Screening for depression in the medically ill: the suggested utility of a cognitive-based approach

Screening for depression in hospitalized medical patients

Depression among hospitalized patients is often unrecognized, undiagnosed, and therefore untreated. Little is known about the feasibility of screening for depression during hospitalization, or whether depression is associated with poorer outcomes, longer hospital stays, and higher readmission rates. We searched PubMed and PsycINFO for published, peer-reviewed articles in English (1990-2016) using search terms designed to capture studies that tested the performance of depression screening tools in inpatient settings and studies that examined associations between depression detected during hospitalization and clinical or utilization outcomes. Two investigators reviewed each full-text article and extracted data. The prevalence of depression ranged from 5% to 60%, with a median of 33%, among hospitalized patients. Several screening tools identified showed high sensitivity and specificity, even when self-administered by patients or when abbreviated versions were administered by individuals without formal training. With regard to outcomes, studies from several individual hospitals found depression to be associated with poorer functional outcomes, worse physical health, and returns to the hospital after discharge. These findings suggest that depression screening may be feasible in the inpatient setting, and that more research is warranted to determine whether screening for and treating depression during hospitalization can improve patient outcomes. Journal of Hospital Medicine 2017;12:118-125.

Are the bipolar disorders best modelled categorically or dimensionally?

OBJECTIVE

Considerable debate exists as to whether the bipolar disorders are best classified according to a categorical or dimensional model. This study explored whether there is evidence for a single or multiple subpopulations and the degree to which differing diagnostic criteria correspond to bipolar subpopulations.

METHOD

A mixture analysis was performed on 1081 clinically diagnosed (and a reduced sample of 497 DSM-IV diagnosed) bipolar I and II disorder patients, using scores on hypomanic severity (as measured by the Mood Swings Questionnaire). Mixture analyses were conducted using two differing diagnostic criteria and two DSM markers to ascertain the most differentiating and their associated clinical features.

RESULTS

The two subpopulation solution was most supported although the entropy statistic indicated limited separation and there was no distinctive point of rarity. Quantification by the odds ratio statistic indicated that the clinical diagnosis (respecting DSM-IV criteria, but ignoring 'high' duration) was somewhat superior to DSM-IV diagnosis in allocating patients to the putative mixture analysis groups. The most differentiating correlate was the presence or absence of psychotic features.

CONCLUSION

Findings favour the categorical distinction of bipolar I and II disorders and argue for the centrality of the presence or absence of psychotic features to subgroup differentiation.

Anxious, irritable and hostile depression re-appraised

BACKGROUND

While classification of the depression disorders currently favors a dimensional model, this study considered the empirical support for a spectrum model linking personality with phenotypic depressive features, specifically examining patients with 'irritable', 'hostile' and 'anxious' depression.

METHODS

Pearson correlations were performed for Temperament and Personality (T&P) scales and state depressive patterns (irritable, hostile and anxious) for patients clinically diagnosed with unipolar melancholic and non-melancholic depressive conditions.

RESULTS

Irritable depression was most strongly associated with T&P irritability and anxious depression with T&P anxious-worrying - although these associations lacked specificity and were also correlated with other T&P scales. Hostile depression was most strongly correlated with T&P irritability suggesting that hostile and irritable depression are synonymous patterns. There were no clear indications for more distinct associations for the non-melancholic, compared to the melancholic, subset.

LIMITATIONS

Study findings are limited in that measures of state depressive patterns were relatively minimalistic and assignment to melancholic and non-melancholic conditions was measured by clinician judgment and may be subjective in nature.

CONCLUSIONS

Findings offer little support in the positioning of anxious and irritable/hostile depression as meaningfully differing patterns, nor for the spectrum model being more specific to the non-melancholic depressive conditions. There would appear to be little utility in preserving these depressive patterns as diagnostic constructs.

Clinical characteristics and temperament influences on 'happy' euphoric and 'snappy' irritable bipolar hypo/manic mood states

BACKGROUND

While mood elevation and euphoria are the most commonly described phenotypic descriptors of hypo/mania, irritability and anger may dominate. This study was designed to pursue possible determinants of such differing states.

METHODS

Patients with bipolar I or II disorder were assigned to an 'irritable/snappy' or 'euphoric/happy' sub-set on the basis of their dominant hypo/manic symptoms. Group differences were examined across clinical, personality, lifestyle and illness impact measures.

RESULTS

The two sub-sets did not differ on age of depression onset, family history of mood disorders, or depression severity and impairment. The snappy sub-set reported higher levels of irritability in depressed phases and were more likely to have a comorbid anxiety disorder. Their hypo/manic episodes were shorter and they were more likely to be hospitalized at such times. On a temperament measure they scored as more irritable and self-focussed and as less cooperative and effective - indicative of higher levels of disordered personality functioning.

LIMITATIONS

Some comparison analyses were undertaken on a reduced sample size, giving rise to power issues. Our bipolar I and II diagnoses deviated to some extent from DSM-5 criteria in not imposing duration criteria for hypo/manic episodes.

CONCLUSIONS

Findings support a spectrum model for the bipolar disorders linking temperament to bipolar symptomatic state and which may have treatment implications.

H2M: a GP-focused multidisciplinary team for patients living with HIV and hepatitis C

OBJECTIVE

To describe the development and functioning of the HIV and hepatitis C mental health in primary care service (H2M), a multidisciplinary team that works with local general practitioners (GPs) and the St Vincent's Hospital immunology clinic to meet the mental health needs of their patients living with HIV/AIDS and those undergoing interferon-based treatment for hepatitis C.

METHOD

The authors describe and review the service, using information from a database of patient characteristics and from a GP satisfaction survey.

RESULTS

GP satisfaction with the service was high and participating GPs have increased their knowledge and understanding of their patients' mental health problems.

CONCLUSIONS

Over eight years, H2M has become a well utilized and valued specialty team with over 1,200 referrals in that time. Patients with other chronic health conditions, such as diabetes, cardiac and renal disease, could benefit from a similar service model.

Use of the long and short forms of the depression in the medically ill questionnaire in a Spanish population

This study sought to translate, using a back-translation procedure, and evaluate the psychometric characteristics of Depression in the Medically Ill questionnaire (DMI-18) and its short version (DMI-10) in a Spanish population. Patients with somatic disorders (N = 366) completed the translated DMI-18 and another depression questionnaire. Among these, 167 were also assessed by a mental health professional (gold standard) to test criterion validity. Furthermore, coefficient alpha for both the versions were high (>.90), and convergent validity assessed against the Beck Depression Inventory for Primary Care, the Hospital Anxiety and Depression Scale, and the Patient Health Questionnaire-9 was satisfactory (r > .74). Confirmatory factor analysis results supported the one-factor model. When compared with the gold standard, sensitivity and specificity were 93% and 73% for DMI-18 and 87% and 74% for DMI-10, respectively. Thus, both the versions are acceptable measures that can be used by nonpsychiatric professionals to detect affective comorbidities in their patients.

Reliability and validity of the Hospital Anxiety and Depression Scale and the Beck Depression Inventory (Full and FastScreen scales) in detecting depression in persons with hepatitis C

BACKGROUND

We examined the performance the Beck Depression Inventory (BDI) and its short form (BDI-FS) and the Hospital Anxiety and Depression Scale depression (HADS-D) and anxiety (HADS-A) subscales in detecting depression in a group of patients with hepatitis C.

METHODS

SCID-CV was used to establish DSM-IV diagnosis. Sensitivity, specificity, positive and negative predictive values were used to assess test performance and Cohen's Kappa to measure agreement with DSM diagnosis.

RESULTS

Twenty-five of 88 participants had a DSM-IV depressive diagnosis. There was considerable non-overlap between 'caseness' on the BDI and HADS (Kappa=0.44). The HADS depression subscale had poor sensitivity (52%) and poor agreement with clinical diagnosis (Kappa=0.35). The full BDI had a sensitivity of 88% and a Kappa of 0.54 against a sensitivity of 84% and Kappa of 0.42 for the short form. The HADS anxiety subscale predicted depression as well as the depression subscale (sensitivity 88%, Kappa 0.47).

CONCLUSIONS

Neither the BDI nor the HADS agrees well with the clinical diagnosis of depressive disorder, nor do they agree well with one another. The anxiety subscale of the HADS appears to measure depression at least as well as the depressive subscale.

Cross-cultural validation of the DMI-10 measure of state depression: the development of a Chinese language version

Depression measurement tools in cross-cultural research require careful design and thorough validation to ensure that cognitive concepts in one culture can be appropriately translated and applied to a differing culture. The aim of this study was to validate the Chinese version of a screening measure of state depression, the 10-item Depression in Medically Ill (DMI-10), and we report three interdependent studies. An initial bilingual test-retest study identified four (of the 10) items as having poor cross-cultural validity. A second study involved focus groups participants exploring the meaning of translated items with Chinese speakers. The third study repeated the bilingual test-retest analyses on the modified DMI-10 form and demonstrated improved correlation coefficients on all items and an excellent overall correlation (r=0.87) between the Chinese and English versions. The Chinese DMI-10 should prove useful as a tool in cross-cultural research to understand the Chinese experience of depression. The findings of this study have methodological implications for cross-cultural research on depression.

Low levels of docosahexaenoic acid identified in acute coronary syndrome patients with depression

As deficiencies in n-3 PUFAs have been linked separately to depression and to cardiovascular disease, they could act as a higher order variable contributing to the established link between depression and cardiovascular disease. We therefore examine the relationship between depression and omega-3 polyunsaturated fatty acids (n-3 PUFA), including total n-3 PUFA, docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), in patients with acute coronary syndrome (ACS). Plasma phospholipid levels of n-3 PUFA were measured in 100 patients hospitalized with ACS. Current major depressive episode was assessed by the Composite International Diagnostic Interview (CIDI). Depression severity was assessed by the 18-item Depression in the Medically Ill (DMI-18) measure. Patients clinically diagnosed with current depression had significantly lower mean total n-3 PUFA and DHA levels. Higher DMI-18 depression severity scores were significantly associated with lower DHA levels, with similar but non-significant trends observed for EPA and total n-3 PUFA levels. The finding that low DHA levels were associated with depression variables in ACS patients may explain links demonstrated between cardiovascular health and depression, and may have prophylactic and treatment implications.

A Validation Study of Two Brief Measures of Depression in the Cardiac Population: The DMI-10 and DMI-18

The authors report on the psychometric characteristics and clinical efficacy of two versions of a recently developed screening measure of depression (the DMI-18 and DMI-10) in the cardiac population. Patients with acute coronary syndrome or heart failure (N = 322) completed the DMI measures, psychosocial questionnaires, and a semistructured clinical interview during the hospital stay. The DMI-18 and DMI-10 measures have adequate psychometric properties, demonstrating high sensitivity and specificity when evaluated against clinical judgment based on a semistructured interview. The DMI-18 and DMI-10 are appropriate for use as screening instruments in cardiac patients.

The prevalence of depression in two districts of Uganda

BACKGROUND

Little information is available on the prevalence of depression in Uganda. Given the recent political history of Uganda, depression may be common.

METHOD

The aim was to estimate the point prevalence of probable clinical depressive disorder among the general population in two contrasting districts of Uganda. Translated versions (in Madi and Lusoga) of the 13-item Beck Depression Inventory (BDI) were administered to a systematic sample of adult residents in the Adjumani and Bugiri districts of Uganda.

RESULTS

The overall prevalence of probably clinically significant depression (BDI score of 20-39) was 17.4%. Significantly higher rates were found in women and in Adjumani District.

CONCLUSION

Depression is common in Uganda and particularly in the more troubled and less socially cohesive district of Adjumani.

Screening for Depression in the Medically Ill: A Comparison of Self-Report Measures, Clinician Judgment, and DSM-IV Diagnoses

The performance of the self-report 10-item Depression in the Medically Ill scale was observed in 210 patients as part of clinical assessment by consultation-liaison psychiatry clinicians. Both the Depression in the Medically Ill scale and the Beck Depression Inventory for Primary Care were completed by the patient, and the clinicians made their judgment of the presence and severity of "clinical depression" and DSM-IV affective disorder diagnoses. Both the Depression in the Medically Ill scale and the Beck Depression Inventory for Primary Care detected 85% of patients with DSM-IV major depressive episode. The Depression in the Medically Ill scale was slightly superior to the Beck Depression Inventory for Primary Care in its relationship to clinicians' judgments of clinical depression caseness.

Capacity of the 10-item Depression in the Medically Ill screening measure to detect depression 'caseness' in psychiatric out-patients

The 10-item Depression in the Medically Ill (DMI-10) screening measures has been demonstrated to be useful in medically ill and general practice patients. Its usefulness as a screening or monitoring measure in depressed psychiatric out-patients is now reported. One hundred subjects-currently depressed or recovered from a recent episode-completed the measure, with scores for those 69 currently meeting DSM-IV depression caseness criteria compared with 31 non-depressed subjects. A cut-off score of 10 or more had high sensitivity and specificity for discriminating between 'cases' and 'non-cases'. The discriminating capacity of each item was also quantified. We conclude that the DMI-10 is brief, gender non-specific and less intrusive than many depression screening measures in clinical practice with depressed patients, with the currently established cut-off score similar to that established in medically ill samples. Analyses suggest useful items for clinicians to determine depression caseness status.

Influence of symptom attribution on reporting depression and recourse to treatment

OBJECTIVE

A Bristol general practice study demonstrated the extent to which patients' attribution style influences psychological diagnostic case rates. We pursue this issue and several implications in this Australian study.

METHOD

A survey was undertaken of six general practices in Sydney, and involving more than 900 routine general practice patients. Subjects completed questionnaires assessing personality styles observed in those with clinical depression, attributional response (i.e. 'psychological', 'somatic' and 'normalizing') to three somatic cues, state depression, lifetime depression, use of antidepressant medication, and recourse to professional help.

RESULTS

Responders attributing psychological explanations to the somatic cues had the highest state and lifetime depression rates, viewed their depression as more likely to be a 'disorder' and were more likely to have received treatment for depression. Those with a personality style of 'anxious worrying' reported increased morbidity across all depression variables, but personality did not make attributional style redundant in multivariate analyses.

CONCLUSIONS

Interpreting somatic cues in a psychological way is associated with higher rates of reported depression and increased recourse to depression treatment. Thus, a normalizing response style may make depression recognition and detection difficult. Study findings challenge the capacity of self-report measures to detect depression, especially in general practice settings.

Clinical and personality correlates of a new measure of depression: a general practice study

OBJECTIVE

There is a need for a brief, efficient depression screening measure for general practice settings, particularly for identifying those who are at high risk of depression. We therefore test the usefulness of a measure developed in a sample of medically ill hospitalized patients.

METHOD

More than 600 patients attending six Sydney general practices completed the Depression in the Medically Ill (DMI-10) measure, in conjunction with sociodemographic, depression history and personality profile measures. The impacts of sociodemographic, personality and lifetime depression variables on DMI-10 scores (and identified 'cases') were examined as a measure of its usefulness.

RESULTS

Gender did not influence depression scores, while there were slight associations between DMI-10 scores and age, marital and occupational status. Higher scores were returned by those with more severe, lengthier and perceived stressful medical illnesses. Using a predetermined cut-off score, 36% rated as putative 'cases', a prevalence almost identical to our general hospital study. 'Cases' were distinctly more likely to have had previous depressive episodes, to have sought help for such episodes and to have received antidepressant medication. They also scored higher on measures of anxious (anxious worrying and irritability) and self-critical ('depressive personality') personality styles.

CONCLUSIONS

The DMI-10 appears useful as a brief and acceptable screen for depression in a general practice setting, both identifying those who are likely to be currently depressed and those with a background of previous depression.

Psychiatric morbidity in first time stroke patients in Hong Kong: a pilot study in a rehabilitation unit

OBJECTIVE

There is a paucity of data on post-stroke psychiatric morbidity in Chinese populations. We examined the frequency of post-stroke psychiatric morbidity in Chinese first time stroke patients, including depressive and anxiety disorders, mania, and psychosis.

METHODS

One hundred and fifty-seven patients following their first stroke, who were consecutively admitted to a rehabilitation unit, participated in this prospective, cross-sectional study. All subjects were interviewed by a qualified psychiatrist using the SCID-DSM-III-R. Subjects' cognitive function, neurological status, and level of functioning were also measured. Twenty-five (92.6%) of the subjects with the diagnosis of depression were followed up 6.0 +/- 3.9 months after the initial assessment.

RESULTS

The frequency of all depressive disorders was 17.2%. Major depressive episodes, adjustment disorder with depressed mood, dysthymia, and generalized anxiety disorder were diagnosed in 7.6%, 8.2%, 1.3% and 0.6% of the subjects, respectively. No cases of other anxiety disorders, mania or psychosis were found. The majority of depressed subjects were in remission at the follow-up assessment.

CONCLUSION

The low morbidity of affective disorders and their relatively favourable short-term outcome in Chinese first time stroke patients warrants further investigation.

Cognitive-based measures screening for depression in the medically ill: the DMI-10 and the DMI-18

OBJECTIVE

We suggest that the identification of depression in the medically ill (DMI) might be improved by focussing on cognitive features.

METHOD

We recruited 302 patients to complete our provisional cognitive-based measure. Subsets also completed one of two comparator screening measures, either the Hospital and Anxiety Depression Scale (HADS) or the Beck Depression Inventory for Primary Care (BDI-PC). One hundred and sixty patients were then assessed by a psychiatrist who estimated whether they were 'clinically depressed' and who also administered a standardized interview for depression (the CIDI).

RESULTS

Analyses identified items discriminating clinically depressed and non-depressed individuals, allowing development of brief (10-item) and extended (18-item) measures. The two new measures were compared with the HADS and the BDI-PC in discriminating depressed and non-depressed medically ill patients.

CONCLUSION

A cognitive construct-based approach to assessing depression in the medically ill appears strongly supported. We provide brief (DMI-10) and extended (DMI-18) measures that appear to have utility as screening instruments. Consideration of the discriminating items may also assist clinical decision making.