

Anxiety and suicidality in the college student population

Objective: This study examined symptoms of anxiety, depression and suicidality in a national sample of college students. Participants: Using national survey data from the Healthy Minds Study (HMS), a random sample from 184 U.S. campuses from fall 2016 to spring 2019 was analyzed (N = 119,875). Methods: Prevalence rates were examined with the Generalized Anxiety Disorder 7-Item scale, Patient Health Questionnaire-9 and suicidality questions. Relationships between anxiety, depression and suicidality were assessed through Spearman's correlations, the Kruskal-Wallis H test and logistic regressions. Results: Findings revealed that screening only for depression would pick up 23% of suicidal ideation, increasing to 35% when also screening for anxiety. Those with anxiety and no to minimal depression had the second highest likelihood of suicide attempt, following those with anxiety and depression. The symptom "feeling afraid something awful might happen" doubled the odds of suicidal ideation. Conclusions: College campuses may benefit from assessing particular anxiety symptoms in relation to suicide.

Stop Asian hate: The mental health impact of racial discrimination among Asian Pacific Islander young and emerging adults during COVID-19

BACKGROUND

The rapid surge in anti-API discrimination and assault during the COVID-19 pandemic has the potential to exacerbate mental health disparities already pervasive among API populations. The primary of this study was to understand the impact of the pandemic and COVID-related discrimination on API college and university student mental health.

METHODS

Secondary data was used from three administrations (Fall 2019, Spring 2020, and Fall 2020) of the Healthy Minds Study (HMS). We conducted Chi-square analyses to analyze differences in mental health symptoms across the three academic semesters. Cross-sectional multivariable logistic regression models were utilized to examine the association between COVID-related discrimination and mental health symptoms and help-seeking behavior during Spring 2020 and Fall 2020.

RESULTS

Comparing Fall 2019 to Fall 2020, we found that API students reported a 17 % increase in severe depression and a 30 % increase in severe anxiety. Mental health treatment utilization among those experiencing clinically-significant mental health problems decreased by 26 % between Fall 2019 and Spring 2020. COVID-related discrimination was associated with greater odds of severe depression in both Spring 2020.

LIMITATIONS

HMS does not include a random sample of campuses as schools themselves elect to participate. Analyses rely on self-report data.

CONCLUSIONS

Throughout the COVID-19 pandemic, API students reported significant increases in clinically-significant mental health symptoms and decreases in treatment utilization. Our analyses also suggest that COVID-related discrimination is correlated with greater odds of clinically-significant mental health symptoms, including severe depression and severe anxiety, as well as lower odds of treatment utilization.

Depression and anxiety symptoms among Arab/Middle Eastern American college students: Modifying roles of religiosity and discrimination

INTRODUCTION

We examine mental health outcomes in a national sample of Arab/Middle Eastern college students using the Healthy Minds Study (HMS) from 2015-2018 and assess the modifying roles of religion and discrimination.

METHODS

HMS is an annual web-based survey administered to random samples of undergraduate and graduate students at participating colleges and universities. A total of 2,494 Arab/Middle Eastern and 84,423 white students were included in our sample. Our primary outcomes of depression and anxiety symptoms were assessed using the Patient Health Questionaire-9 (PHQ-9) and the Generalized Anxiety Disorder 7-item (GAD-7) scale, respectively. Survey-weighted logistic regression models were fit for each outcome using an Arab ethnicity indicator. Effect modification by religiosity and discrimination was examined by adding an interaction term to the model.

RESULTS

Odds of depression (adjusted odds ratio, AOR: 1.40, 95% CI: 1.24, 1.57) and anxiety (AOR: 1.41, 95% CI: 1.25, 1.60) were higher for Arab/Middle Eastern students than for white students. For Arab/Middle Eastern students, religiosity was a protective factor for both depression (AOR: 0.84, 95% CI: 0.79, 0.90) and anxiety (AOR: 0.91, 95% CI: 0.85, 0.97). Arab/Middle Eastern students who experienced discrimination had higher odds of depression (AOR: 1.41, 95% CI: 1.28, 1.56) and anxiety (AOR: 1.49, 95% CI: 1.36, 1.65) than those who had not.

DISCUSSION

Arab/Middle Eastern American college students are a vulnerable subgroup on college campuses experiencing a high burden of depression and anxiety symptoms which are dampened by religiosity and amplified by discrimination.

Identifying Mental Disorders in Primary Care: Diagnostic Accuracy of the Connected Mind Fast Check (CMFC) Electronic Screen

Primary care physicians (PCPs) often daily address diagnoses and treatment of mental disorders in their practices. The current study examined the Connected Mind Fast Check (CMFC), a two-tiered electronic screen, assessing six common mental disorders. The eight-item Initial Screen assesses possible symptoms, whereas SAM modules establish provisional diagnoses and areas of clinical concern. With 234 patients from five independent PCP offices, diagnostic accuracy was tested with the SCID-5-RV as the external criterion. Concerningly, many patients were unaware of their current mental disorders and comorbidities. The CMFC Initial Screen evidenced strong sensitivity, identifying with very few missing diagnoses. About two-thirds of provisional SAM diagnoses were confirmed with high specificities. Bipolar Disorder posed the most challenges at both tiers. Importantly, the suicide screen identified all patients with suicide plans and three-fourths with ideation. In general, the CMFC effectively identified provisional diagnoses, impairment, and potential suicidality.

Exploring the impact of the COVID-19 pandemic on medical learner wellness: a needs assessment for the development of learner wellness interventions

BACKGROUND

On March 11, 2020 the World Health Organization declared the novel coronavirus SARS-CoV-2 disease (COVID-19) a global pandemic. We sought to understand impact of COVID-19 on learner wellness at a large tertiary care academic institution to inform the future development of learner wellness interventions during the COVID-19 pandemic.

METHODS

A cross-sectional, internet-based survey collected quantitative and qualitative data from learners April-June 2020. Descriptive statistics and univariate analyses were reported for quantitative data. Open-ended, qualitative responses were analyzed deductively using thematic analysis.

RESULTS

Twenty percent of enrolled learners in that faculty of medicine (540/2741) participated including undergraduate [Bachelor's] students (25.7%), graduate [science] students (27.5%), undergraduate medical students (22.8%), and postgraduate resident physicians (23.5%). We found that learner wellness across all stages of training was negatively impacted and the ways in which learners were impacted varied as a result of their program's response to the COVID-19 pandemic.

CONCLUSIONS

Learners in health sciences and medical education report worsening well-being because of the programs and the systems in which they function with the added burden of the COVID-19 pandemic. Future interventions would benefit from a holistic framework of learner wellness while engaging in systems thinking to understand how individuals, programs and respective systems intersect. The importance of acknowledging equity, diversity and inclusion, fostering psychological safety and engaging learners as active participants in their journey during a pandemic and beyond are key elements in developing wellness interventions.

Validation of the Patient Health Questionnaire-2 to screen for depression in Canadian Armed Forces personnel

Post-deployment screening within the Canadian Armed Forces (CAF) aims to capture those with mental health issues so that appropriate and timely treatment can be provided. However, the process is lengthy and places considerable burden on CAF members and clinicians. Evaluation of shorter measures of mental health is an important step toward reducing the length of the process while still capturing those in need of care. This study evaluated the 2-item Patient Health Questionnaire (PHQ-2) as a potential brief measure of depression to be included in screening. Operating characteristics of the PHQ-2 were assessed against the full scale using existing recommended cutoffs, as well as clinician impressions of depression being of major concern. Correlations of the PHQ-2 with other measures of health were also examined. The PHQ-2 demonstrated good sensitivity and specificity for detecting depression compared to the full scale and to clinician impressions, at cutoffs similar to those found in past research. As well, it exhibited high correlations with other measures of mental health. This study provides evidence for the validity of the PHQ-2 as a brief screening tool for depression in CAF members following deployment.

Cut-off points for Polish-language versions of depression screening tools among patients with Type 2 diabetes

AIMS

Screening tools can help improve the detection of depression in patients with diabetes, yet the psychometric properties of most translations of scales, which are originally published in English, have not been assessed. Thus we studied the screening performance of widely used depression measures.

METHOD

We applied the cut-off points of the English-language versions of the Beck Depression Inventory (BDI); Hospital Anxiety and Depression Scale (HADS); Depression in Diabetes Self-Rating Scale (DDS-RS); Brief Self-Rating Scale of Depression and Anxiety (BS-RSDA); and Problematic Areas in Diabetes Survey (PAID), all of which were used to assess diabetes-specific distress in a sample of 101 patients with Type 2 diabetes. The Mini International Neuropsychiatric Interview and the Hamilton Depression Rating Scale (HDRS) were used to diagnose depression.

RESULTS

When the English cut-off points were used, the tools had varied values of both sensitivity and specificity. When the best cut-off points were used, all measures had either very good or good sensitivity. Taking into account their length, the HADS and the BS-RSDA seem to be the best among the screening tools.

CONCLUSIONS

Effective initial diagnosis of depression in patients with diabetes during a routine medical visit requires the use of screening tools that have adequate cut-off points. The analyses presented in this article show that screening tools should be validated and the cut-off points that are used should be population-specific.

Pathways from health beliefs to treatment utilization for severe depression

BACKGROUND

Untreated depression is associated with negative behavioral, psychosocial, and physical outcomes leading to socioeconomic costs, disability, and premature mortality. Research has not yet fully developed intervention models to increase the utilization of mental health treatments. The objective of the current study was to characterize the pathways linking health beliefs to treatment utilization among depressed young adults.

METHODS

Data were collected in 2017 from 53,760 college students at 54 universities in the United States. Among the respondents, 5,343 screened positive for moderately severe to severe depression. Becker's Health Belief Model (HBM) was the guiding theoretical paradigm. Confirmatory factor analysis and structural equation modeling (SEM) were conducted to elucidate treatment-seeking behavior based on health beliefs (perceived severity, perceived benefit, perceived barriers, self-efficacy, and cues-to-action) while controlling for relevant sociodemographic covariates.

RESULTS

Depression treatment utilization was significantly associated with all domains of the HBM. SEM parameter estimates indicated that higher levels of perceived severity, self-efficacy, and cues-to-action were associated with greater depression treatment utilization, whereas perceived benefits and perceived barriers were associated with lower depression treatment utilization.

CONCLUSIONS

The HBM may be useful to predict the frequency of seeking treatment by individuals for depression. However, individualized intervention strategies targeting different aspects of the HBM are needed to promote help-seeking behaviors in young adults with depression.

Psychosocial Underpinnings of Pain and Sleep Disturbance in Safety-Net Primary Care Patients

Objective

The aim of this study was to uncover possible psychosocial underpinnings of pain and sleep disturbance in a safety-net primary care sample.

Methods

Patients (n = 210) awaiting care in a safety-net primary care clinic waiting room completed measures of cynical hostility, social support, mental health, sleep disturbance, and pain. This study was cross-sectional and observational.

Results

A structural equation model suggested that higher cynical hostility was associated with lower social support, which in turn was associated with poorer mental health, which then corresponded with higher pain and sleep disturbance. All possible indirect (mediational) effects within this model were statistically significant, suggesting a possible route through which cynical hostility may shape pain and sleep, two common presenting problems in primary care.

Conclusions

These findings illustrate the interplay of psychosocial factors with chronic pain and sleep disturbance in a sample of low-income, predominantly African-American patients seeking care at a safety-net primary care clinic. The findings support integrated primary care as a way to target not only behavioral health issues but also the psychosocial factors entangled with physical health.

The Depression Scale (DEPS) as a case finder for depression in various subgroups of primary care patients

Purpose

The quick and simple Depression Scale (DEPS) has been a popular self-rating depression scale in Finland for nearly 15 years. The purpose was to assess the validity of the DEPS in various subgroups of patients.

Materials and methods

Primary care patients, aged 18–64, completed a postal questionnaire including the DEPS. Of the 1643 patients all screen-positive subjects and every 10th screen-negative subject were invited for interview (the Present State Examination, PSE). Complete DEPS scores were available for 410 patients. They were grouped by gender, age, marital status, perceived physical health, basic education and the Michigan Alcoholism Screening Test (MAST) score. Separately for each subgroup, receiver operating characteristic (ROC) curve analyses were done, sensitivity, specificity, area under the curve (AUC), predictive values and likelihood ratios were calculated, and Cronbach's α was estimated.

Results

The DEPS was valid in general, but best for patients with basic education longer than 9 years.

Discussion

The key statistical figures for the DEPS were comparable to the figures for other short self-rating scales.

Conclusion

The DEPS is a valid case finder for primary care patients in the age group 18–64 years, and especially suitable for more highly educated patients. Future studies comparing the DEPS with other simple depression rating scales are needed.

Validation of the Polish version of WHO-5 as a screening instrument for depression in adults with diabetes

AIMS

The aim of this study was to validate and report the factorial analysis of the World Health Organization's 5-item Well-being Index (WHO-5) among outpatients with type 2 diabetes. We investigated the psychometric properties of the WHO-5 and its suitability for identifying potential depressive symptoms in Polish adults with diabetes.

METHODS

Participants were randomly chosen among Polish diabetes outpatients and invited to participate in the cross-sectional study (N = 216). Participants completed the Polish version of the WHO-5, Problem Areas in Diabetes Scale and Patient Health Questionnaire.

RESULTS

Factor analyses identified the one-factor structure of the Polish version of the WHO-5. The internal consistency of the Polish version of the WHO-5 is satisfying. With regard to convergent validity, there were significant negative associations between the WHO-5 and PAID, the PHQ-9, HbA1c and the amount of medical complications. The AUC indicates that the WHO-5 is an effective measure for identifying depressive symptoms. The optimal cut off values of ≤12 yielded the best sensitivity/specificity trade-off for identifying depression among people with diabetes.

CONCLUSIONS

The Polish version of the WHO-5 is a reliable, valid outcome measure for outpatients with type 2 diabetes and can be a useful instrument for screening for depression in people with diabetes.

Preference-based measure of health-related quality of life and its determinants in sickle cell disease in Nigeria

Background

Health-related quality of life (HRQL) and economic burden are important issues for people with sickle cell disease (SCD) owing to better survival due to medical advances. Preference-based or utility information is necessary to make informed economic decisions on treatment and alternative therapies. This study aimed to assess preference-based measures of HRQL in sickle cell patients.

Methods and findings

Data were collected from two SCD outpatient clinics in Ibadan, Nigeria. A standard algorithm was used to derive utility scores, and measure SF-6D from the SF-36. A multivariate regression model was used to assess predictors and their impact. A combination of socio-demographic, bio-physiological and psychosocial variables predicted utility score in people with SCD. Socio-demographic and bio-physiological factors explained 7.5% and 17.9% of the variance respectively, while psychosocial factors explained 4.9%. Women had lower utility scores with a small effect size (d = 0.17). Utility score increased with level of education but decreased with age, anxiety, frequency of pain episodes and number of co-morbidities.

Conclusions

Utility score in SCD was low indicating a substantial impact of the disease on HRQL of patients and the value they place on their health state due to the limitations they experienced. Interventions should include both clinical and psychosocial approach to help in improving their quality of life of the patients.

Web-based CBT for the prevention of anxiety symptoms among medical and health science graduate students

Medical and health science graduate students report greater anxiety problems than the general population, but they are less likely to seek treatment due to cultural and logistical barriers. One preventative approach that overcomes these barriers is web-based cognitive behavioral therapy (webCBT). It is unknown whether webCBT is effective for preventing anxiety escalation within this population. A randomized controlled trial was conducted, comparing the effects of webCBT versus a control group (CG). Medical university students (n=594; Mage=27; 67% female; 80% Caucasian) completed online baseline measures and four assigned online activities. Measures were re-administered after approximately three months. There was a small interaction effect between time of assessment and treatment condition. Anxiety severity was lower in the webCBT (M[SD]=2.88[3.36]) versus CG condition (M[SD]=3.69 [3.35]) at follow-up. This effect was moderate for students with mild, versus minimal, anxiety at baseline. The proportion of students with possible anxiety disorder was lower in the webCBT (4.5%) versus CG (8.5%) condition, and the proportion of mildly anxious students with a clinically significant increase in symptoms was lower in the webCBT (10%) versus CG (20%) condition. WebCBT may aid in preventing anxiety escalation in this population, particularly for at-risk students who report mild anxiety symptoms.

Reliability and validity of the Turkish version of the WHO-5, in adults and older adults for its use in primary care settings

Background:

This study aims to determine the psychometric properties of the World Health Organization Well-Being Index (WHO-5) Turkish version in Turkish adults and older adults.

Methods:

This is a multicenter cultural adaptation study carried out with 1752 participants. Internal consistency (by Cronbach’s alpha); Construct validity (by known groups and confirmatory factor analysis-CFI) and discriminant validity are evaluated stratified by adults and older adults. Cohen’s Effect Size is used in known groups and discriminant validity analyses.

Results:

Distribution properties of the WHO-5 Turkish version are in acceptable limits. Alpha values are 0.81 for adults and 0.86 for older adults. The variances of the 58.5% of the adults sample and 63.9% of the older adults sample are explained in Exploratory FA. Model fits (CFI) are satisfactory ( > 0.95) in both samples; but RMSEA is poor in the older adults sample (0.166) whereas it is acceptable (0.073) in the adults sample. Known groups validity and discriminant analyses are satisfactory in both adults and older adults.

Conclusion:

The WHO-5 Turkish version has a good measurement capacity, internal consistency and good model fits in both samples. The error values in the older adults group suggest that the results when testing older adults should be interpreted with caution.

The Relationship Between Grit, Burnout, and Well-being in Emergency Medicine Residents

BACKGROUND

Burnout has become endemic in medicine, across all specialties and levels of training. Grit, defined as "perseverance and passion for long-term goals," attempts to quantify the ability to maintain sustained effort throughout an extended length of time. Our objective is to assess burnout and well-being and examine their relationship with the character trait, grit, in emergency medicine residents.

METHODS

In Fall 2016, we conducted a multicenter cross-sectional survey at five large, urban, academically affiliated emergency departments. Residents were invited to anonymously provide responses to three validated survey instruments; the Short Grit Scale, the Maslach Burnout Inventory, and the World Health Organization-5 Well-Being Index.

RESULTS

A total of 222 residents completed the survey (response rate = 86%). A total of 173 residents (77.9%) met criteria for burnout and 107 residents (48.2%) met criteria for low well-being. Residents meeting criteria for burnout and low well-being had significantly lower mean grit scores than those that did not meet criteria. Residents with high grit scores had lower odds of experiencing burnout and low well-being (odds ratio [OR] = 0.26, 95% confidence interval [CI] = 0.46-0.85; and [OR] = 0.33, 95% CI = 0.16-0.72, respectively). Residents with low grit scores were more likely to experience burnout and more likely to have low well-being (OR = 6.17, 95% CI = 1.43-26.64; and OR = 2.76, 95% CI = 1.31-5.79, respectively).

CONCLUSION

A significant relationship exists between grit, burnout, and well-being. Residents with high grit appear to be less likely to experience burnout and low well-being while those with low grit are more likely to experience burnout and low well-being.

Common health problems in safety-net primary care: Modeling the roles of trauma history and mental health

OBJECTIVE

This study described trauma exposure and investigated mediational effects of mental health on the relationships between trauma and pain, sleep, smoking, and general health.

METHOD

Participants were 210 low-income primary care patients. The study used a crosssectional, self-report survey design.

RESULTS

Eighty-five percent of the sample reported adult trauma and 54% reported four or more childhood traumas. Moderate or higher depression and anxiety levels were present in 59% and 48% of participants, respectively. Structural equation model fit was good for sleep, pain, and general health, showing that trauma indirectly affected health variables via mental health.

CONCLUSIONS

Participants endorsed substantial adult and childhood trauma, which likely had cascading effects on mental health and common primary care presenting health issues.

Using Mobile Technology to Provide Personalized Reminiscence for People Living With Dementia and Their Carers: Appraisal of Outcomes From a Quasi-Experimental Study

BACKGROUND

Dementia is an international research priority. Reminiscence is an intervention that prompts memories and has been widely used as a therapeutic approach for people living with dementia. We developed a novel iPad app to support home-based personalized reminiscence. It is crucial that technology-enabled reminiscence interventions are appraised.

OBJECTIVE

We sought to measure the effect of technology-enabled reminiscence on mutuality (defined as the level of "closeness" between an adult living with dementia and their carer), quality of carer and patient relationship, and subjective well-being.

METHODS

A 19-week personalized reminiscence intervention facilitated by a program of training and a bespoke iPad app was delivered to people living with dementia and their family carers at their own homes. Participants (N=60) were recruited in dyads from a cognitive rehabilitation team affiliated with a large UK health care organization. Each dyad comprised a person living with early to moderate dementia and his or her family carer. Outcome measurement data were collected at baseline, midpoint, and intervention closure.

RESULTS

Participants living with dementia attained statistically significant increases in mutuality, quality of carer and patient relationship, and subjective well-being (P<.001 for all 3) from baseline to endpoint. Carers attained nonsignificant increases in mutuality and quality of carer and patient relationship and a nonsignificant decrease in subjective well-being.

CONCLUSIONS

Our results indicate that individual-specific reminiscence supported by an iPad app may be efficient in the context of early to moderate dementia. A robust randomized controlled trial of technology-enabled personalized reminiscence is warranted.

Mental Health Disparities Among College Students of Color

PURPOSE

Understanding the mental health needs of students of color is a growing priority on college and university campuses nationwide. This study aims to capture the state of mental health among students of color, including the prevalence of mental health problems and treatment utilization.

METHODS

The sample is comprised of 43,375 undergraduate and graduate students at 60 institutions that participated in the survey-based Healthy Minds Study from 2012 to 2015. These data include over 13,000 students of color; we look separately at African-American, Latinx, Asian/Asian American, and Arab/Arab American students. Data are analyzed at the individual level using bivariate and multivariate modeling to elucidate variations across race/ethnicity. We examine symptom prevalence (measured by validated screens such as the Patient Health Questionnaire-9 for depression), help-seeking behaviors, and related factors (including knowledge and stigma).

RESULTS

Across race/ethnicity, we find modest variation in symptom prevalence and larger variation in service utilization. Overall, treatment use is lower among students of color relative to white students, even when controlling for other variables in regression models. Asian/Asian American students have the lowest prevalence of treatment, at only 20% among those with apparent mental health conditions. Attitudes related to mental health treatment also vary significantly and help to explain the primary findings.

CONCLUSIONS

College students of color represent a disparities population based on greater levels of unmet mental health needs relative to white students. This paper takes an important step toward understanding these needs and points to implications for future research and practice.

Cross-cultural validation of the German and Turkish versions of the PHQ-9: an IRT approach

BACKGROUND

The Patient Health Questionnaire's depression module (PHQ-9) is a widely used screening tool to assess depressive disorders. However, cross-linguistic and cross-cultural validation of the PHQ-9 is mostly lacking. This study investigates whether scores on the German and Turkish versions of the PHQ-9 are comparable.

METHODS

Data from Germans without a migration background (German version, n = 1670) and Turkish immigrants in Germany (either German or Turkish version, n = 307) were used. Differential Item Functioning (DIF) was assessed using Item Response Theory (IRT) models.

RESULTS

Several items of the PHQ-9 were found to exhibit DIF related to language or ethnicity, e.g. 'sleep problems', 'appetite changes' and 'anhedonia'. However, PHQ-9 sum scores were found to be unbiased, i.e., DIF had no notable impact on scale levels.

CONCLUSIONS

PHQ-9 sum scores can be compared between Turkish immigrants and Germans without a migration background without any adjustments, regardless of whether they complete the German or the Turkish version.

Comorbidity of depressive symptoms among primary care patients with diabetes in a federally qualified health center

Depression is frequently comorbid with diabetes; however, less is known about this comorbidity in socially disadvantaged populations. This cross-sectional study examined depressive symptomatology among 424 patients with prediabetes or type 2 diabetes mellitus at a federally qualified health center. Prevalence of clinically significant depressive symptoms was assessed using the World Health Organization Five-Item Well-Being Index. The majority (67.7%) endorsed depressive symptoms, with greater prevalence among middle-aged adults (45–64 years) than younger or older counterparts. More women than men endorsed depressive symptoms. Findings suggest the need for routine depression screening in both prediabetes and type 2 diabetes mellitus, particularly among middle-aged and low-income individuals.

The psychometric properties of depression screening tools in primary healthcare settings: A systematic review

BACKGROUND

Consensus on a tool for depression screening among adults in primary healthcare (PHC) settings is lacking. This systematic review aimed to explore the psychometric properties of depression screening tools.

METHODS

A systematic literature search composed of four terms (screening AND psychometric AND depression AND primary healthcare) was conducted in PubMed, EMBASE, PsycINFO and MEDLINE, between January 1995 through October 2015. Studies that aimed to psychometrically test a depression screening tool among the general adult population in a PHC setting were included. Studies exploring the diagnostic properties of depression screening tools among specific populations were excluded.

RESULTS

Sixty publications, evaluating the psychometric properties of 55 tools or adaptations, were included. Studies were conducted in 24 countries and 18 languages on 48234 adults. The Patient Health Questionnaire-9 was the most evaluated tool with 14 studies evaluating its psychometric properties. Fifty-four studies reported on at least one measure of receiver operating characteristics. Sensitivity and specificity values ranged from 28% to 100% and 43% to 100%, respectively. Cronbach alpha values ranged from 0.56 to 0.94. Other forms of reliability and validity testing were less consistently and commonly reported.

LIMITATIONS

The inclusion of studies regardless of methodological quality or design may have limited generalizability, but allowed for a comprehensive and detailed overview of the current literature.

CONCLUSIONS

Depression screening tools vary in their psychometric properties. The PHQ-9 was the most extensively psychometrically tested tool. This systematic review may aid PHC professionals in choosing a depression screening tool for universal use as it provides a comprehensive overview of their psychometric properties.

Depression screening in HIV-positive Tanzanian adults: comparing the PHQ-2, PHQ-9 and WHO-5 questionnaires

BACKGROUND

HIV-positive individuals are at significantly increased risk of depression. In low- and middle-income countries, depression is frequently under-detected, hampered by a lack of data regarding available screening tools. The 5-item World Health Organization Well-Being Index (WHO-5) is widely used to screen for depression, yet its validity in African adults with HIV has yet to be examined.

METHODS

In this cross-sectional study, we enrolled HIV-positive adults presenting to an outpatient HIV clinic in Mwanza, Tanzania. Patients were administered the Patient Health Questionnaires (PHQ)-2/9 and WHO-5 questionnaires. The rate of positive screens was calculated. Fisher's exact test and Pearson's correlation coefficients between PHQ-2/9 and WHO-5 scores were calculated.

RESULTS

We enrolled 72 HIV-positive adults: rates of positive depression screen were 62.5%, 77.8%, and 47.2% according to PHQ-2, PHQ-9, and WHO-5, respectively. PHQ and WHO results for depression were significantly associated (Fisher's exact test: PHQ-2 v. WHO-5, p = 0.028; PHQ-9 v. WHO-5, p = 0.002). The level of correlation between PHQ and WHO results for depression was moderate (Pearson's correlation coefficient: PHQ-2 v. WHO-5 -0.3289; PHQ-9 v. WHO-5 -0.4463).Per Mantel-Haenszel analysis, screening results were significantly more concordant among patients in the following strata: men, age >40, Sukuma ethnicity, Christian, unmarried, self-employed, at least primary school education completed, and higher than the median income level.

CONCLUSIONS

WHO-5 scores correlated well with those of the PHQ-9, suggesting that the WHO-5 represents a valid screening tool. The concordance of PHQ-9 and WHO-5 results was poorer in marginalized socioeconomic groups. Positive depression screens were exceedingly common among HIV-positive Tanzanian adults according to all three questionnaires.

Well-Being and Associated Factors among Women in the Gender-Segregated Country

Well-being is an essential measure that contributes to the evaluation of the health and quality of life of populations. In 1948, the World Health Organization (WHO) defined health as physical, mental and social well-being. A cross-sectional survey was conducted in Riyadh, Saudi Arabia, between July and September 2015. Women aged 18 years old and above were invited to participate in the study. The data were collected using the WHO’s Well-Being Index questionnaire. Univariate and multivariate logistic regression models were fitted to identify factors that are significantly associated with well-being. A total of 900 women completed the survey. Approximately 58% of the women reported moderate to high (≥50) score of well-being, whereas 41.7% reported ill-being/likely depression. Experiencing violence, living in unfavorable physical conditions and reporting morbidities were shown to be significantly associated with low levels of subjective well-being (ill-being) (p < 0.0001). Our study revealed a significant percentage of low levels of well-being among women in Riyadh, Saudi Arabia, and identified the factors associated with them. Further research in this domain is recommended to better investigate additional causes of the low levels of well-being hence help in planning and guiding necessary interventions.

Validation of the WHO-5 as a first-step screening instrument for depression in adults with diabetes: Results from Diabetes MILES - Australia

AIMS

Screening for depression is recommended internationally. The World Health Organization's 5-item Well-being Index (WHO-5) is used clinically to screen for depression but its empirical suitability for this purpose is not well documented. We investigated the psychometric properties of the WHO-5 and its suitability for identifying likely depression in Australian adults with diabetes.

METHODS

The Diabetes MILES - Australia study dataset provided a sample of N=3249 who completed the WHO-5 (positively-worded 5-item measure of emotional well-being) and the PHQ-9 (9-item measure of depressive symptoms). Analyses were conducted for the full sample, and separately by diabetes type and treatment (type 1, non-insulin-treated type 2, and insulin-treated type 2 diabetes). Construct (convergent and factorial) validity and reliability of the WHO-5 were examined. ROC analyses were used to examine the sensitivity and specificity of the WHO-5 as a depression screening instrument, comparing two commonly used WHO-5 cut-off values (≤7 and <13) with the PHQ-9.

RESULTS

For the whole sample, the WHO-5 demonstrated satisfactory internal consistency reliability (α=0.90) and convergent validity with the PHQ-9 (r=-0.73, p<0.001). Confirmatory factor analysis partially supported factorial validity: Χ²(5)=834.94, p<0.001; RMSEA=0.23, 90% CI 0.21-0.24; CFI=0.98, TLI=0.96; factor loadings=0.78-0.92. The AUC was 0.87 (95% CI: 0.86-0.89, p<0.001). The sensitivity/specificity of the WHO-5 for detecting likely depression was 0.44/0.96 for the ≤7 cut-off, and 0.79/0.79 for the <13 cut-off, with similar findings by diabetes type and treatment.

CONCLUSIONS

These findings support use of a WHO-5 cut-point of <13 to identify likely depression in Australian adults with diabetes, regardless of type/treatment.

Are there researcher allegiance effects in diagnostic validation studies of the PHQ-9? A systematic review and meta-analysis

OBJECTIVES

To investigate whether an authorship effect is found that leads to better performance in studies conducted by the original developers of the Patient Health Questionnaire (PHQ-9) (allegiant studies).

DESIGN

Systematic review with random effects bivariate diagnostic meta-analysis. Search strategies included electronic databases, examination of reference lists and forward citation searches.

INCLUSION CRITERIA

Included studies provided sufficient data to calculate the diagnostic accuracy of the PHQ-9 against a gold standard diagnosis of major depression using the algorithm or the summed item scoring method at cut-off point 10.

DATA EXTRACTION

Descriptive information, methodological quality criteria and 2×2 contingency tables.

RESULTS

Seven allegiant and 20 independent studies reported the diagnostic performance of the PHQ-9 using the algorithm scoring method. Pooled diagnostic OR (DOR) for the allegiant group was 64.40, and 15.05 for non-allegiant studies group. The allegiance status was a significant predictor of DOR variation (p<0.0001).Five allegiant studies and 26 non-allegiant studies reported the performance of the PHQ-9 at recommended cut-off point of 10. Pooled DOR for the allegiant group was 49.31, and 24.96 for the non-allegiant studies. The allegiance status was a significant predictor of DOR variation (p=0.015).Some potential alternative explanations for the observed authorship effect including differences in study characteristics and quality were found, although it is not clear how some of them account for the observed differences.

CONCLUSIONS

Allegiant studies reported better performance of the PHQ-9. Allegiance status was predictive of variation in the DOR. Based on the observed differences between independent and non-independent studies, we were unable to conclude or exclude that allegiance effects are present in studies examining the diagnostic performance of the PHQ-9. This study highlights the need for future meta-analyses of diagnostic validation studies of psychological measures to evaluate the impact of researcher allegiance in the primary studies.

The Validity of the Montgomery-Asberg Depression Rating Scale in an Inpatient Sample with Alcohol Dependence

BACKGROUND

The Montgomery-Asberg Depression Rating Scale (MADRS) is commonly used to examine depressive symptoms in clinical settings, including facilities treating patients for alcohol addiction. No studies have examined the validity of the MADRS compared to an established clinical diagnostic tool of depression in this population. This study aimed to examine the following: (i) the validity of the MADRS compared to a clinical diagnosis of a depressive disorder (using the Structured Clinical Interview for DSM-IV-TR [SCID-IV-TR]) in patients seeking treatment for alcohol dependence (AD); (ii) whether the validity of the MADRS differs by type of SCID-IV-TR-based diagnosis of depression; and (iii) which items contribute to the optimal predictive model of the MADRS compared to a SCID-IV-TR diagnosis of a depressive disorder.

METHODS

Individuals seeking treatment for AD and admitted to an inpatient unit were administered the MADRS at day 2 of their detoxification program. Clinical diagnoses of AD and depression were made via the SCID-IV-TR at the beginning of treatment.

RESULTS

In total, 803 participants were included in the study. The MADRS demonstrated low overall accuracy relative to the clinical diagnosis of depression with an area under the receiver operating characteristic curve of 0.68. The optimal threshold for balancing sensitivity and specificity identified by the Euclidean distance was >14. This cut-point demonstrated a sensitivity of 66%, a specificity of 60%, a positive predictive value of 50%, and a negative predictive value of 75%. The MADRS performed slightly better for major depressive disorders compared to alcohol-induced depression. Items related to lassitude, concentration, and appetite slightly decreased the accuracy of the MADRS.

CONCLUSIONS

The MADRS does not appear to be an appropriate substitute for a diagnostic tool among alcohol-dependent patients. The MADRS may, however, still be a useful screening tool assuming careful consideration of cut-points.

Factor structure and validity of the Depression, Anxiety and Stress Scale-21 in Swedish translation

WHAT IS KNOWN ON THE SUBJECT?: The Depression, Anxiety and Stress Scale-21 (DASS-21) is a widely used measurement for psychological symptoms and distress. Some previous studies have shown that the DASS-21 can accurately measure symptoms of anxiety, depression and stress, while other studies have indicated that the DASS-21 mainly measures overall distress. The factor structure of the DASS-21 is important and debated since if affects interpretations of findings. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: In this study, the DASS-21 was translated into Swedish and evaluated in three diverse samples. The DASS-21 subscales of Depression and Anxiety correlated significantly with corresponding criteria instruments. The DASS-21 Stress subscale showed more diverse associations with psychological distress. The analyses supported a bifactor model of the DASS-21 with three specific factors of depression, anxiety and stress as well as a general distress factor. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The results show that the DASS-21 may be used to measure unique symptoms of depression, anxiety and, with some caveat, stress as well as overall psychological distress. This study confirms that the DASS-21 is theoretically sound instrument that is feasible for both research and clinical practice. The DASS-21 can be an accessible tool for screening and evaluation in first-line mental health services.

ABSTRACT

Introduction There is a constant need for theoretically sound and valid self-report instruments for measuring psychological distress. Previous studies have shown that the Depression, Anxiety and Stress Scale-21 (DASS-21) is theoretically sound, but there have been some inconsistent results regarding its factor structure. Aims The aim of the present study was to investigate and elucidate the factor structure and convergent validity of the DASS-21. Methods A total of 624 participants recruited from student, primary care and psychotherapy populations. The factor structure of the DASS-21 was assessed by confirmatory factor analyses and the convergent validity by investigating its unique correlations with other psychiatric instruments. Results A bifactor structure with depression, anxiety, stress and a general factor provided the best fit indices for the DASS-21. The convergent validity was adequate for the Depression and Anxiety subscales but more ambiguous for the Stress subscale. Discussion The present study overall supports the validity and factor structure of the DASS-21. Implications for practice The DASS-21 can be used to measure symptoms of depression and anxiety as well as overall distress. It can be useful for mental health nurses, and other first-line psychiatric professionals, in need of a short, feasible and valid instrument in everyday care.

Identifying depression with the PHQ-2: A diagnostic meta-analysis

BACKGROUND

There is interest in the use of very brief instruments to identify depression because of the advantages they offer in busy clinical settings. The PHQ-2, consisting of two questions relating to core symptoms of depression (low mood and loss of interest or pleasure), is one such instrument.

METHOD

A systematic review was conducted to identify studies that had assessed the diagnostic performance of the PHQ-2 to detect major depression. Embase, MEDLINE, PsychINFO and grey literature databases were searched. Reference lists of included studies and previous relevant reviews were also examined. Studies were included that used the standard scoring system of the PHQ-2, assessed its performance against a gold-standard diagnostic interview and reported data on its performance at the recommended (≥3) or an alternative cut-off point (≥2). After assessing heterogeneity, where appropriate, data from studies were combined using bivariate diagnostic meta-analysis to derive sensitivity, specificity, likelihood ratios and diagnostic odds ratios.

RESULTS

21 studies met inclusion criteria totalling N=11,175 people out of which 1529 had major depressive disorder according to a gold standard. 19 of the 21 included studies reported data for a cut-off point of ≥3. Pooled sensitivity was 0.76 (95% CI =0.68-0.82), pooled specificity was 0.87 (95% CI =0.82-0.90). However there was substantial heterogeneity at this cut-off (I(2)=81.8%). 17 studies reported data on the performance of the measure at cut-off point ≥2. Heterogeneity was I(2)=43.2% pooled sensitivity at this cut-off point was 0.91 (95% CI =0.85-0.94), and pooled specificity was 0.70 (95% CI =0.64-0.76).

CONCLUSION

The generally lower sensitivity of the PHQ-2 at cut-off ≥3 than the original validation study (0.83) suggests that ≥2 may be preferable if clinicians want to ensure that few cases of depression are missed. However, in situations in which the prevalence of depression is low, this may result in an unacceptably high false-positive rate because of the associated modest specificity. These results, however, need to be interpreted with caution given the possibility of selectively reported cut-offs.

Case finding and screening clinical utility of the Patient Health Questionnaire (PHQ-9 and PHQ-2) for depression in primary care: a diagnostic meta-analysis of 40 studies

BACKGROUND

The Patient Health Questionnaire (PHQ) is the most commonly used measure to screen for depression in primary care but there is still lack of clarity about its accuracy and optimal scoring method.

AIMS

To determine via meta-analysis the diagnostic accuracy of the PHQ-9-linear, PHQ-9-algorithm and PHQ-2 questions to detect major depressive disorder (MDD) among adults.

METHOD

We systematically searched major electronic databases from inception until June 2015. Articles were included that reported the accuracy of PHQ-9 or PHQ-2 questions for diagnosing MDD in primary care defined according to standard classification systems. We carried out a meta-analysis, meta-regression, moderator and sensitivity analysis.

RESULTS

Overall, 26 publications reporting on 40 individual studies were included representing 26 902 people (median 502, s.d.=693.7) including 14 760 unique adults of whom 14.3% had MDD. The methodological quality of the included articles was acceptable. The meta-analytic area under the receiver operating characteristic curve of the PHQ-9-linear and the PHQ-2 was significantly higher than the PHQ-9-algorithm, a difference that was maintained in head-to-head meta-analysis of studies. Our best estimates of sensitivity and specificity were 81.3% (95% CI 71.6-89.3) and 85.3% (95% CI 81.0-89.1), 56.8% (95% CI 41.2-71.8) and 93.3% (95% CI 87.5-97.3) and 89.3% (95% CI 81.5-95.1) and 75.9% (95% CI 70.1-81.3) for the PHQ-9-linear, PHQ-9-algorithm and PHQ-2 respectively. For case finding (ruling in a diagnosis), none of the methods were suitable but for screening (ruling out non-cases), all methods were encouraging with good clinical utility, although the cut-off threshold must be carefully chosen.

CONCLUSIONS

The PHQ can be used as an initial first step assessment in primary care and the PHQ-2 is adequate for this purpose with good acceptability. However, neither the PHQ-2 nor the PHQ-9 can be used to confirm a clinical diagnosis (case finding).

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Intra-household evaluations of alcohol abuse in men with depression and suicide in women: A cross-sectional community-based study in Chennai, India

BACKGROUND

Harmful effects of alcohol abuse are well documented for drinkers, and adverse effects are also reported for the physical and emotional well-being of family members, with evidence often originating from either drinkers or their families in clinic-based settings. This study evaluates intra-household associations between alcohol abuse in men, and depression and suicidal attempts in women, in community-based settings of Chennai, India.

METHODS

This community-based cross-sectional study of chronic disease risk factors and outcomes was conducted in n = 259 households and n = 1053 adults (aged 15 years and above) in rural and urban Chennai. The Alcohol Use Disorder Identification Test (AUDIT) score was used to classify alcohol consumption into 'low-risk', 'harmful', 'hazardous' and 'alcohol dependence' drinking and the Patient Health Questionnaire (PHQ-9) score to classify depression as 'mild', 'moderate', 'moderate-severe' and 'severe'. Multivariate logistic regression models estimated the association of depression in women with men's drinking patterns in the same household.

RESULTS

A significant 2.5-fold increase in any depression (PHQ-9 ≥ 5) was observed in men who were 'alcohol-dependent' compared to non-drinkers (OR = 2.53; 95% CI: 1.26, 5.09). However, there was no association between men's drinking behavior and depression in women of the same household, although suicidal attempts approached a significant dose-response relationship with increasing hazard-level of men's drinking (p = 0.08).

CONCLUSION

No significant intra-household association was observed between men's alcohol consumption and women's depression, though an increasing (non-significant) trend was associated with suicidal attempts. Complex relationships between suicidal attempts and depression in women and male abusive drinking require further exploration, with an emphasis on intra-household mechanisms and pathways.

Development of a Review-of-Systems Screening Tool for Orthopaedic Physical Therapists: Results From the Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort

STUDY DESIGN

Literature review and cross-sectional study.

BACKGROUND

Direct access to physical therapy necessitates greater responsibility to determine appropriateness of care by recognizing the potential for concomitant disease or systemic involvement. Recent research has identified excessive variability in the reporting of red flag symptoms. An initial step to improve the identification of red flag symptoms is the development of a standardized screening tool.

OBJECTIVE

To describe the development of a review-of-systems screening tool appropriate for use by orthopaedic physical therapists.

METHODS

First, a red flag symptom item bank was compiled from a systematic literature review to allow for further psychometric testing and development of a screening tool. Second, physical therapists in 11 outpatient clinics recruited patients presenting with primary complaints of neck, shoulder, low back, or knee pain. Patients completed the red flag symptom item bank and standard questionnaires for comorbidities, negative mood, quality of life, pain, and function. The development of the screening tool involved identifying and combining different 3-item sets that characterized the highest number of patients reporting at least 1 positive symptom response (operationally defined as "red flag symptom responder").

RESULTS

The literature search yielded 103 studies that met the inclusion criteria, and the final item bank consisted of 97 items representing 8 body systems. Four hundred thirty-one patients with primary complaints of neck (n = 93), shoulder (n = 108), low back (n = 119), or knee (n = 111) disorders contributed to the cross-sectional study. The number of red flag symptom responders was 393 of 431 (91.2%). These patients were older, more likely to be female, had lower income, and were more likely to report neck or back pain (all, P<.05). A 10-item review-of-systems screening tool correctly identified 372 of 393 (94.7%) responders, and a 23-item version identified all 393 (100%) responders. The review-of-systems screening tools and the complete 97-item bank had similar correlations with concurrent clinical measures, except for depressive symptoms.

CONCLUSION

Concise red flag symptom identification appears to be feasible in outpatient orthopaedic physical therapy settings. Future research will determine how this review-of-systems screening tool needs refinement for different patient populations and whether it predicts clinical outcomes or the need for referral to other providers.

Diagnosis of depressed young people--criterion validity of WHO-5 and HSCL-6 in Denmark and Norway

BACKGROUND

According to the World Health Organization, depression ranks as a major contributor to the global burden of disease. A large proportion of adult depressions had their first appearance in adolescence. Brief and reliable rating scales are needed for early detection.

OBJECTIVE

The aim of this study is to validate the WHO-5 and the HSCL-6 for detection of depression among adolescents.

METHODS

The project is a GP multicentre study conducted in Denmark and Norway. A total of 294 adolescents (14-16 years) responded by answering a paper- or web-based questionnaire and later completed a Composite International Diagnostic Interview, which was used as the gold standard. Depression was defined by ICD-10 criteria. Criterion validity was examined, the likelihood ratios measured and cut-offs for depression were calculated using the Youden index.

RESULTS

The prevalence of depression was 11.8% in our sample. The optimal cut-off point was 11 for the WHO-5 test and 9 for the HSCL-6 test. There were no gender differences. For the WHO-5 and the HSCL-6, respectively, the sensitivity was 0.88 [95% confidence interval (CI): 0.74-0.96] and 0.85 (95% CI: 0.70-0.94), the specificity was 0.80 (95% CI: 0.75-0.85) and 0.79 (95% CI: 0.74-0.84) and the likelihood ratio was 4.5 and 3.8 (P = 0.39). We observed no statistically significant diagnostic differences with respect to nationality or administration procedure.

CONCLUSIONS

The WHO-5 and the HSCL-6 may both serve as valid case finding instruments for depression in young people in primary care.

Predictors of Well-Being in Resident Physicians: A Descriptive and Psychometric Study

BACKGROUND

It is important to describe the characteristics of well-being in resident physicians to develop resident wellness initiatives in postgraduate medical education.

OBJECTIVE

To characterize the predictors of well-being in resident physicians by assessing personal and work-related burnout, work dissatisfaction, nutritional needs while on call, and sleep needs while on call.

METHODS

We set up an online survey in 2012 to collect data from current residents at the University of Calgary in Canada. The WHO-Five Well-Being Index, personal and work-related subscales of the Copenhagen Burnout Inventory, questions on work dissatisfaction, as well as sleep and nutrition management needs while on call, were used in the survey. Descriptive statistics, univariate analysis, and linear regression were applied to the data.

RESULTS

The survey response rate was 45% (317 of 706) of eligible residents, with a mean age of 30.9 years (SD  =  4.3). Fifty-three percent (168 of 317) of residents had a well-being score of 13 or less, indicating poor mental well-being. There were significant differences between men and women with respect to personal burnout (47.9 versus 54.2, P  =  .002) and work-related burnout (46.4 versus 50.4, P  =  .008). The only significant predictors of well-being overall were personal burnout and work dissatisfaction.

CONCLUSIONS

Survey results suggest that a high proportion of residents at this institution have low well-being. This study did not find work-related burnout to be a significant predictor of well-being, after adjustment for other variables.

Finding a depression app: a review and content analysis of the depression app marketplace

Background

Depression is highly prevalent and causes considerable suffering and disease burden despite the existence of wide-ranging treatment options. Mobile phone apps offer the potential to help close this treatment gap by confronting key barriers to accessing support for depression.

Objectives

Our goal was to identify and characterize the different types of mobile phone depression apps available in the marketplace.

Methods

A search for depression apps was conducted on the app stores of the five major mobile phone platforms: Android, iPhone, BlackBerry, Nokia, and Windows. Apps were included if they focused on depression and were available to people who self-identify as having depression. Data were extracted from the app descriptions found in the app stores.

Results

Of the 1054 apps identified by the search strategy, nearly one-quarter (23.0%, 243/1054) unique depression apps met the inclusion criteria. Over one-quarter (27.7%, 210/758) of the excluded apps failed to mention depression in the title or description. Two-thirds of the apps had as their main purpose providing therapeutic treatment (33.7%, 82/243) or psychoeducation (32.1%, 78/243). The other main purpose categories were medical assessment (16.9%, 41/243), symptom management (8.2%, 20/243), and supportive resources (1.6%, 4/243). A majority of the apps failed to sufficiently describe their organizational affiliation (65.0%, 158/243) and content source (61.7%, 150/243). There was a significant relationship (χ²₅=50.5, P<.001) between the main purpose of the app and the reporting of content source, with most medical assessment apps reporting their content source (80.5%, 33/41). A fifth of the apps featured an e-book (20.6%, 50/243), audio therapy (16.9%, 41/243), or screening (16.9%, 41/243) function. Most apps had a dynamic user interface (72.4%, 176/243) and used text as the main type of media (51.9%, 126/243), and over a third (14.4%, 35/243) incorporated more than one form of media.

Conclusion

Without guidance, finding an appropriate depression app may be challenging, as the search results yielded non-depression–specific apps to depression apps at a 3:1 ratio. Inadequate reporting of organization affiliation and content source increases the difficulty of assessing the credibility and reliability of the app. While certification and vetting initiatives are underway, this study demonstrates the need for standardized reporting in app stores to help consumers select appropriate tools, particularly among those classified as medical devices.

Online suicide risk screening and intervention with college students: a pilot randomized controlled trial

OBJECTIVE

This pilot randomized controlled trial examined the effect of an online intervention for college students at risk for suicide, Electronic Bridge to Mental Health Services (eBridge), which included personalized feedback and optional online counseling delivered in accordance with motivational interviewing principles. Primary outcomes were readiness to seek information or talk with family and friends about mental health treatment, readiness to seek mental health treatment, and actual treatment linkage.

METHOD

Participants were 76 college students (45 women, 31 men; mean age = 22.9 years, SD = 5.0 years) at a large public university who screened positive for suicide risk, defined by at least 2 of the following: suicidal thoughts, history of suicide attempt, depression, and alcohol abuse. Racial/ethnic self-identifications were primarily Caucasian (n = 54) and Asian (n = 21). Students were randomized to eBridge or the control condition (personalized feedback only, offered in plain report format). Outcomes were measured at 2-month follow-up.

RESULTS

Despite relatively modest engagement in online counseling (29% of students posted ≥1 message), students assigned to eBridge reported significantly higher readiness for help-seeking scores, especially readiness to talk to family, talk to friends, and see a mental health professional. Students assigned to eBridge also reported lower stigma levels and were more likely to link to mental health treatment.

CONCLUSIONS

Findings suggest that offering students personalized feedback and the option of online counseling, using motivational interviewing principles, has a positive impact on students' readiness to consider and engage in mental health treatment. Further research is warranted to determine the robustness of this effect, the mechanism by which improved readiness and treatment linkage occurs, and the longer term impact on student mental health outcomes.

A diagnostic meta-analysis of the Patient Health Questionnaire-9 (PHQ-9) algorithm scoring method as a screen for depression

BACKGROUND

The depression module of the Patient Health Questionnaire-9 (PHQ-9) is a widely used depression screening instrument in nonpsychiatric settings. The PHQ-9 can be scored using different methods, including an algorithm based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria and a cut-off based on summed-item scores. The algorithm was the originally proposed scoring method to screen for depression. We summarized the diagnostic test accuracy of the PHQ-9 using the algorithm scoring method across a range of validation studies and compared the diagnostic properties of the PHQ-9 using the algorithm and summed scoring method at the proposed cut-off point of 10.

METHODS

We performed a systematic review of diagnostic accuracy studies of the PHQ-9 using the algorithm scoring method to detect major depressive disorder (MDD). We used meta-analytic methods to calculate summary sensitivity, specificity, likelihood ratios and diagnostic odds ratios for diagnosing MDD of the PHQ-9 using algorithm scoring method. In studies that reported both scoring methods (algorithm and summed-item scoring at proposed cut-off point of ≥10), we compared the diagnostic properties of the PHQ-9 using these methods.

RESULTS

We found 27 validation studies that validated the algorithm scoring method of the PHQ-9 in various settings. There was substantial heterogeneity across studies, which makes the pooled results difficult to interpret. In general, sensitivity was low whereas specificity was good. Thirteen studies reported the diagnostic properties of the PHQ-9 for both scoring methods. Pooled sensitivity for algorithm scoring method was lower while specificities were good for both scoring methods. Heterogeneity was consistently high; therefore, caution should be used when interpreting these results.

INTERPRETATION

This review shows that, if the algorithm scoring method is used, the PHQ-9 has a low sensitivity for detecting MDD. This could be due to the rating scale categories of the measure, higher specificity or other factors that warrant further research. The summed-item score method at proposed cut-off point of ≥10 has better diagnostic performance for screening purposes or where a high sensitivity is needed.

Which instruments to support diagnosis of depression have sufficient accuracy? A systematic review

BACKGROUND

Instruments are frequently used in case finding, diagnosis and severity grading of major depression, but the evidence supporting their utility is weak.

AIM

To systematically review the specificity and sensitivity of instruments used to diagnose and grade the severity of depression.

METHODS

MEDLINE, PsycInfo, Embase and the Cochrane Library databases were searched until April 2014. Fifty studies fulfilled the inclusion criteria. Risk of bias was assessed with QUADAS. The average sensitivity and specificity of each instrument was estimated with hierarchical summary receiver operating characteristics analyses and the confidence in the estimates was evaluated using GRADE. Minimum acceptable sensitivity/specificity, with structured interview as the reference, was 80%/80% for structured interviews and 80%/70% for case-finding instruments. The minimum acceptable standard for severity measures was a correlation of 0.7 with DSM-IV classification.

RESULTS

Twenty instruments were investigated. The average sensitivity/specificity was 85%/92% for the Structured Clinical Interview for DSM-IV-Axis-I Disorders (SCID-I), 95%/84% for the Mini International Neuropsychiatric Interview (MINI), < 70%/85% for the Primary Care Evaluation of Mental Disorders (PRIME-MD), 88%/78% for the Patient Health Questionnaire-9 (PHQ-9) with a cut-off score of 10, 69%/95% for PHQ-9 as a diagnostic algorithm and 70%/83% for the Hospital Anxiety and Depression Scale (HADS) with a cut-off score of 7. The confidence in the estimates for the other instruments was very low.

CONCLUSIONS

Only the SCID-I, MINI and PHQ-9 with a cut-off score of 10 fulfilled the minimum criteria for sensitivity and specificity. The use of the PRIME-MD and HADS is not supported by current evidence.

Mental health status and work environment among workers in small- and medium-sized enterprises in Guangdong, China-a cross-sectional survey

BACKGROUND

Small- and medium-sized enterprises (SMEs) generate nearly 80% of the jobs in China, but the dangerous work environment often found in these enterprises poses a major concern for public health. Psychosocial pressure and mental health problems among the workers are also common in SMEs. However, mental health of workers in SMEs is largely neglected in occupational health research and practice in China. The purpose of this study is to assess mental health of the workers and to explore the associations between physical and psychosocial work environment and workers' mental health in SMEs in South China.

METHODS

Data were collected in 2012 through a cross-sectional survey among 1200 workers working in small- and medium-sized enterprises (SMEs) in Guangdong, China. Mental health was measured by psychological well-being in the current study. Job Demand-Control-Support (JDCS) model was used as a theoretical framework to examine the psychosocial factors associated with workers' psychological well-being. Data were analyzed using SPSS 20.0 and analysis was performed using bivariate analyses and multivariate logistic regression.

RESULTS

About three in ten workers (35.3%) in the sample had poor psychological well-being. Those who were men, younger in age, or migrant workers had worse psychological outcome in bivariate analyses. After controlling for individual variables (gender, age, marital status, and household registration), we found that longer weekly work hours (OR = 1.30, 95% CI: 1.13 ~ 1.50), more exposure to hazardous work environment (OR = 1.26, 95% CI: 1.10 ~ 1.44), higher job demands (OR = 1.29, 95% CI: 1.12 ~ 1.49), and lower job autonomy (OR = 0.70, 95% CI: 0.60 ~ 0.81) were significant associated with worse psychological well-being. The results were consistent with predictions of the JDCS model.

CONCLUSIONS

The results indicate that the JDCS model is a useful framework in predicting psychological well-being among Chinese workers in SMEs. Future mental health promotion should focus on young migrant male workers as they appear to be most vulnerable in their psychological well-being. Both physical and psychosocial aspects of the work environment should be taken into account in policy making to prevent mental disorder and promote psychological well-being among workers in SMEs.

The distribution of wellbeing in Ireland

Objectives: There is a substantial knowledge gap about the distribution of mental health in community populations. The European Social Survey is particularly useful as it contains information on over 40,000 individuals, including 2,286 Irish adults. The objective of this study is to conduct a large scale statistical analysis to examine the distribution and determinants of mental wellbeing in a large representative sample of the Irish population.

Method: Analysis of the European Social Survey using robust multiple linear and non-linear regression techniques. The data-set contains WHO-Five scores and subjective wellbeing for a sample of 2,286 Irish people interviewed in their homes in 2005.

Results: Ireland has the second highest average WHO-Five score among the 22 countries in the European Social Survey. Multiple linear regression analysis across the distribution of WHO-Five reveals a wellbeing gradient largely related to education and social capital variables. A probit model examining the determinants of vulnerability to psychiatric morbidity reveals that a similar set of factors predict scores below the threshold point on the WHO-Five scale.

Conclusions: The results are consistent with marked differences in mental wellbeing across education levels and variables relating to social capital factors. Such indicators provide a useful index for policy-makers and researchers. However, much further work is needed to identify causal mechanisms generating observed differences in mental health across different socioeconomic groups.

The relationship of the Korean version of the WHO Five Well-Being Index with depressive symptoms and quality of life in the community-dwelling elderly

BACKGROUND

Depression in the geriatric population is becoming markedly more prevalent. Quality of life has been linked with the development of depression. A screening tool for assessing both geriatric depression and quality of life is needed.

OBJECTIVE

The purpose of this study was to assess the utility of the Korean version of the World Health Organization Five Well-Being Index (WHO-5) in evaluating geriatric depression and quality of life as compared to the widely used Short Geriatric Depression Scale of Korean version (SGDS-K).

METHODS

Two hundred and forty four elderly people (>60-years-of-age) living in the Yanggu and Inje areas of Gangwon Province, Korea, were interviewed and responded to scales including WHO-5, SGDS-K, Mini Mental Status Examination in the Korean version of the CERAD assessment packet (MMSE-KC), and Geriatric Quality of Life-Dementia (GQOL-D). A total WHO-5 score<13 indicated low well-being.

RESULTS

The SGDS-K score showed a reverse correlation with the WHO-5, MMSE-KC, and GQOL-D scores. The WHO-5 score reversely correlated with the SGDS-K score and positively correlated with GQOL-D, but showed no significant correlation with MMSE-KC score. Subjects ranked as having poor well-being (WHO-5 score<13) had a significantly lower GQOL-D score and a significantly higher SGDS-K score. In multiple regression analysis, WHO-5 was significantly associated with GQOL-D and SGDS-K.

CONCLUSION

The Korean version of WHO-5 is useful in evaluating both depressive symptoms and quality of life of community-dwelling elderly.

Measuring depression with a well-being index: further evidence for the validity of the WHO Well-Being Index (WHO-5) as a measure of the severity of depression

BACKGROUND

In recent years, the WHO Wellbeing Index (WHO-5) has been used as a screening measure for depression. Nevertheless, research on the validity of this measure in the context of clinical depression is sparse.

QUESTIONS

The aim of the present study was to investigate the measurement invariance of the WHO-5 across depressed and non-depressed individuals, as well as the shape and specificity of its relationship to measures of depression severity.

METHOD

Of the 414 subjects who completed the WHO-5 and the Beck Depression Inventory-II (BDI-II), 207 had a diagnosis of a major depressive episode (MDE). A subsample also completed the Beck Anxiety Inventory (BAI) and was assessed by clinicians using the Hamilton Depression Rating Scale (HAM-D) and the Hamilton Anxiety Rating Scale (HAM-A).

RESULTS

The WHO-5 demonstrated strong measurement invariance regarding the presence or absence of a current MDE. The WHO-5 showed a very high negative association with self- and observer-rated measures of depressive symptoms, especially in the range of mild to moderate symptoms. These associations were still substantial after controlling for measures of anxiety symptoms.

LIMITATIONS

In addition to a diagnostic interview, only one measure for self- and observer-rated symptoms of depression was used. Furthermore, the observer-rated measure was only assessed in one subsample that exhibited a somewhat restricted range of depression severity.

CONCLUSION

Although this index was originally designed as a measure of well-being, the results support the use of the WHO-5 in the context of depression research.

Screening for Depression with the Depression in Old Age Scale (DIA-S) and the Geriatric Depression Scale (GDS15)

Purpose of the study. The Depression in Old Age Scale (DIA-S), a new screening tool for geriatric depression, was designed to be both practical and appropriate for use with medically ill geriatric patients. The diagnostic accuracy of the DIA-S and the short form of the Geriatric Depression Scale (GDS15) were tested and compared. Methods. Using the Montgomery and Asberg Depression Rating Scale (MADRS) as gold standard, the scales were validated with a sample of N = 331 geriatric inpatients. Results. ROC curves, AUC outcomes, sensitivity and specificity, and logistic regression models for impact factors on misclassification rates indicate good psychometrical qualities of the DIA-S, whereas the validity of the GDS15 was lower.

Employees' negative and positive work-home interaction and their association with depressive symptoms

BACKGROUND

Depression is the leading cause of disability and high costs worldwide. One possibility for preventing depression in the workplace, which has received little consideration so far, is the promotion of a successful balance between work and personal life. The aim of this study was to investigate employees' negative and positive work-home interaction and their association with depressive symptoms.

METHODS

A cross-sectional study was conducted in the micro- and nanotechnology sector in Germany. A stepwise multivariate logistic regression analysis was performed using data from N = 213 employees.

RESULTS

The results suggest that while negative work-home interaction is associated with an increased risk for depressive symptoms, positive work-home interaction is correlated with a lower risk. Neither positive nor negative interaction in the home-to-work direction demonstrated a significant association with depressive symptoms.

CONCLUSION

When attempting to prevent mental illnesses, such as depression, it is important to develop strategies aimed at reducing conflict between work and personal life and promoting a positive exchange between these two domains.

Predictors of waterpipe smoking among secondary school adolescents in Al Hassa, Saudi Arabia

BACKGROUND

There has been a global upsurge of waterpipe (WP) smoking over the past several years. This can be attributed at least partly to various factors like lack of knowledge regarding its health effects, social acceptability, and intensive preventive programs focusing selectively on cigarettes smoking.

PURPOSE

This study aimed to determine the prevalence and psychosocial determinants of WP smoking among secondary school adolescents in Al Hassa, Saudi Arabia, and also to assess their attitudes toward WPs smoking and knowledge regarding the related health effects.

METHODS

Cross-sectional study included 1,652 students of both genders selected by multistage proportionate sampling method. Data collection was carried out using a self-administered anonymous Arabic version of the Global Youth Tobacco Survey, modified with items dedicated to WP smoking. Items to assess participants' knowledge about the health-related hazards and attitude towards WP were added. Patient Health Questionnaire was used to screen for the presence of anxiety and depressive disorders.

RESULTS

Of the included adolescents, 358 (21.7%) were current smokers; cigarettes (46.1%), both cigarettes and WP (16.5%), and only WP (37.4%). Current WP users accounted for 193; 96.4% were males and 62.7% were ≥18 years of age. Outing, boredom, meeting friends, and family gatherings were the most frequently stated motives. WP users demonstrated a higher incidence of depressive and generalized anxiety disorders. Common assumptions regarding WP smoking included: WP smoking is less harmful than cigarettes and with no addictive property as stated by 47.8% and 65.9% of adolescents, respectively, harmful substances are purified through water filtration as believed by 59.2%, and it is more socially acceptable than cigarettes as agreed by 54.1%. Hierarchical regression analysis showed that male gender and increasing age of adolescents, WP smoking among close family and friends, and socializing motives were significant predictors for the current WP smoking state.

CONCLUSION

Social acceptability, poor knowledge of WP health-related hazards, and socio-demographics are favoring the current increasing trend of WP use among adolescents in Al Hassa, Saudi Arabia.

Screening for depression in medical research: ethical challenges and recommendations

Background

Due to the important role of depression in major illnesses, screening measures for depression are commonly used in medical research. The protocol for managing participants with positive screens is unclear and raises ethical concerns. The aim of this article is to identify and critically discuss the ethical issues that arise when a positive screen for depression is detected, and offer some guidance on managing these issues.

Discussion

Deciding on whether to report positive screens to healthcare practitioners is both an ethical and a pragmatic dilemma. Evidence suggests that reporting positive depression screens should only be considered in the context of collaborative care. Possible adverse effects, such as the impact of false-positive results, potentially inappropriate labelling, and potentially inappropriate treatment also need to be considered. If possible, the psychometric properties of the selected screening measure should be determined in the target population, and a threshold for depression that minimises the rate of false-positive results should be chosen. It should be clearly communicated to practitioners that screening scores are not diagnostic for depression, and they should be informed about the diagnostic accuracy of the measure. Research participants need to be made aware of the consequences of the detection of high scores on screening measures, and to be fully informed about the implications of the research protocol.

Summary

Further research is needed and the experiences of researchers, participants, and practitioners need to be collated before the value of reporting positive screens for depression can be ascertained. In developing research protocols, the ethical challenges highlighted should be considered. Participants must be agreeable to the agreed protocol and efforts should be made to minimise potentially adverse effects.