Screening for depression in medical care: pitfalls, alternatives, and revised priorities

Emergency health services use and medically-treated suicidal behaviors following depression screening among adolescents: A longitudinal cohort study

The primary goal of depression screening is to reduce adverse psychiatric outcomes, which may have downstream implications for reducing avoidable health services use. The objective of this study was to examine the association of depression screening with emergency health services use and medically-treated suicidal behaviors among adolescents in the U.S. This longitudinal cohort study used insurance claims data from 57,732 adolescents who had at least one well-visit between 2014 and 2017. Propensity score matching was used to compare adolescents who were screened for depression to similar adolescents who were not screened for depression during the well-visit. Outcomes were examined over two-year follow-up and included emergency department use and inpatient hospitalizations for depression-related reasons, mental health-related reasons, and any reason as well as medically-treated suicidal behaviors. Log-binomial regression models were used to examine associations between depression screening and each outcome in the matched sample. Heterogeneity of associations by sex was examined with interaction terms. Being screened for depression was not consistently associated with emergency department use (depression-related reasons: RR = 1.00, 95% CI = 0.76-1.30; mental health-related reasons: RR = 1.02, 95% CI = 0.80-1.29; any reason: RR = 0.96, 95% CI = 0.83-1.11), inpatient hospitalizations (depression-related reasons: RR = 1.05, 95% CI = 0.84-1.31; mental health-related reasons: RR = 1.16, 95% CI = 1.00-1.33; any reason: RR = 1.05, 95% CI = 0.99-1.12), or medically-treated suicidal behaviors (RR = 0.83, 95% CI = 0.51-1.36). Associations were similar in magnitude among male and female adolescents. The results of this study suggest that depression screening, as it is currently practiced in the U.S., may not deter avoidable health services use among adolescents.

Accuracy of the Patient Health Questionnaire-9 for screening to detect major depression: updated systematic review and individual participant data meta-analysis

OBJECTIVE

To update a previous individual participant data meta-analysis and determine the accuracy of the Patient Health Questionnaire-9 (PHQ-9), the most commonly used depression screening tool in general practice, for detecting major depression overall and by study or participant subgroups.

DESIGN

Systematic review and individual participant data meta-analysis.

DATA SOURCES

Medline, Medline In-Process, and Other Non-Indexed Citations via Ovid, PsycINFO, Web of Science searched through 9 May 2018.

REVIEW METHODS

Eligible studies administered the PHQ-9 and classified current major depression status using a validated semistructured diagnostic interview (designed for clinician administration), fully structured interview (designed for lay administration), or the Mini International Neuropsychiatric Interview (MINI; a brief interview designed for lay administration). A bivariate random effects meta-analytic model was used to obtain point and interval estimates of pooled PHQ-9 sensitivity and specificity at cut-off values 5-15, separately, among studies that used semistructured diagnostic interviews (eg, Structured Clinical Interview for Diagnostic and Statistical Manual), fully structured interviews (eg, Composite International Diagnostic Interview), and the MINI. Meta-regression was used to investigate whether PHQ-9 accuracy correlated with reference standard categories and participant characteristics.

RESULTS

Data from 44 503 total participants (27 146 additional from the update) were obtained from 100 of 127 eligible studies (42 additional studies; 79% eligible studies; 86% eligible participants). Among studies with a semistructured interview reference standard, pooled PHQ-9 sensitivity and specificity (95% confidence interval) at the standard cut-off value of ≥10, which maximised combined sensitivity and specificity, were 0.85 (0.79 to 0.89) and 0.85 (0.82 to 0.87), respectively. Specificity was similar across reference standards, but sensitivity in studies with semistructured interviews was 7-24% (median 21%) higher than with fully structured reference standards and 2-14% (median 11%) higher than with the MINI across cut-off values. Across reference standards and cut-off values, specificity was 0-10% (median 3%) higher for men and 0-12 (median 5%) higher for people aged 60 or older.

CONCLUSIONS

Researchers and clinicians could use results to determine outcomes, such as total number of positive screens and false positive screens, at different PHQ-9 cut-off values for different clinical settings using the knowledge translation tool at www.depressionscreening100.com/phq.

STUDY REGISTRATION

PROSPERO CRD42014010673.

The Potential for Improving the Population Health Effectiveness of Screening: A Simulation Study

BACKGROUND AND OBJECTIVES

Screening interventions in pediatric primary care often have limited effects on patients' health. Using simulation, we examined what conditions must hold for screening to improve population health outcomes, using screening for depression in adolescence as an example.

METHODS

Through simulation, we varied parameters describing the working recognition and treatment of depression in primary care. The outcome measure was the effect of universal screening on adolescent population mental health, expressed as a percentage of the maximum possible effect. Through simulations, we randomly selected parameter values from the ranges of possible values identified from studies of care delivery in real-world pediatric settings.

RESULTS

We examined the comparative effectiveness of universal screening over assessment as usual in 10 000 simulations. Screening achieved a median of 4.2% of the possible improvement in population mental health (average: 4.8%). Screening had more impact on population health with a higher sensitivity of the screen, lower false-positive rate, higher percentage screened, and higher probability of treatment, given the recognition of depression. However, even at the best levels of each of these parameters, screening usually achieved <10% of the possible effect.

CONCLUSIONS

The many points at which the mental health care delivery process breaks down limit the population health effects of universal screening in primary care. Screening should be evaluated in the context of a realistic model of health care system functioning. We need to identify health care system structures and processes that strengthen the population effectiveness of screening or consider alternate solutions outside of primary care.

Accuracy of the Hospital Anxiety and Depression Scale Depression subscale (HADS-D) to screen for major depression: systematic review and individual participant data meta-analysis

OBJECTIVE

To evaluate the accuracy of the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) to screen for major depression among people with physical health problems.

DESIGN

Systematic review and individual participant data meta-analysis.

DATA SOURCES

Medline, Medline In-Process and Other Non-Indexed Citations, PsycInfo, and Web of Science (from inception to 25 October 2018).

REVIEW METHODS

Eligible datasets included HADS-D scores and major depression status based on a validated diagnostic interview. Primary study data and study level data extracted from primary reports were combined. For HADS-D cut-off thresholds of 5-15, a bivariate random effects meta-analysis was used to estimate pooled sensitivity and specificity, separately, in studies that used semi-structured diagnostic interviews (eg, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders), fully structured interviews (eg, Composite International Diagnostic Interview), and the Mini International Neuropsychiatric Interview. One stage meta-regression was used to examine whether accuracy was associated with reference standard categories and the characteristics of participants. Sensitivity analyses were done to assess whether including published results from studies that did not provide raw data influenced the results.

RESULTS

Individual participant data were obtained from 101 of 168 eligible studies (60%; 25 574 participants (72% of eligible participants), 2549 with major depression). Combined sensitivity and specificity was maximised at a cut-off value of seven or higher for semi-structured interviews, fully structured interviews, and the Mini International Neuropsychiatric Interview. Among studies with a semi-structured interview (57 studies, 10 664 participants, 1048 with major depression), sensitivity and specificity were 0.82 (95% confidence interval 0.76 to 0.87) and 0.78 (0.74 to 0.81) for a cut-off value of seven or higher, 0.74 (0.68 to 0.79) and 0.84 (0.81 to 0.87) for a cut-off value of eight or higher, and 0.44 (0.38 to 0.51) and 0.95 (0.93 to 0.96) for a cut-off value of 11 or higher. Accuracy was similar across reference standards and subgroups and when published results from studies that did not contribute data were included.

CONCLUSIONS

When screening for major depression, a HADS-D cut-off value of seven or higher maximised combined sensitivity and specificity. A cut-off value of eight or higher generated similar combined sensitivity and specificity but was less sensitive and more specific. To identify medically ill patients with depression with the HADS-D, lower cut-off values could be used to avoid false negatives and higher cut-off values to reduce false positives and identify people with higher symptom levels.

TRIAL REGISTRATION

PROSPERO CRD42015016761.

Factors associated with non-initiation of mental healthcare after detection of poor mental health at a scheduled health check: a cohort study

INTRODUCTION

Poor mental health is an important public health concern, but mental health problems are often under-recognised. Providing feedback to general practitioners (GPs) on their patients' mental health status may improve the identification of cases in need of mental healthcare.

OBJECTIVES

To investigate the extent of initiation of mental healthcare after identification of poor mental health and to identify factors associated with non-initiation.

DESIGN

Prospective cohort study with 1-year follow-up.

SETTING

In a population-based health preventive programme, Check Your Health, we conducted a combined mental and physical health check in Randers Municipality, Denmark, in 2012-2015 in collaboration with local GPs.

PARTICIPANTS

Participants were 350 individuals aged 30-49 years old with screen-detected poor mental health who had not received mental healthcare within the past year. The cohort was derived from 14 167 randomly selected individuals of whom 52% (n=7348) participated. Mental health was assessed by the mental component summary score of the 12-item Short-Form Health Survey.

OUTCOME

The outcome was initiation of mental healthcare. Mental healthcare included psychometric testing by GP, talk therapy by GP, contact with a psychologist, contact with a psychiatrist and psychotropic medication.

RESULTS

Within 1 year, 22% (95% CI 18 to 27) of individuals with screen-detected poor mental health initiated mental healthcare. Among individuals who initiated mental healthcare within follow-up, one in six had visited their GP once or less in the preceding year. Male sex (OR: 0.49 (95% CI 0.28 to 0.86)) and less impaired mental health (OR: 0.93 (95% CI 0.89 to 0.98)) were associated with non-initiation of mental healthcare. We found no overall association between socioeconomic factors and initiating mental healthcare.

CONCLUSION

Systematic provision of mental health test results to GPs may improve the identification of cases in need of mental healthcare, but does not translate into initiation of mental healthcare. Further research should focus on methods to improve initiation of mental healthcare, especially among men.

TRIAL REGISTRATION NUMBER

NCT02028195.

Screening Older Adults for Depression: Barriers Across Clinical Discipline Training

Background and Objectives

Depressed older adults are more likely to be seen in primary care than in specialty mental health settings, but research shows that physicians may not routinely screen for depression. Other clinical disciplines are also in a position to screen for depression, but have not been studied. This study examined barriers to screening older adults for depression, and disciplinary differences in clinical trainees’ likelihood of screening.

Research Design and Methods

We used a cross-sectional, online survey with experimental manipulation of vignettes. A four-way mixed analysis of variance explored the effects of clinical discipline (between subjects) and time pressure, patient difficulty, and level of symptoms (within subjects) on trainees’ likelihood of screening.

Results

Participants were 229 trainees in medicine (83), psychology (51), nursing (49), and social work (46). Lower time pressure and greater symptom severity increased likelihood of screening. There was a significant three-way interaction among discipline, patient difficulty, and symptom level that was driven by social work graduate trainees’ greater likelihood of screening for depression when there were more symptoms present, which was diminished if the patient was being difficult. There was a two-way interaction between patient difficulty and level of symptoms: more symptoms resulted in increased likelihood of screening, an effect that diminished with greater patient difficulty.

Discussion and Implications

The study holds implications for identifying and addressing gaps in education on depression screening to minimize the effects of barriers. Interventions could address education about older adults and depression, including practice-based screening, time management, and behavior management skills.

Effects of the 2009 USPSTF Depression Screening Recommendation on Diagnosing and Treating Mental Health Conditions in Older Adults: A Difference-in-Differences Analysis

BACKGROUND

Depression is a common mental condition in U.S. older adults. To improve rates of underdiagnosis and undertreatment for depression and other mental health conditions in primary care settings, the U.S. Preventive Services Task Force (USPSTF) updates and disseminates its depression screening guideline regularly.

OBJECTIVE

To examine the effects of the 2009 USPSTF depression screening recommendation on the 3 following outcomes: diagnoses of mental health conditions, antidepressant prescriptions (overall and potentially inappropriate), and provision of nonpharmacological psychiatric services in office-based outpatient primary care visits made by adults aged 65 or older.

METHODS

Data from the 2006-2012 National Ambulatory Medical Care Survey (NAMCS), a nationally representative sample of office-based outpatient primary care visits among older adults (n = 15,596 unweighted), were used. NAMCS represents physician practicing patterns of ambulatory medical care services utilization at the national level. Using a series of multivariate difference-in-differences analyses, we estimated effects of the USPSTF depression screening recommendation on the previously mentioned outcomes by comparing pre- (2006-2009) and post- (2010-2012) periods to describe primary care physician practice patterns.

RESULTS

Differences in any mental health diagnosis by the depression screening status were -34.7% in the pre-2009 period and -20.2% in the post-2009 period, resulting in a differential effect of -14.4% (95% CI = -28.2, -0.6; P = 0.040). No differential effect was found in other outcomes.

CONCLUSIONS

While there are mixed findings about efficacy and effectiveness of depression screening in the existing literature, more population-based observational research is needed to strengthen and support current USPSTF depression screening recommendation statements in the United States.

DISCLOSURES

Funding for this study was provided by the National Institute on Aging of the National Institutes of Health (#T32AG019134). The authors declare that they do not have any conflicts of interest. Publicly available data were obtained from the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC). Analyses, interpretation, and conclusions are solely those of the authors and do not necessarily reflect the views of the Division of Health Interview Statistics or NCHS of the CDC.

Depression Screening and Health Outcomes in Children and Adolescents: A Systematic Review

OBJECTIVE

Depression screening among children and adolescents is controversial. In 2009, the United States Preventive Services Task Force first recommended routine depression screening for adolescents, and this recommendation was reiterated in 2016. However, no randomized controlled trials (RCTs) of screening were identified in the original 2009 systematic review or in an updated review through February 2015. The objective of this systematic review was to provide a current evaluation to determine whether there is evidence from RCTs that depression screening in childhood and adolescence improves depression outcomes.

METHOD

Data sources included the MEDLINE, MEDLINE In-Process, EMBASE, PsycINFO, Cochrane CENTRAL and LILACS databases searched February 2, 2017. Eligible studies had to be RCTs that compared depression outcomes between children or adolescents aged 6 to 18 years who underwent depression screening and those who did not.

RESULTS

Of 552 unique title/abstracts, none received full-text review. No RCTs that investigated the effects of screening on depression outcomes in children or adolescents were identified.

CONCLUSIONS

There is no direct RCT evidence that supports depression screening among children and adolescents. Groups that consider recommending screening should carefully consider potential harms, as well as the use of scarce health resources, that would occur with the implementation of screening programs.

Effects of depression screening on diagnosing and treating mood disorders among older adults in office-based primary care outpatient settings: An instrumental variable analysis

Existing literature shows mixed findings regarding the efficacy and effectiveness of depression screening, and relatively little is known about the effectiveness of depression screening among older adults in primary care visits in the U.S. This study examines the effects of depression screening on the three following outcomes: mood disorder diagnoses, overall antidepressant prescriptions, and potentially inappropriate antidepressant prescriptions among older adults ages 65 or older in office-based outpatient primary care settings. We used data from 2010-2012 National Ambulatory Medical Care Survey (NAMCS), a nationally representative sample of office-based primary care outpatient visits among older adults (n=9,313 unweighted). We employed an instrumental variable approach to control for selection bias in our repeated cross-sectional population-based study. Injury prevention and stress management were selected as instrumental variables, as they were considered completely exogenous to outcomes of interests using conceptual and statistical criteria. We conducted multivariate bivariate probit (biprobit) regression analyses to investigate the effect of depression screening on each outcome, when controlled for other covariates. We found that depression screening was negatively associated with potentially inappropriate antidepressant prescriptions (β=-2.17; 95% CI -2.80 to -1.53; p<0.001). However, no significant effect of depression screening on diagnosis of mood disorders and overall antidepressant prescriptions was found. Overall, depression screening had a negative effect on potentially inappropriate antidepressant prescriptions. Primary care physicians and other healthcare providers should actively utilize depression screening to minimize potentially inappropriate antidepressant prescriptions in older adult patients.

Job strain as a risk factor for clinical depression: systematic review and meta-analysis with additional individual participant data

BACKGROUND

Adverse psychosocial working environments characterized by job strain (the combination of high demands and low control at work) are associated with an increased risk of depressive symptoms among employees, but evidence on clinically diagnosed depression is scarce. We examined job strain as a risk factor for clinical depression.

METHOD

We identified published cohort studies from a systematic literature search in PubMed and PsycNET and obtained 14 cohort studies with unpublished individual-level data from the Individual-Participant-Data Meta-analysis in Working Populations (IPD-Work) Consortium. Summary estimates of the association were obtained using random-effects models. Individual-level data analyses were based on a pre-published study protocol.

RESULTS

We included six published studies with a total of 27 461 individuals and 914 incident cases of clinical depression. From unpublished datasets we included 120 221 individuals and 982 first episodes of hospital-treated clinical depression. Job strain was associated with an increased risk of clinical depression in both published [relative risk (RR) = 1.77, 95% confidence interval (CI) 1.47-2.13] and unpublished datasets (RR = 1.27, 95% CI 1.04-1.55). Further individual participant analyses showed a similar association across sociodemographic subgroups and after excluding individuals with baseline somatic disease. The association was unchanged when excluding individuals with baseline depressive symptoms (RR = 1.25, 95% CI 0.94-1.65), but attenuated on adjustment for a continuous depressive symptoms score (RR = 1.03, 95% CI 0.81-1.32).

CONCLUSIONS

Job strain may precipitate clinical depression among employees. Future intervention studies should test whether job strain is a modifiable risk factor for depression.

Selective Cutoff Reporting in Studies of Diagnostic Test Accuracy: A Comparison of Conventional and Individual-Patient-Data Meta-Analyses of the Patient Health Questionnaire-9 Depression Screening Tool

In studies of diagnostic test accuracy, authors sometimes report results only for a range of cutoff points around data-driven "optimal" cutoffs. We assessed selective cutoff reporting in studies of the diagnostic accuracy of the Patient Health Questionnaire-9 (PHQ-9) depression screening tool. We compared conventional meta-analysis of published results only with individual-patient-data meta-analysis of results derived from all cutoff points, using data from 13 of 16 studies published during 2004-2009 that were included in a published conventional meta-analysis. For the "standard" PHQ-9 cutoff of 10, accuracy results had been published by 11 of the studies. For all other relevant cutoffs, 3-6 studies published accuracy results. For all cutoffs examined, specificity estimates in conventional and individual-patient-data meta-analyses were within 1% of each other. Sensitivity estimates were similar for the cutoff of 10 but differed by 5%-15% for other cutoffs. In samples where the PHQ-9 was poorly sensitive at the standard cutoff, authors tended to report results for lower cutoffs that yielded optimal results. When the PHQ-9 was highly sensitive, authors more often reported results for higher cutoffs. Consequently, in the conventional meta-analysis, sensitivity increased as cutoff severity increased across part of the cutoff range-an impossibility if all data are analyzed. In sum, selective reporting by primary study authors of only results from cutoffs that perform well in their study can bias accuracy estimates in meta-analyses of published results.

A randomised controlled trial of the effectiveness of a program for early detection and treatment of depression in primary care

OBJECTIVE

There is considerable uncertainty about whether depression screening programs in primary care may improve outcomes and what specific features of such programs may contribute to success. We tested the effectiveness of a program involving substantial commitment from local mental health services.

METHODS

Prospective, randomised, patient- and evaluator-masked, parallel-group, controlled study. Participants were recruited in several urban primary care practices where they completed the PC-SAD screener and WHOQOL-Bref. Those who screened positive and did not report suicidal ideation (N=115) were randomised to an intervention group (communication of the result and offer of psychiatric evaluation and treatment free of charge; N=56) or a control group (no feedback on test result for 3 months; N=59). After 3 months, 100 patients agreed to a follow-up telephone interview including the administration of the PC-SAD5 and WHOQOL-Bref.

RESULTS

Depression severity and quality of life improved significantly in both groups. Intent-to-treat analysis showed no effect of the intervention. As only 37% of patients randomised to the intervention group actually contacted the study outpatient clinic, we performed a per-protocol analysis to determine whether the intervention, if delivered as planned, had been effective. This analysis revealed a significant positive effect of the intervention on severity of depressive symptoms, and on response and remission rate. Complier average causal effect analysis yielded similar results.

CONCLUSION

Due to the relatively small sample size, our findings should be regarded as preliminary and have limited generalizability. They suggest that there are considerable barriers on the part of many patients to the implementation of depression screening programs in primary care. While such programs can be effective, they should be designed based on the understanding of patients' perspectives.

Sample sizes and precision of estimates of sensitivity and specificity from primary studies on the diagnostic accuracy of depression screening tools: a survey of recently published studies

Depression screening tools are useful to the extent that they accurately discriminate between depressed and non-depressed patients. Studies without enough patients to generate precise estimates make it difficult to evaluate accuracy. We conducted a survey of recently published studies on depression screening tool accuracy to evaluate the percentage with sample size calculations; the percentage that provided confidence intervals; and precision, based on the width and lower bounds of 95% confidence intervals for sensitivity and specificity. We calculated 95% confidence intervals, if possible, when not provided. Only three of 89 studies (3%) described a viable sample size calculation. Only 30 studies (34%) provided reasonably accurate confidence intervals. Of 86 studies where 95% confidence intervals were provided or could be calculated, only seven (8%) had interval widths for sensitivity of ≤ 10%, whereas 53 (62%) had widths of ≥ 21%. Lower bounds of confidence intervals were < 80% for 84% of studies for sensitivity and 66% of studies for specificity. Overall, few studies on the diagnostic accuracy of depression screening tools reported sample size calculations, and the number of patients in most studies was too small to generate reasonably precise accuracy estimates. The failure to provide confidence intervals in published reports may obscure these shortcomings. Copyright © 2016 John Wiley & Sons, Ltd.

Diagnostic accuracy of the Depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) for detecting major depression: protocol for a systematic review and individual patient data meta-analyses

INTRODUCTION

The Depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) has been recommended for depression screening in medically ill patients. Many existing HADS-D studies have used exploratory methods to select optimal cut-offs. Often, these studies report results from a small range of cut-off thresholds; cut-offs with more favourable accuracy results are more likely to be reported than others with worse accuracy estimates. When published data are combined in meta-analyses, selective reporting may generate biased summary estimates. Individual patient data (IPD) meta-analyses can address this problem by estimating accuracy with data from all studies for all relevant cut-off scores. In addition, a predictive algorithm can be generated to estimate the probability that a patient has depression based on a HADS-D score and clinical characteristics rather than dichotomous screening classification alone. The primary objectives of our IPD meta-analyses are to determine the diagnostic accuracy of the HADS-D to detect major depression among adults across all potentially relevant cut-off scores and to generate a predictive algorithm for individual patients. We are already aware of over 100 eligible studies, and more may be identified with our comprehensive search.

METHODS AND ANALYSIS

Data sources will include MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO and Web of Science. Eligible studies will have datasets where patients are assessed for major depression based on a validated structured or semistructured clinical interview and complete the HADS-D within 2 weeks (before or after). Risk of bias will be assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Bivariate random-effects meta-analysis will be conducted for the full range of plausible cut-off values, and a predictive algorithm for individual patients will be generated.

ETHICS AND DISSEMINATION

The findings of this study will be of interest to stakeholders involved in research, clinical practice and policy.

Screening for anxiety disorders with the GAD-7 and GAD-2: a systematic review and diagnostic metaanalysis

OBJECTIVE

To systematically review the accuracy of the GAD-7 and GAD-2 questionnaires for identifying anxiety disorders.

METHODS

A systematic review of the literature was conducted to identify studies that validated the GAD-7 or GAD-2 against a recognized gold standard diagnosis. Pooled estimates of diagnostic test accuracy were produced using random-effects bivariate metaanalysis. Heterogeneity was explored using the I(2) statistic.

RESULTS

A total of 12 samples were identified involving 5223 participants; 11 samples provided data on the accuracy of the GAD-7 for identifying generalized anxiety disorder (GAD). Pooled sensitivity and specificity values appeared acceptable at a cutoff point of 8 [sensitivity: 0.83 (95% CI 0.71-0.91), specificity: 0.84 (95% CI 0.70-0.92)] although cutoff scores 7-10 also had similar pooled estimates of sensitivity/specificity. Six samples provided data on the accuracy of the GAD-2 for identifying GAD. Pooled sensitivity and specificity values appeared acceptable at a cutoff of 3 [sensitivity: 0.76 (95% CI 0.55-0.89), specificity: 0.81 (95% CI 0.60-0.92)]. Four studies looked at the accuracy of the questionnaires for identifying any anxiety disorder.

CONCLUSIONS

The GAD-7 had acceptable properties for identifying GAD at cutoff scores 7-10. The GAD-2 had acceptable properties for identifying GAD at a cutoff score of 3. Further validation studies are needed.

Patient-reported depression measures in cancer: a meta-review

The patient-reported depression measures that perform best in oncology settings have not yet been identified. We did a meta-review to integrate the findings of reviews of more than 50 depression measures used in adults with, or recovering from, any type of cancer. We searched Medline, PsycINFO, Embase, and grey literature from 1999 to 2014 to identify 19 reviews representing 372 primary studies. 11 reviews were rated as being of high quality (defined as meeting at least 20 criteria in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement). The Hospital Anxiety Depression Scale (HADS) was the most thoroughly evaluated measure, but was limited by cutpoint variability. The HADS had moderate screening utility indices and was least recommended in advanced cancer or palliative care. The Beck Depression Inventory was more generalisable across cancer types and disease stages, with good indices for screening and case finding. The Center for Epidemiologic Studies Depression Scale was the best-weighted measure in terms of responsiveness. This meta-review provides a comprehensive overview of the strengths and limitations of available depression measures. It can inform the choice of the best measure for specific settings and purposes.

Use of the Patient Health Questionnaire-9 and a detailed suicide evaluation in determining imminent suicidality in distressed patients with cardiac disease

BACKGROUND

The risk of suicide is elevated in patients with cardiac disease in comparison with the general population.

OBJECTIVE

In distressed cardiac inpatients, we explored the use of Item 9 of the Patient Health Questionnaire-9, which inquires about thoughts of death or suicide, and a detailed suicide evaluation (DSE) triggered by positive responses to Item 9 as means of assessing suicide.

METHODS

Among cardiac inpatients endorsing current emotional distress, we recorded the prevalence of positive responses to Item 9, gathered information about outcomes and time spent completing the DSE, and examined the frequency of imminent suicidality identified by the DSE among Item 9-positive patients.

RESULTS

Among 366 patients, 77 (21%) answered affirmatively to Item 9. All DSEs were successfully completed but consumed 17 clinician hours. Among the 71 patients receiving the DSE, 2 (0.5% of total sample; 2.8% of Item 9-positive patients) were imminently suicidal (i.e., had intent or plan).

CONCLUSION

Nearly 1 in 4 patients had a positive response to Item 9, but very few had imminent suicidality; the DSE was easy to use and acceptable to patients but time consuming. A more narrowly focused alternative to Item 9 may more accurately predict imminent suicidality and reduce the burden of further detailed suicide screening.

Routine depression screening in an MS clinic and its association with provider treatment recommendations and related treatment outcome

Depression, a frequent concomitant disorder in multiple sclerosis (MS), can impact MS treatment adherence and quality of life. Depression screening in MS care settings may facilitate needed intervention when providers are responsive to screening findings. This study sought to examine the relationship between depression screening results and provider depression treatment recommendations documented in the medical records of 283 patients receiving care in an integrated MS clinic. Forty-six percent of patients screening positive for depression received a treatment recommendation; females, those with past mental health diagnoses, on psychotropic medications, and those with higher symptom severity were more likely to receive a treatment recommendation. On subsequent screenings, patients reported fewer depressive symptoms regardless of whether a formal treatment recommendation was documented. These findings suggest that while depression screening does lead to depression related intervention in many cases, more research is necessary to determine who is most likely to benefit and under what conditions.

Depression screening and patient outcomes in pregnancy or postpartum: a systematic review

OBJECTIVE

Clinical practice guidelines disagree on whether health care professionals should screen women for depression during pregnancy or postpartum. The objective of this systematic review was to determine whether depression screening improves depression outcomes among women during pregnancy or the postpartum period.

METHODS

Searches included the CINAHL, EMBASE, ISI, MEDLINE, and PsycINFO databases through April 1, 2013; manual journal searches; reference list reviews; citation tracking of included articles; and trial registry reviews. RCTs in any language that compared depression outcomes between women during pregnancy or postpartum randomized to undergo depression screening versus women not screened were eligible.

RESULTS

There were 9,242 unique titles/abstracts and 15 full-text articles reviewed. Only 1 RCT of screening postpartum was included, but none during pregnancy. The eligible postpartum study evaluated screening in mothers in Hong Kong with 2-month-old babies (N=462) and reported a standardized mean difference for symptoms of depression at 6 months postpartum of 0.34 (95% confidence interval=0.15 to 0.52, P<0.001). Standardized mean difference per 44 additional women treated in the intervention trial arm compared to the non-screening arm was approximately 1.8. Risk of bias was high, however, because the status of outcome measures was changed post-hoc and because the reported effect size per woman treated was 6-7 times the effect sizes reported in comparable depression care interventions.

CONCLUSION

There is currently no evidence from any well-designed and conducted RCT that screening for depression would benefit women in pregnancy or postpartum. Existing guidelines that recommend depression screening during pregnancy or postpartum should be re-considered.

Managing Cancer And Living Meaningfully (CALM): phase 2 trial of a brief individual psychotherapy for patients with advanced cancer

BACKGROUND

Advanced cancer brings substantial physical and psychosocial challenges that may contribute to emotional distress and diminish well-being. In this study, we present preliminary data concerning the effectiveness of a new brief individual psychotherapy, Managing Cancer And Living Meaningfully (CALM), designed to help individuals cope with this circumstance.

AIM

To test the feasibility and preliminary effectiveness of CALM to reduce emotional distress and promote psychological well-being and growth.

DESIGN

CALM is a brief, manualized, semi-structured individual psychotherapy for patients with advanced cancer. This study employed a phase 2 intervention-only design. The primary outcome was depressive symptoms and the secondary outcomes were death anxiety, attachment security, spiritual well-being and psychological growth. These were assessed at 3 months (t1) and 6 months (t2). Multilevel regression was used to model change over time.

SETTING/PARTICIPANTS

A total of 50 patients with advanced or metastatic cancer were recruited from the Princess Margaret Cancer Centre, Toronto, Canada.

RESULTS

A total of 39 patients (78%) were assessed at baseline, 24 (48%) at t1, and 16 (32%) at t2. Analyses revealed reductions over time in depressive symptoms: beta = -0.13, confidence interval (CI.95) = (-0.23, -0.022) and death anxiety: beta = -0.23, CI.95 (-0.40, -0.061); and an increase in spiritual well-being: beta = 0.14, CI.95 (0.026, 0.26).

CONCLUSIONS

CALM may be a feasible intervention to benefit patients with advanced cancer. The results are encouraging, despite attrition and small effect sizes, and support further study.

There are no randomized controlled trials that support the United States Preventive Services Task Force Guideline on screening for depression in primary care: a systematic review

BACKGROUND

The United States Preventive Services Task Force (USPSTF) recommends screening adults for depression in primary care settings when staff-assisted depression management programs are available. This recommendation, however, is based on evidence from depression management programs conducted with patients already identified as depressed, even though screening is intended to identify depressed patients not already recognized or treated. The objective of this systematic review was to evaluate whether there is evidence from randomized controlled trials (RCTs) that depression screening benefits patients in primary care, using an explicit definition of screening.

METHODS

We re-evaluated RCTs included in the 2009 USPSTF evidence review on depression screening, including only trials that compared depression outcomes between screened and non-screened patients and met the following three criteria: determined patient eligibility and randomized prior to screening; excluded patients already diagnosed with a recent episode of depression or already being treated for depression; and provided the same level of depression treatment services to patients identified as depressed in the screening and non-screening trial arms. We also reviewed studies included in a recent Cochrane systematic review, but not the USPSTF review; conducted a focused search to update the USPSTF review; and reviewed trial registries.

RESULTS

Of the nine RCTs included in the USPSTF review, four fulfilled none of three criteria for a test of depression screening, four fulfilled one of three criteria, and one fulfilled two of three criteria. There were two additional RCTs included only in the Cochrane review, and each fulfilled one of three criteria. No eligible RCTs were found via the updated review.

CONCLUSIONS

The USPSTF recommendation to screen adults for depression in primary care settings when staff-assisted depression management programs are available is not supported by evidence from any RCTs that are directly relevant to the recommendation. The USPSTF should re-evaluate this recommendation. Please see related article: http://www.biomedcentral.com/1741-7015/12/14 REGISTRATION: PROSPERO (#CRD42013004276).

Screening for depression: a systematic review and meta-analysis

BACKGROUND

The Canadian Task Force on Preventive Health Care has a guideline on screening for depression among adults 18 years of age or older at average or high risk for depression. To provide evidence for an update of this guideline, we evaluated the literature on the effectiveness of screening for depression in adults.

METHODS

For the period 1994 to May 23, 2012, we searched the following electronic databases: MEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews. Randomized controlled trials, observational studies and systematic reviews with evidence for the benefits or harms of screening for depression were eligible for inclusion. We performed screening for relevance, extraction of data, analysis of risk of bias and quality assessments in duplicate. We used the generic inverse variance method to conduct a meta-analysis. To determine confidence in the effect, we analyzed the results according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

RESULTS

Five quasi-experimental studies (before-after design with a nonrandomized control group) met the inclusion criteria for this review. These studies reported on the effect of community-based screening for depression, with follow-up on the risk of suicide completion, for older residents in regions of rural Japan with high suicide rates. Meta-analysis showed that the screening program had a protective effect on the overall incidence of suicide completion (ratio of rate ratios [RRR] 0.50, 95% confidence interval [CI], 0.32-0.78). When sex was considered, the RRR indicated a significantly lower rate of suicide among women (RRR 0.37, 95% CI 0.21-0.66) but not among men (RRR 0.67, 95% CI 0.35-1.27). The overall GRADE rating applied to this evidence indicated very low quality. No studies addressing the harms of screening for depression met the inclusion criteria for the review.

INTERPRETATION

There is very limited research evidence allowing conclusions about the effectiveness of screening for depression in either average-risk or high-risk populations.

Systematic depression screening in high-risk patients attending primary care: a pragmatic cluster-randomized trial

BACKGROUND

Systematic screening for depression in high-risk patients is recommended but remains controversial. The aim of this study was to assess the effectiveness of such screening in everyday clinical practice on depression recognition.

METHODS

A pragmatic, cluster randomized, controlled study that randomized primary care physicians (PCPs) in Spain either to an intervention or control group. The intervention group (35-PCPs) received training in depression screening and used depression screening routinely for at least 6 months. The control group (34-PCPs) managed depression in their usual manner. Adherence to (1-6; never-very frequently), feasibility (1-4; unfeasible-very feasible), and acceptance (1-5; very poor-very good) of the screening were evaluated. Underrecognition (primary outcome) and undertreatment rates of major depressive disorder (MDD) in the two groups were compared 6 months after randomization in a random sample of 3737 patients assigned to these PCPs using logistic regression adjusting for the clustering effect.

RESULTS

No significant differences were found for recognition rates (58.0% vs. 48.1% intervention vs. control; OR [95%CI] 1.40 [0.73-2.68], p = 0.309). The undertreatment rate did not differ significantly either (p = 0.390). The mean adherence to depression screening was 4.4 ± 1.0 ('occasionally'), the mean feasibility was 3.1 ± 0.5 ('moderately feasible'), and the mean acceptance was 4.2 ± 0.6 ('good').

CONCLUSIONS

This research was not able to show effectiveness of the systematic screening for MDD in high-risk patients on depression recognition in primary care. The poor adherence to screening implementation could partially explain the results. These reflect the difficulties of putting into practice the clinical guidelines usually based on interventional research.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01662817.

Now what? Toward an integrated research and practice agenda in distress screening

Significant gains have been made in the detection and treatment of cancer, contributing to increased survival, but a cancer diagnosis and treatment may be accompanied by physical and psychosocial after-effects. Distress screening has been championed as a mechanism to identify patients with high levels of psychosocial morbidity for subsequent assessment and psychosocial care delivery. However, implementation of distress screening has been variable, in scope and in the consistency and quality of metrics and methods used. This capstone article identifies challenges in the measurement and implementation of distress screening and examines future opportunities for research and implementation.

Patients' and Health Care Providers' Evaluation of Quality of Life Issues in Advanced Cancer Using Functional Assessment of Chronic Illness Therapy - Palliative Care Module (FACIT-Pal) Scale

Background

To examine the agreement of Health Care Providers (HCPs) and patients’ evaluation of quality of life on the Functional Assessment of Chronic Illness therapy - Palliative care module (FACIT-Pal) scale.

Methods

Sixty advanced cancer patients and fifty-six health care providers involved in their care at Sunnybrook Health Sciences Centre completed a modified version of the FACIT- Pal. In the survey, patients and HCPs indicated the 10 top issues affecting the quality of life of patients with advanced cancer most profoundly. The percentage of participants selecting each item as one of their 10 most relevant items was calculated in HCPs and patients.

Results

There were differences in relative rankings of QOL issues among patients and HCPs. Among the top 10 items which were identified from both patients and HCPs, there were differences in the rankings. Patients ranked emotional support from family (40.9%) as most important followed by pain (38.6%), lack of energy (31.8%) and able to enjoy life (29.6%). HCPs ranked in the following order: pain (73.2%), lack of energy (63.4%), nausea (51.2%) and dyspnea (51.2%) whereas patients rated nausea at 18.2 % and dyspnea at 9.09%.

Conclusion

There is a discrepancy between scores of patients and HCPs as they may prioritize differently. HCPs tended to put more emphasis on physical symptoms, whereas patients had emotional and global issues as priorities.

What happens now? Psychosocial care for cancer survivors after medical treatment completion

The growing population of adults living with a history of cancer in the United States mandates attention to quality of life and health in this group, as well as to the implementation of evidence-based interventions to address psychosocial and physical concerns at completion of medical treatments and beyond. The goals of this article are to document the need for attention to psychosocial domains during the re-entry and later phases of the cancer survivor trajectory, offer an overview of current evidence on efficacy of psychosocial interventions during those phases, and offer suggestions for application and research regarding post-treatment psychosocial care.

Depression screening and patient outcomes in cancer: a systematic review

Background

Several practice guidelines recommend screening for depression in cancer care, but no systematic reviews have examined whether there is evidence that depression screening benefits cancer patients. The objective was to evaluate the potential benefits of depression screening in cancer patients by assessing the (1) accuracy of depression screening tools; (2) effectiveness of depression treatment; and (3) effect of depression screening, either alone or in the context of comprehensive depression care, on depression outcomes.

Methods

Data sources were CINAHL, Cochrane, EMBASE, ISI, MEDLINE, PsycINFO and SCOPUS databases through January 24, 2011; manual journal searches; reference lists; citation tracking; trial registry reviews. Articles on cancer patients were included if they (1) compared a depression screening instrument to a valid criterion for major depressive disorder (MDD); (2) compared depression treatment with placebo or usual care in a randomized controlled trial (RCT); (3) assessed the effect of screening on depression outcomes in a RCT.

Results

There were 19 studies of screening accuracy, 1 MDD treatment RCT, but no RCTs that investigated effects of screening on depression outcomes. Screening accuracy studies generally had small sample sizes (median = 17 depression cases) and used exploratory methods to set sample-specific cutoff scores that varied substantially across studies. A nurse-delivered intervention for MDD reduced depressive symptoms moderately (effect size = 0.37).

Conclusions

The one treatment study reviewed reported modest improvement in depressive symptoms, but no evidence was found on whether or not depression screening in cancer patients, either alone or in the context of optimal depression care, improves depression outcomes compared to usual care. Depression screening in cancer should be evaluated in a RCT in which all patients identified as depressed, either through screening or via physician recognition and referral in a control group, have access to comprehensive depression care.

How reliable is depression screening in alcohol and drug users? A validation of brief and ultra-brief questionnaires

BACKGROUND

Depression is highly comorbid with alcohol and drug problems, resulting in greater impairment, reduced treatment adherence and poor outcomes. Little evidence exists to support the use of mental health screening tools in routine addiction treatment. This study tested the validity and reliability of PHQ-9 and PHQ-2 as depression case finding tools in an outpatient drug treatment sample in the United Kingdom.

METHODS

A sample of 103 patients took part in diagnostic assessments using CIS-R and completed brief screening questionnaires. A subgroup of 60 patients completed retests after 4 weeks. Diagnostic results were compared to brief measures using receiver operating characteristic (ROC) curves. Psychometric properties were also calculated to evaluate the validity and reliability of self-completed questionnaires.

RESULTS

A PHQ-9 score ≥ 12 had a sensitivity of 81% and specificity of 75% for major depression, also displaying good retest reliability (intra-class correlation, 0.78) and internal consistency (Cronbach's alpha, 0.84). PHQ-2 had 68% sensitivity and 70% specificity, with more modest retest reliability (0.66) and internal consistency (0.64).

LIMITATIONS

Diagnostic interviews did not consider the temporal sequencing of the onset of drug use and mental health problems.

CONCLUSIONS

PHQ-9 is a valid and reliable depression screening tool for drug and alcohol users. The brevity and ease of administration of self-completed questionnaires make them useful clinical tools in addiction services commonly encountering a high prevalence of depression.

Is screening effective in detecting untreated psychiatric disorders among newly diagnosed breast cancer patients?

BACKGROUND

A key purpose of routine distress screening is to ensure that cancer patients receive appropriate mental health care. Most studies validating screening instruments overestimate the effectiveness of screening by not differentiating between patients with untreated disorders and patients who are already being treated. This study adopts the novel strategy of evaluating the effectiveness of screening after correcting for disorder for which treatment is already being provided.

METHODS

A total of 437 recently diagnosed breast cancer patients received in-clinic distress screening and telephone-based psychiatric interviews. Analyses were conducted using receipt of psychotropic medication for mental health difficulties in the context of a psychiatric disorder as a proxy for identification and treatment.

RESULTS

Rates of elevated distress (33%), major depressive disorder (8%), minor depression (6%), dysthymia (2%), or generalized anxiety disorder (3%) were similar to those in other samples. Thirty-six percent of patients received psychotropic medication around the time of cancer diagnosis, including 64% of those with a current psychiatric diagnosis. Although 39% of patients with elevated distress had a psychiatric disorder, the positive predictive value of screening fell to 15% for an untreated psychiatric disorder and 6% had untreated depression.

CONCLUSION

Given the high rates of existing treatment, screening may not be efficient for identifying untreated disorder. Almost two-thirds of patients with treated disorders remain symptomatic. Use of symptom scales might reasonably be expanded to surveillance of treatment response or ruling out disorder. Substantial resources would likely be required to coordinate or manage psychiatric care among patients, as would a willingness to intervene in existing relationships with other providers.

Can general practitioners identify people with distress and mild depression? A meta-analysis of clinical accuracy

BACKGROUND

There is increasing emphasis on distress and mild depression but uncertainty regarding how well general practitioners (GPs) identify these conditions. Further, the proportion of attendees suffering distress is also unclear.

AIM

To quantify the rate of distress in primary care and to clarify the ability of GPs to identify distressed and/or mildly depressed individuals using their clinical skills.

METHODS

Meta-analysis of clinical recognition of distress and mild depression defined on a continuum (severity scale) or categorically (semi-structured interview).

RESULTS

From 157 studies that examined the ability of GPs to diagnose any emotional or mental disorder, we identified 23 that focused on defined distress and 9 that reported on mild depression. The prevalence of broadly defined distress was 37.4% (n=23, 95% CI=29.5% to 45.5) although it was 47.3% (n=14, 95% CI=38.0% to 56.7%) using self-report methods. GPs correctly identified distressed individuals in 48.4% (n=21, 95% CI=42.6% to 54.2%) of presentations and identified non-distressed people in 79.4% (n=21, 95% CI=74.3% to 84.1%) of presentations without distress. GPs correctly identified 33.8% (95% CI=27.3% to 40.7%) of people with mild depression and had a detection specificity of 80.6% (95% CI=66.4% to 91.6%) for the non-depressed. Clinicians' ability to recognize mild depression was significantly lower than their ability to recognize moderate-severe depression. Out of 100 consecutive presentations, a typical GP making a single assessment would correctly identify 19 out of 39 people with distress, missing 20. He or she would correctly re-assure 48 out of 61 people without distress, falsely label 13 people as distressed. For mild depression, out of 100 consecutive presentations, a typical GP would correctly identify 4 out of 11 people with mild depression, missing 7. GPs would correctly re-assure 72 out of 89 people without distress, falsely diagnosing 19.

CONCLUSIONS

Clinicians have considerable difficulty accurately identifying distress and mild depression in primary care with only one in three people correctly diagnosed. Clinicians are better able to identify distress than mild depression but success remains limited. However not all such individuals want professional help, and some people who are overlooked get help elsewhere, or improve spontaneously, therefore the implications of these detection problems are not yet clear.

Does Depression Screening Have an Effect on the Diagnosis and Treatment of Mood Disorders in General Medical Settings? An Instrumental Variable Analysis of the National Ambulatory Medical Care Survey

This study examined the association of depression screening with the diagnoses of mood disorders and prescription of antidepressants in 73,712 visits to nonpsychiatrist physician offices drawn from the 2005-2007 U.S. National Ambulatory Medical Care Survey. Physicians used depression screening selectively for patients whom they perceived as more likely to have a mood disorder. In bivariate probit analyses with instrumental variables, depression screening did not increase the prevalence of either mood disorder diagnoses or prescription of antidepressants. However, screening was associated with lower rates of antidepressants prescription without a diagnosis of a mood disorder. In visits in which antidepressants were prescribed, 47.4% of the screened visits compared with 16.3% of nonscreened visits had a mood disorder diagnosis. As currently practiced in medical settings, depression screening may help improve targeting and appropriate use of antidepressant medications. Wider use of depression screening may help curb the growing trend of off-label antidepressant prescriptions.

Does screening for distress efficiently uncover meetable unmet needs in cancer patients?

OBJECTIVES

We evaluated screening for distress in terms of its ability to uncover unmet need for psychosocial services in cancer patients. Correlates of distress, need for services and met and unmet need for services were investigated.

METHODS

Immediately after cancer treatment (T1) and 2 months later (T2), 302 patients completed the Hopkins Symptom Checklist-25 (HSCL-25) and a single question assessing the need for services. All distressed patients (HSCL-25≥39) and non-distressed patients endorsing a need for services were then called (n = 99) to assess their need.

RESULTS

Thirty-seven percent (T1) and 31% (T2) of patients were distressed and 31% (T1) and 18% (T2) expressed the need for services. Both time points showed higher distress in younger patients and females and lower distress in prostate cancer and patients treated by radiotherapy only. Less need for services was found in prostate cancer (T1), greater need was related to being single (T1) and younger (T2). Distress and need for services were positively related (p<0.001). The HSCL-25 showed modest sensitivity (T1: 0.59, T2: 0.65) and specificity (T1: 0.75, T2: 0.78) as an indicator of need for services. Interviews at T2 revealed that 51% of distressed patients needed no psychosocial services and 25% were already receiving services. At T2, regardless of distress level, 10% of all screened patients reported an unmet need for psychosocial services.

CONCLUSIONS

Depending on the clinical context, screening might be more efficient if it assessed the unmet need for services rather than distress. More attention should be concentrated on directing patients with meetable unmet needs to available services.

The oncologist's role in managing depression, anxiety, and demoralization with advanced cancer

The incidence of psychological distress-depression, anxiety, delirium-in patients with cancer ranges from 35% to 50%. Demoralization, a new concept, has not been included in most studies. The role of the oncologist in managing depression, anxiety, and demoralization involves diagnosing the problem, providing verbal support, first-line psychotropic medications, and referral to the psycho-oncology team. Empirical studies have shown that oncologists have difficulties in recognizing psychological stress and talking with patients about it. Reasons include a belief that distress is "normal"; the subject matter is embarrassing and uncomfortable; they feel unskilled; and time constraints. Therefore, the role of communication training in medical school and for oncologists in training is important. Screening for psychological distress may identify patients; however, inadequate psychosocial follow up and support may make screening counterproductive. Depression and anxiety constitute most psychological distress and will be described in formal psychiatric terms (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) and subjective descriptions. Demoralization, a concept recently introduced to psycho-oncology, is reviewed. Demoralization acts as a bridge from traditional psychiatric terminology to newer concepts used to describe the particular psychological distress characteristic of advanced cancer. Word concepts, such as meaning, spiritual, dignity, and existential, capture the patients' distress that is not defined by formal psychiatric taxonomy. Management modalities for depression, anxiety, and demoralization are discussed.

Which version of the geriatric depression scale is most useful in medical settings and nursing homes? Diagnostic validity meta-analysis

BACKGROUND

The Geriatric Depression Scale (GDS) has been evaluated in individual studies, but its validity and added value in medical settings and nursing homes is uncertain. Therefore, the authors conducted a meta-analysis, analyzing the diagnostic accuracy of long, short, and ultrashort versions of the GDS and stratified this into those with and without cognitive impairment.

METHODS

A comprehensive search identified 69 studies that measured the diagnostic validity of the GDS against a semistructured psychiatric interview, and of these, 43 analyses (in 36 publications) took place inmedical settings. Twenty-one studies examined the GDS₃₀, 12 studies examined the GDS₁₅, and 3 examined the GDS₄(/)₅. For comparison, the authors also summarized studies examining unassisted clinical judgment. Heterogeneity was moderate to high; therefore, random effects meta-analysis was used.

RESULTS

Across all studies, the prevalence of late-life depression was 29.2% (95% confidence interval [CI] = 24.7%–33.9%), with no difference between inpatients, outpatients, and nursing homes. Diagnostic accuracy of the GDS₃₀ aftermeta-analytic weighting was given by a sensitivity of 81.9% (95% CI = 76.4%–86.9%) and a specificity of 77.7% (95% CI = 73.0%–82.1%). For the GDS₁₅, sensitivity was 84.3% (95% CI = 79.7%–88.4%) and specificity was 73.8% (95% CI = 68.0%–79.2%). For the GDS₄(/)₅, the sensitivity and specificity were 92.5% (95% CI = 85.5%–97.4%) and 77.2% (95% CI = 66.6%–86.3%), respectively. Results were not significantly influenced by the presence of dementia. Concerning added value, when identification using the GDS was compared with routine clinicians’ ability to diagnose late-life depressions, at a prevalence of 30%, of every 100 attendees, the GDS₃₀ would help correctly identify an additional 22 people as depressed but at a cost of 13 additional false positives. The GDS₁₅ performed the same as GDS₃₀ but with 15 false positives. The ultrashort form would help identify an additional 25 true positives with only 10 false positives. Thus, the best option when choosing between versions of the GDS seems to be the GDS₄(/)₅.

CONCLUSION

All versions of the GDS yield potential added value in medical settings, but the GDS₄(/)₅ is the most efficient. In nursing homes, given an absence of data on the GDS₄(/)₅, the GDS₁₅ may be preferred until more studies are reported.

Diagnostic validity and added value of the Geriatric Depression Scale for depression in primary care: a meta-analysis of GDS30 and GDS15

BACKGROUND

The Geriatric Depression Scale (GDS) has been evaluated in hospital settings but its validity and added value in primary care is uncertain. We therefore conducted a meta-analysis analysing the diagnostic accuracy, clinical utility and added value of the GDS in primary care.

METHODS

A comprehensive search identified 69 studies that measured the diagnostic validity of the GDS against a semi-structured psychiatric interview and of these 17 analyses (in 14 publications) took place in primary care. Seven studies examined the GDS(30) and 10 studies examined the GDS(15). Heterogeneity was moderate to high, therefore random effects meta-analysis was used.

RESULTS

Diagnostic accuracy of the GDS(30) after meta-analytic weighting was given by a sensitivity of 77.4% (95% CI=66.3% to 86.8%) and a specificity=65.4% (95% CI=44.2% to 83.8%). For the GDS(15) the sensitivity was 81.3% (95% CI=77.2% to 85.2%) and specificity=78.4% (95% CI=71.2% to 84.8%). The fraction correctly identified (also known as efficiency) by the GDS(15) was significantly higher than the GDS(30) (77.6% vs 71.2%, Chi(2)=24.8 P<0.0001). The clinical utility of both the GDS(30) and GDS(15) was "poor" for case-finding (UI+ 0.29, UI+ 0.32 respectively). However the GDS(15) was rated as "good" for screening (UI- 0.75) whereas the GDS(30) was "adequate" (UI- 0.60). Concerning added value, when identification using the GDS was compared with general practitioners' ability to diagnose late-life depressions unassisted by tools, at a prevalence of 15% the GDS(30) had no added benefit whereas the GDS(15) helped identify an additional 4 cases per 100 primary care attendees and also helped rule-out an additional 4 non-cases per 100 attendees. Thus we estimate the potential gain of the GDS(15) in primary care to be 8% over unassisted clinical detection but at a cost of 3-4 minutes of extra time per appointment.

CONCLUSION

The GDS yields potential added value in primary care. We recommend the GDS(15) but not the GDS(30) in the diagnosis of late-life depression in primary care.

Reinvention of depression instruments by primary care clinicians

PURPOSE

Despite the sophisticated development of depression instruments during the past 4 decades, the critical topic of how primary care clinicians actually use those instruments in their day-to-day practice has not been investigated. We wanted to understand how primary care clinicians use depression instruments, for what purposes, and the conditions that influence their use.

METHODS

Grounded theory method was used to guide data collection and analysis. We conducted 70 individual interviews and 3 focus groups (n = 24) with a purposeful sample of 70 primary care clinicians (family physicians, general internists, and nurse practitioners) from 52 offices. Investigators' field notes on office practice environments complemented individual interviews.

RESULTS

The clinicians described occasional use of depression instruments but reported they did not routinely use them to aid depression diagnosis or management; the clinicians reportedly used them primarily to enhance patients' acceptance of the diagnosis when they anticipated or encountered resistance to the diagnosis. Three conditions promoted or reduced use of these instruments for different purposes: the extent of competing demands for the clinician's time, the lack of objective evidence of depression, and the clinician's familiarity with the patient. No differences among the 3 clinician groups were found for these 3 conditions.

CONCLUSIONS

Depression instruments are reinvented by primary care clinicians in their real-world primary care practice. Although depression instruments were originally conceptualized for screening, diagnosing, or facilitating the management of depression, our study suggests that the real-world practice context influences their use to aid shared decision making-primarily to suggest, tell, or convince patients to accept the diagnosis of depression.

Sociodemographic factors contribute to the depressive affect among African Americans with chronic kidney disease

Depression is common in end-stage renal disease and is associated with poor quality of life and higher mortality; however, little is known about depressive affect in earlier stages of chronic kidney disease. To measure this in a risk group burdened with hypertension and kidney disease, we conducted a cross-sectional analysis of individuals at enrollment in the African American Study of Kidney Disease and Hypertension Cohort Study. Depressive affect was assessed by the Beck Depression Inventory II and quality of life by the Medical Outcomes Study-Short Form and the Satisfaction with Life Scale. Beck Depression scores over 14 were deemed consistent with an increased depressive affect and linear regression analysis was used to identify factors associated with these scores. Among 628 subjects, 166 had scores over 14 but only 34 were prescribed antidepressants. The mean Beck Depression score of 11.0 varied with the estimated glomerular filtration rate (eGFR) from 10.7 (eGFR 50-60) to 16.0 (eGFR stage 5); however, there was no significant independent association between these. Unemployment, low income, and lower quality and satisfaction with life scale scores were independently and significantly associated with a higher Beck Depression score. Thus, our study shows that an increased depressive affect is highly prevalent in African Americans with chronic kidney disease, is infrequently treated with antidepressants, and is associated with poorer quality of life. Sociodemographic factors have especially strong associations with this increased depressive affect. Because this study was conducted in an African-American cohort, its findings may not be generalized to other ethnic groups.