Rethinking recommendations for screening for depression in primary care

Development and psychometric evaluation of a questionnaire for the assessment of depression in primary care: a cross-sectional study

OBJECTIVES

To develop a new questionnaire for the diagnostic assessment of depression adapted to the primary care setting by combining psychiatric criteria and heuristics of general practitioners (GPs). Psychometric evaluation of the new questionnaire and first validity evidence.

DESIGN

The questionnaire was developed using cognitive interviews with think-aloud technique. Factorial validity was then examined in a cross-sectional study.

SETTING

Primary care. Five general practices in Bavaria, Germany.

PARTICIPANTS

15 GPs, 4 psychiatrists/psychotherapists and 13 patients participated in cognitive expert interviews. A primary care sample of N=277 consecutive patients participated in the cross-sectional study.

METHODS

After consultation with experts and literature research, the questionnaire contained a self-rating part for patients and an external part for GPs. Items were then iteratively optimised using cognitive interviews. Factorial validity was examined. To estimate internal consistency, Cronbach's α was calculated. Validity was assessed by correlating the new questionnaire and the Patient Health Questionnaire-9 (PHQ-9).

RESULTS

The preliminary version of the two-part 'Questionnaire for the assessment of DEpression SYmptoms in Primary Care' (DESY-PC) comprised 52 items for patients (DESY-PAT-1: questions about patient's environment; DESY-PAT-2: questions about depression-specific symptoms) and 21 items for GPs (DESY-GP). The analysis of the DESY-PAT-1 revealed a one-factor solution ('environmental factors') with Cronbach's α of 0.55. The items of the DESY-PAT-2 were assigned to three factors, 'depressive cognitions', 'suicidality' and 'symptoms of fatigue', with Cronbach's α of 0.86, 0.79 and 0.85, respectively. Factorial analysis revealed two factors for the DESY-GP: 'depression symptoms' and 'medical history/external factors'. Cronbach's α was 0.90 and 0.59, respectively. After factorial analysis, the DESY-PAT was reduced to 28 items, and the DESY-GP was reduced to 15 items. Correlations of the DESY-PC with the PHQ-9 were high and significant, indicating convergent validity.

CONCLUSIONS

The new questionnaire represents an innovative extension of depression questionnaires and could be particularly suitable for general practices.

Content agreement of depressive symptomatology in children and adolescents: a review of eighteen self-report questionnaires

Identifying major depression in children and adolescents is more challenging than in adults. Questionnaires are often used for screening or guiding clinical assessment. Several instruments of different lengths are used as equivalent measures in diagnostic decisions. In this paper, we explore to what extent 18 commonly used depression scales for children and adolescents explore depression clinical symptoms as established by standard DSM-5 diagnosis criteria. We analyzed scale content adequacy by examining the overlap between scale contents and consensus clinical symptoms, the diagnostic time frame for active symptom assessment, and readability for the target age group. The 18 scales encompassed 52 distinct symptoms. These scales included just 50% of clinical symptoms required for diagnosis. The content overlap was low; on average, 29% of symptoms coincide across scales. Half of the scales did not use the standard period for active symptom appraisal, and some did not include a period for assessment. The reading levels on six scales were inappropriate for the scale's target population age group. The substantial heterogeneity in defining the depressive syndrome, the low overlap among scales, different periods of a positive diagnosis, and mismatch of reading competence for detecting may lead to heterogeneity in clinical diagnoses when using different scales. Improving the content of self-report in terms of homogeneity of diagnostic criteria would lead to better diagnostic decisions and patient management.

Perceptions of physicians on the use of screening tools for mental disorders in primary health care in Brazil

AIM

This study aimed to analyse perceptions, knowledge and ways of incorporating screening tools for mental disorders (MDs) into the daily practice of physicians working in primary health care (PHC) in the Brazilian public health system.

METHODS

This is a descriptive qualitative study with a sample of 24 physicians. The data collected in the semi-structured interviews were subjected to reflective thematic analysis.

RESULTS

The use of screening tools was low, not only due to lack of knowledge, but also due to reasoned criticism of this strategy developed by physicians trained in PHC. Physicians also presented a scenario of chaos, work overload and the fragility of the psychosocial care network as barriers to effective care of patients with MDs and to the incorporation of innovations in this care.

CONCLUSIONS

Interventions aimed at improving the quality of mental health care should include training on the topic, (re)organizing work processes, strengthening the health care network and producing robust scientific evidence on interventions aimed at qualifying professionals in mental health in PHC.

An Evaluation of the Health Economics of Postnatal Depression Prevention and Treatment Strategies in China: A Cost-Effectiveness Analysis

OBJECTIVE

The primary objectives of this study are to assess the cost-effectiveness of early postnatal screening and prenatal psychological interventions for the prevention and treatment of postpartum depression (PPD) among Chinese pregnant women. Additionally, we aim to explore the most cost-effective prevention and treatment strategies for PPD in China.

METHODS

We used TreeAge 2019 to construct a decision tree model, with the model assuming a simulated queue size of 10,000 people. The model employed Monte Carlo simulation to assess the cost-effectiveness of PPD prevention and treatment strategies. Transfer probabilities were derived from published studies and meta-analyses. Cost and effectiveness data were obtained from published sources and relevant studies. Incremental cost-effectiveness ratios (ICERs) were used to describe the results, with willingness-to-pay (WTP) thresholds set at China's gross domestic product (GDP) per capita.

RESULTS

Compared to the usual care group, the cost per additional quality-adjusted life year (QALY) for the early postnatal screening group and the prenatal psychological interventions is USD 6840.28 and USD 3720.74, respectively. The cure rate of mixed treatments for PPD has the greatest impact on the model, while patient participation in treatment has a minor impact on the cost-effectiveness of prevention and treatment strategies.

CONCLUSION

Both early postnatal screening and prenatal psychological interventions are found to be highly cost-effective strategies for preventing and treating PPD in China. Prenatal psychological interventions for pregnant women are the most cost-effective prevention and treatment strategy. As such, from the perspective of national payers, we recommend that maternal screening for PPD be implemented in China to identify high-risk groups early on and to facilitate effective intervention.

Can routine assessment of older people's mental health lead to improved outcomes: A regression discontinuity analysis

OBJECTIVE

To assess whether case finding for depression among people aged 65 and above improves mental health.

DESIGN

Opportunistic evaluation using a regression discontinuity analysis with data from a randomised controlled trial.

SETTING

The REFORM trial, a falls prevention study that recruited patients from NHS podiatry clinics.

PARTICIPANTS

1010 community-dwelling adults over the age of 65 with at least one risk factor for falling (recent previous fall or fear of falling).

INTERVENTION

Letter sent to patient's General Practitioner if they scored 10 points or above on the 15-item Geriatric Depression Scale (GDS-15) informing them of the patient's risk of depression.

MAIN OUTCOME MEASURE

GDS-15 score six months after initial completion of GDS-15.

RESULTS

895 (88.6%) of the 1010 participants randomised into REFORM had a valid baseline and six-month GDS-15 score and were included in this study. The mean GDS-15 baseline score was 3.5 (SD 3.0, median 3.0, range 0-15); 639 (71.4%) scored 0-4, 204 (22.8%) scored 5-9 indicating mild depression, and 52 (5.8%) scored 10 or higher indicating severe depression. At six months follow-up, those scoring 10 points or higher at baseline had, on average, a reduction of 1.08 points on the GDS-15 scale (95% confidence interval -1.83 to -0.33, p = 0.005) compared to those scoring less than 10, using the simplest linear regression model.

CONCLUSION

Case finding of depression in podiatry patients based on a GDS-15 score of 10 or more followed by a letter to their General Practitioner significantly reduced depression severity. Whether this applies to all older patients in primary care is unknown. Further research is required to confirm these findings. Regression discontinuity analyses could be prespecified and embedded within other existing research studies.

Routine screening for adverse childhood experiences (ACEs) still doesn't make sense

When a serious health or social problem is identified as both prevalent and in need of attention, a common response is to propose that various systems implement routine identification, such as universal screening. However, these well-intentioned responses often fail to consider the key requirements necessary to determine whether benefits outweigh harms. Unfortunately, this continues to be the case for calls to implement routine screening for Adverse Childhood Experiences (ACEs). Persistent evidence gaps for this type of screening include the lack of any randomized controlled trials demonstrating that ACEs screening programs lead to any benefits. Rather than being informed by established screening principles, the calls to proceed with ACEs screening appear to rely on the assumption that simply identifying risk factors can lead to beneficial outcomes that outweigh any risk of harms. This may reflect a gap in understanding that patterns identified at the population level (e.g., that more ACEs are associated with more health and social problems) cannot be directly translated to practices at the level of the individual. This commentary does not question the importance of ACEs; rather it identifies that directing limited resources to screening approaches for which there is no evidence that benefits outweigh harms is problematic. Instead, we advocate for the investment in high-quality trials of prevention interventions to determine where best to direct limited resources to reduce the occurrence of ACEs, and for the prioritization of evidence-based treatment services for those with existing health and social conditions, whether or not they are attributed to ACEs.

A prospective longitudinal study of depression, perceived stress, and perceived control in resettled Syrian refugees' mental health and psychosocial adaptation

This prospective study examined the psychosocial adaptation of a community sample of newly resettled Syrian refugees in Canada (N = 235). Specifically, depressive symptoms, perceived stress, and perceived control were collected in Arabic at baseline and 1-year follow-up. Two theory-informed, cross-lagged panel models demonstrated that higher baseline depressive symptoms predicted lower perceived self-efficacy and lower perceived control at 1-year follow-up. Similarly, baseline depressive symptoms were concurrently correlated with higher perceived helplessness, lower perceived self-efficacy, and lower perceived control. Secondary regression analyses further demonstrated that baseline depressive symptoms predicted lower perceived social support and higher anxiety symptoms, though neither were assessed at baseline. Empirical results identify a potentially broad, precipitating, and persistent effect of depressive symptoms on Syrian refugees' psychosocial resources and adaptation post-migration, which is consistent with both the transactional model of stress and coping and the self-efficacy theory of depression, respectively. Clinically, the study results highlight the importance of early screening for depressive symptoms among refugee newcomers within a culturally and trauma-informed, integrated health setting. Furthermore, this study underscores the value and need for theoretically guided longitudinal studies to advance future research on refugee mental health and psychosocial adaptation.

Psychological Distress and the Risk of Adverse Cardiovascular Outcomes in Patients With Coronary Heart Disease

BACKGROUND

Psychological distress is a recognized risk factor in patients with coronary heart disease (CHD), but its clinical significance is unclear.

OBJECTIVES

The purpose of this study was to determine if an index of psychological distress is independently associated with adverse outcomes and significantly contributes to risk prediction.

METHODS

Pooled analysis of 2 prospective cohort studies of patients with stable CHD (N = 891). A psychological distress score was constructed using measures of depression, anxiety, anger, perceived stress, and post-traumatic stress disorder, measured at baseline. The study endpoint included cardiovascular death or first or recurrent nonfatal myocardial infarction or hospitalization for heart failure at 5.9 years.

RESULTS

In both cohorts, first and recurrent events occurred more often among those in the highest tertile of distress score than those in the lowest tertile. After combining the 2 cohorts, compared with the lowest tertile, the hazards ratio for having a distress score in the highest tertile was 2.27 (95% CI: 1.69-3.06), and for the middle tertile, it was 1.52 (95% CI: 1.10-2.08). Adjustment for demographics and clinical risk factors only slightly weakened the associations. When the distress score was added to a traditional clinical risk model, C-statistic, net reclassification index, and integrative discrimination index all significantly improved.

CONCLUSIONS

Among patients with CHD, a composite measure of psychological distress was significantly associated with an increased risk of adverse events and significantly improved risk prediction.

Optimal cut-offs of depression screening tools during the COVID-19 pandemic: a systematic review

BACKGROUND

Studies have reported an increase in the prevalence of depression during the COVID-19 pandemic. The accuracy of screening tools may change with the prevalence and distribution of a disease in a population or sample: the "Spectrum Effect".

METHODS

First, we selected commonly used screening tools and developed search strategies for the inclusion of original studies during the pandemic. Second, we searched PsycINFO, EMBASE, and MEDLINE from March 2020 to September 2022 to obtain original studies that investigated the accuracy of depression screening tools during the pandemic. We then searched these databases to identify meta-analyses summarizing the accuracy of these tools conducted before the pandemic and compared the optimal cut-offs for depression screening tools during the pandemic with those before.

RESULT

Four original studies evaluating the optimal cut-offs for four screening tools (Beck Depression Inventory [BDI-II], Hospital Anxiety and Depression Scale-Depression [HADS-D], Patient Health Questionnaire-9 [PHQ-9], and Geriatric Depression Scale-4 [GDS-4]) were published during the pandemic. Four meta-analyses summarizing these tools before the pandemic. We found that the optimal cut-off of BDI-II was 14 during the pandemic (23.8% depression prevalence, screening patients with Type 2 diabetes) and 14.5 before the pandemic (17.6% depression prevalence, screening psychiatric, primary care, and healthy populations); HADS-D was 10 during the pandemic (23.8% depression prevalence, screening patients with type 2 diabetes) and 7 before the pandemic (15.0% depression prevalence, screening medically ill patients); PHQ-9 was 11 during the pandemic (14.5% depression prevalence, screening university students) and 8 before the pandemic (10.9% depression prevalence, screening the unrestricted population), and GDS-4 was 1.8 during the pandemic (29.0% depression prevalence, screening adults seen in a memory clinic setting) and 3 before the pandemic (18.5% depression prevalence, screening older adults).

CONCLUSION

The optimal cut-off for different screening tools may be sensitive to changes in study populations and reference standards. And potential spectrum effects that should be considered in post-COVID time which aiming to improve diagnostic accuracy.

How adults with suspected depressive disorder experience online depression screening: A qualitative interview study

Background

While evidence on the effects and mechanisms of online depression screening is inconclusive, publicly available 'online depression tests' are already frequently used. To further a comprehensive understanding of online depression screening and evince the perspectives of those affected, we aimed to qualitatively explore how adults with undiagnosed but suspected depressive disorder experience the screening process.

Methods

This study is a qualitative follow-up of a German-wide, 3-arm, randomised controlled trial on feedback after online depression screening conducted between Jan 2021 and Sep 2022. A subsample of 26 participants with undiagnosed but suspected depressive disorder (Patient Health Questionnaire-9 ≥ 10; no depression diagnosis/treatment within the last year) were purposefully selected based on maximum variation in gender, age, and study arm. In-depth semi-structured telephone interviews (mean = 37 min) were conducted approximately six months after screening. Data were analysed within a contextualist theoretical framework using inductive reflexive thematic analysis.

Results

Participants were balanced in terms of gender (female/male, n = 15/11), age (range = 22 to 61 years), and study arm (no feedback/standard feedback/tailored feedback, n = 7/11/8). Reported experiences of online depression screening can be described as a two-step process: Step 1 is the initial reaction to the screening procedure and comprises the theme recognition of depressive symptoms: from denial to awareness. Step 2 describes a subsequent self-explorative process encompassing the themes cognitive positioning: rejection vs. acceptance, emotional reaction: between overload and empowerment, and personal activation: from reflection to action.

Conclusions

Findings indicate that online depression screening with and without feedback of results is experienced as a two-step process promoting symptom recognition and subsequent self-exploration. While few participants reported negative effects, the majority described the screening process as insightful, empowering, and activating. Future research should determine to what extent online depression screening may pose a standalone form of low-threshold support for individuals with undiagnosed depressive disorder, while focusing as well on potential negative effects.

Utilization of Whole Health and Longitudinal Outcomes After Screening Positive for Possible Depression Documented in Veterans Health Administration's Electronic Health Record

Objectives: Depression is common among Veterans. Veterans Health Administration (VHA) is transforming into a Whole Health system of care that includes holistic treatment planning, well-being programs, and health coaching. This evaluation explores the impact of Whole Health on improving symptoms of depression among Veterans who screen positive for possible depression diagnosis. Materials and Methods: We examined a cohort of Veterans who started using Whole Health after screening positive for possible depression (having a PHQ-2 score ≥3) at 18 VA Whole Health sites. We compared Whole Health users with non-Whole Health users on their follow-up PHQ-2 scores (9-36 months after baseline), using propensity score matching with multivariable regression to adjust for baseline differences. Results: Of the 13,559 Veterans screening positive for possible depression on the PHQ-2 and having a follow-up PHQ-2, 902 (7%) began using Whole Health after their initial positive PHQ-2. Whole Health users at baseline were more likely than non-Whole Health users to have posttraumatic stress disorder or acute stress (43% vs. 29%), anxiety (22% vs. 12%), ongoing opioid use (14% vs. 8%), recent severe pain scores (15% vs. 8%), or obesity (51% vs. 40%). Both groups improved at follow-up, with mean PHQ-2 scores decreasing from 4.49 to 1.77 in the Whole Health group and 4.46 to 1.46 in the conventional care group, with the Whole Health group significantly higher at follow-up. Also, the proportion continuing to screen positive at follow-up trended higher in the Whole Health group (26% and 21%, respectively). Conclusions: After screening positive for depression, Veterans with more mental and physical health conditions were more likely to subsequently use Whole Health services, suggesting that Whole Health is becoming a tool used in VHA to address the needs of complex patients. Nevertheless, the Whole Health group did not improve compared to the Conventional Care group. Results add to the growing body of literature that Whole Health services may play an important role among patients with complex symptom presentations by promoting self-management of symptoms and targeting "what matters most" to Veterans.

Predictive Factors Associated with Declining Psycho-Oncological Support in Patients with Cancer

(1) Background: International cancer treatment guidelines recommend low-threshold psycho-oncological support based on nurses' routine distress screening (e.g., via the distress thermometer and problem list). This study aims to explore factors which are associated with declining psycho-oncological support in order to increase nurses' efficiency in screening patients for psycho-oncological support needs. (2) Methods: Using machine learning, routinely recorded clinical data from 4064 patients was analyzed for predictors of patients declining psycho-oncological support. Cross validation and nested resampling were used to guard against model overfitting. (3) Results: The developed model detects patients who decline psycho-oncological support with a sensitivity of 89% (area under the cure of 79%, accuracy of 68.5%). Overall, older patients, patients with a lower score on the distress thermometer, fewer comorbidities, few physical problems, and those who do not feel sad, afraid, or worried refused psycho-oncological support. (4) Conclusions: Thus, current screening procedures seem worthy to be part of daily nursing routines in oncology, but nurses may need more time and training to rule out misconceptions of patients on psycho-oncological support.

Capturing mood dynamics through adolescent smartphone social communication

Most adolescents with depression remain undiagnosed and untreated-missed opportunities that are costly from both personal and public health perspectives. A promising approach to detecting adolescent depression in real-time and at a large scale is through their social communication on the smartphone (e.g., text messages, social media posts). Past research has shown that language from online social communication reliably indicates interindividual differences in depression. To move toward detecting the emergence of depression symptoms intraindividually, the present study tested whether sentiment (i.e., words connoting positive and negative affect) from smartphone social communication prospectively predicted daily mood fluctuations in 83 adolescents (Mage = 16.49, 73.5% female) with a wide range of depression severity. Participants completed daily mood ratings across a 90-day period, during which 354,278 messages were passively collected from social communication apps. Greater positive sentiment (i.e., more positive weighted composite valence score and a greater proportion of words expressing positive sentiment) predicted more positive next-day mood, controlling for previous-day mood. Moreover, greater proportions of positive and negative sentiment were, respectively, associated with lower anhedonia and greater dysphoria symptoms measured at baseline. Exploratory analyses of nonaffective linguistic features showed that greater use of social engagement words (e.g., friends and affiliation) and emojis (primarily consisting of hearts) predicted more positive changes in mood. Collectively, findings suggest that language from smartphone social communication can detect mood fluctuations in adolescents, laying the foundation for language-based tools to identify periods of heightened depression risk. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

'Optimal' cutoff selection in studies of depression screening tool accuracy using the PHQ-9, EPDS, or HADS-D: A meta-research study

OBJECTIVES

Optimal cutoff thresholds are selected to separate 'positive' from 'negative' screening results. We evaluated how depression screening tool studies select optimal cutoffs.

METHODS

We included studies from previously conducted meta-analyses of Patient Health Questionnaire-9, Edinburgh Postnatal Depression Scale, or Hospital Anxiety and Depression Scale-Depression accuracy. Outcomes included whether an optimal cutoff was selected, method used, recommendations made, and reporting guideline and protocol citation.

RESULTS

Of 212 included studies, 172 (81%) attempted to identify an optimal cutoff, and 147 of these 172 (85%) reported one or more methods. Methods were heterogeneous with Youden's J (N = 35, 23%) most common. Only 23 of 147 (16%) studies described a rationale for their method. Rationales focused on balancing sensitivity and specificity without describing why desirable. 131 of 172 studies (76%) identified an optimal cutoff other than the standard; most did not make use recommendations (N = 56; 43%) or recommended using a non-standard cutoff (N = 53; 40%). Only 4 studies cited a reporting guideline, and 4 described a protocol with optimal cutoff selection methods, but none used the protocol method in the published study.

CONCLUSIONS

Research is needed to guide how selection of cutoffs for depression screening tools can be standardized and reflect clinical considerations.

Managing depression in frail older people; too little too late or pathologising loss?

It is testament to the advances of modern medicine that we have a population with more older people than ever before. While we are increasingly adept at managing their physical comorbidities, we have made relatively little progress in addressing the psychological impact of ageing. In this article we consider the prevalence and complex aetiology of depression in older people who often have to deal with profound loss, while simultaneously managing multiple comorbidities. We consider the challenges of diagnosing depression faced by healthcare professionals including access to resources and training, and what differentiates depression from socially appropriate low mood. Finally, we discuss treatment options and the difficulties that clinicians face when they have only limited resources and skills available, but a desire to help. We consider the role for antidepressants, and when not to prescribe, before addressing the challenges of providing talking therapies and social interventions.

Individual participant data meta-analysis to compare EPDS accuracy to detect major depression with and without the self-harm item

Item 10 of the Edinburgh Postnatal Depression Scale (EPDS) is intended to assess thoughts of intentional self-harm but may also elicit concerns about accidental self-harm. It does not specifically address suicide ideation but, nonetheless, is sometimes used as an indicator of suicidality. The 9-item version of the EPDS (EPDS-9), which omits item 10, is sometimes used in research due to concern about positive endorsements of item 10 and necessary follow-up. We assessed the equivalence of total score correlations and screening accuracy to detect major depression using the EPDS-9 versus full EPDS among pregnant and postpartum women. We searched Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, and Web of Science from database inception to October 3, 2018 for studies that administered the EPDS and conducted diagnostic classification for major depression based on a validated semi-structured or fully structured interview among women aged 18 or older during pregnancy or within 12 months of giving birth. We conducted an individual participant data meta-analysis. We calculated Pearson correlations with 95% prediction interval (PI) between EPDS-9 and full EPDS total scores using a random effects model. Bivariate random-effects models were fitted to assess screening accuracy. Equivalence tests were done by comparing the confidence intervals (CIs) around the pooled sensitivity and specificity differences to the equivalence margin of δ = 0.05. Individual participant data were obtained from 41 eligible studies (10,906 participants, 1407 major depression cases). The correlation between EPDS-9 and full EPDS scores was 0.998 (95% PI 0.991, 0.999). For sensitivity, the EPDS-9 and full EPDS were equivalent for cut-offs 7-12 (difference range - 0.02, 0.01) and the equivalence was indeterminate for cut-offs 13-15 (all differences - 0.04). For specificity, the EPDS-9 and full EPDS were equivalent for all cut-offs (difference range 0.00, 0.01). The EPDS-9 performs similarly to the full EPDS and can be used when there are concerns about the implications of administering EPDS item 10.Trial registration: The original IPDMA was registered in PROSPERO (CRD42015024785).

Transparency and completeness of reporting of depression screening tool accuracy studies: A meta-research review of adherence to the Standards for Reporting of Diagnostic Accuracy Studies statement

OBJECTIVES

Accurate and complete study reporting allows evidence users to critically appraise studies, evaluate possible bias, and assess generalizability and applicability. We evaluated the extent to which recent studies on depression screening accuracy were reported consistent with Standards for Reporting of Diagnostic Accuracy Studies (STARD) statement requirements.

METHODS

MEDLINE was searched from January 1, 2018 through May 21, 2021 for depression screening accuracy studies.

RESULTS

106 studies were included. Of 34 STARD items or sub-items, the number of adequately reported items per study ranged from 7 to 18 (mean = 11.5, standard deviation [SD] = 2.5; median = 11.5), and the number inadequately reported ranged from 3 to 17 (mean = 10.1, SD = 2.5; median = 10.0). There were eight items adequately reported, seven partially reported, 11 inadequately reported, and four not applicable in ≥50% of studies; the remaining four items had mixed reporting. Items inadequately reported in ≥70% of studies related to the rationale for index test cut-offs examined, missing data management, analyses of variability in accuracy results, sample size determination, participant flow, study registration, and study protocol.

CONCLUSION

Recently published depression screening accuracy studies are not optimally reported. Journals should endorse and implement STARD adherence.

Teachers at risk: Depressive symptoms, emotional intelligence, and burnout during COVID-19

Background

Previous studies indicated that depressive symptoms are common among teachers due to job stress and difficulty in managing emotions. The aim of this research was to determine the levels of depressive symptomatology in a sample of secondary school teachers who worked during the COVID-19 pandemic and to analyze the relationships with their levels of burnout and emotional intelligence.

Methods

The study involved 430 secondary school teachers residing in Madrid (Spain) who worked during the COVID-19 pandemic. Participants' age was between 25 and 60 (M = 41.40; SD = 11.07) and the gender distribution was 53.72% men and 46.28% women. We used the Spanish version of the Patient Health Questionnaire (PHQ-9), the Maslach Burnout Inventory Educators Survey (MBI-ES) and the Trait Meta-Mood Scale (TMMS-24).

Results

The main results indicated that teachers presented high means of depressive symptomatology, with women obtaining higher scores than men. Significant relationships were also observed between the levels of depressive symptomatology and the dimensions of burnout and emotional intelligence. Finally, the three dimensions of emotional intelligence would contribute to the depressive symptomatology of teachers, while of the burnout dimensions only Emotional Exhaustion would make a contribution.

Conclusion

The possible consequences of depressive symptomatology in teachers during the pandemic are discussed, as well as the need to enhance protective factors such as emotional intelligence and to study burnout levels.

Effects of psychological treatment for depression among people not actively seeking help: a meta-analysis

Although psychological treatments have been found to be effective for depression in adults, many individuals with depression do not actively seek help. It is currently unclear whether psychological treatments are effective among those not actively seeking help. Besides, little is known about the proportion of patients who completed a screening questionnaire who end up in a clinical trial. Therefore, we conducted a meta-analysis of 52 randomized trials comparing psychotherapies for adults with a diagnosis or elevated symptoms of depression against control conditions (care-as-usual, waiting list, and other inactive treatment). Only studies recruiting participants who do not actively seek help (participants who have been recruited through screening instead of advertisements and clinical referrals) were included. To obtain an overall effect estimate of psychotherapy, we pooled all post-test differences with a random-effects model. We found that psychological treatments had a moderate to high effect on reducing depressive symptoms compared to control groups [g = 0.55; 95% confidence interval (CI) 0.41-0.69]. Heterogeneity was high (I² = 75%; 95% CI 68-80). At 12 months' follow-up, the effects were small but significant (6-8 months: g = 0.33; 95% CI 0.14-0.52; 9-12 months: g = 0.24; 95% CI 0.11-0.37). As a secondary outcome, we found that 13% of patients who completed a screening questionnaire met the inclusion criteria for depression and agreed to be randomized in the trial. Based on the current evidence, psychological treatments for depression might be effective for depressed patients who are not actively seeking help.

Optimizing the predictive power of depression screenings using machine learning

Objective

Mental health self-report and clinician-rating scales with diagnoses defined by sum-score cut-offs are often used for depression screening. This study investigates whether machine learning (ML) can detect major depressive episodes (MDE) based on screening scales with higher accuracy than best-practice clinical sum-score approaches.

Methods

Primary data was obtained from two RCTs on the treatment of depression. Ground truth were DSM 5 MDE diagnoses based on structured clinical interviews (SCID) and PHQ-9 self-report, clinician-rated QIDS-16, and HAM-D-17 were predictors. ML models were trained using 10-fold cross-validation. Performance was compared against best-practice sum-score cut-offs. Primary outcome was the Area Under the Curve (AUC) of the Receiver Operating Characteristic curve. DeLong's test with bootstrapping was used to test for differences in AUC. Secondary outcomes were balanced accuracy, precision, recall, F1-score, and number needed to diagnose (NND).

Results

A total of k = 1030 diagnoses (no diagnosis: k = 775; MDE: k = 255) were included. ML models achieved an AUCQIDS-16 = 0.94, AUCHAM-D-17 = 0.88, and AUCPHQ-9 = 0.83 in the testing set. ML AUC was significantly higher than sum-score cut-offs for QIDS-16 and PHQ-9 (ps ≤ 0.01; HAM_D-17: p = 0.847). Applying optimal prediction thresholds, QIDS-16 classifier achieved clinically relevant improvements (Δbalanced accuracy = 8%, ΔF1-score = 14%, ΔNND = 21%). Differences for PHQ_9 and HAM-D-17 were marginal.

Conclusions

ML augmented depression screenings could potentially make a major contribution to improving MDE diagnosis depending on questionnaire (e.g., QIDS-16). Confirmatory studies are needed before ML enhanced screening can be implemented into routine care practice.

Combining the GP's assessment and the PHQ-9 questionnaire leads to more reliable and clinically relevant diagnoses in primary care

Background

Screening questionnaires are not sufficient to improve diagnostic quality of depression in primary care. The additional consideration of the general practitioner’s (GP’s) assessment could improve the accuracy of depression diagnosis. The aim of this study was to examine whether the GP rating supports a reliable depression diagnosis indicated by the PHQ-9 over a period of three months.

Methods

We performed a secondary data analysis from a previous study. PHQ-9 scores of primary care patients were collected at the time of recruitment (t1) and during a follow-up 3 months later (t2). At t1 GPs independently made a subjective assessment whether they considered the patient depressive (yes/no). Two corresponding groups with concordant and discordant PHQ-9 and GP ratings at t1 were defined. Reliability of the PHQ-9 results at t1 and t2 was assessed within these groups and within the entire sample by Cohen’s Kappa, Pearson’s correlation coefficient and Bland-Altman plots.

Results

364 consecutive patients from 12 practices in the region of Upper Bavaria/Germany participated in this longitudinal study. 279 patients (76.6%) sent back the questionnaire at t2. Concordance of GP rating and PHQ-9 at t1 led to higher replicability of PHQ-9 results between t1 and t2. The reliability of PHQ-9 was higher in the concordant subgroup (κ = 0.507) compared to the discordant subgroup (κ = 0.211) (p = 0.064). The Bland-Altman Plot showed that the deviation of PHQ-9 scores at t1 and t2 decreased by about 15% in the concordant subgroup. Pearson’s correlation coefficient between PHQ-9 scores at t1 and t2 increased significantly if the GP rating was concordant with the PHQ-9 at t1 (r = 0.671) compared to the discordant subgroup (r = 0.462) (p = 0.044).

Conclusions

The combination of PHQ-9 and GP rating might improve diagnostic decision making regarding depression in general practices. PHQ-9 positive results might be more reliable and accurate, when a concordant GP rating is considered.

The importance of assessing and addressing mental health barriers to PrEP use during pregnancy and postpartum in sub-Saharan Africa: state of the science and research priorities

Introduction

Pregnant and postpartum women (PPW) in sub‐Saharan Africa are at disproportionately high risk of HIV infection compared to non‐pregnant women. When used consistently, pre‐exposure prophylaxis (PrEP) can prevent HIV acquisition and transmission to the foetus or infant during these critical periods. Recent studies have demonstrated associations between mental health challenges (e.g. depression and traumatic stress associated with intimate partner violence) and decreased PrEP adherence and persistence, particularly among adolescents, younger women and women in the postpartum period. However, mental health is not currently a major focus of PrEP implementation research and programme planning for PPW.

Discussion

PrEP implementation programmes for PPW need to assess and address mental health barriers to consistent PrEP use to ensure effectiveness and sustainability in routine care. We highlight three key research priorities that will support PrEP adherence and persistence: (1) include mental health screening tools in PrEP implementation research with PPW, both to assess the feasibility of integrating these tools into routine antenatal and postpartum care and to ensure that limited resources are directed towards women whose symptoms may interfere most with PrEP use; (2) identify cross‐cutting, transdiagnostic psychological mechanisms that affect consistent PrEP use during these periods and can realistically be targeted with intervention in resource‐limited settings; and (3) develop/adapt and test interventions that target those underlying mechanisms, leveraging strategies from existing interventions that have successfully mitigated mental health barriers to antiretroviral therapy use among people with HIV.

Conclusions

For PPW, implementation of PrEP should be guided by a robust understanding of the unique psychological difficulties that may act as barriers to uptake, adherence and persistence (i.e. sustained adherence over time). We strongly encourage PrEP implementation research in PPW to incorporate validated mental health screening tools and ultimately treatment in routine antenatal and postnatal care, and we stress the potential public health benefits of identifying women who face mental health barriers to PrEP use.

Trajectories of Depression Symptoms From Pregnancy Through 24 months Postpartum Among Kenyan Women Living With HIV

BACKGROUND

We examined longitudinal patterns and cofactors of depressive symptoms among pregnant and postpartum women living with HIV (WLWH).

METHODS

This study used data from a randomized trial of a text messaging intervention. WLWH were serially assessed for depressive symptoms from pregnancy through 24 months postpartum at 6 time points (pregnancy, 6 weeks, and 6, 12, 18, and 24 months postpartum). Depressive symptoms were assessed using Patient Health Questionnaire-9 and longitudinal patterns using group-based trajectory modeling. Moderate-to-severe depressive symptoms (MSD) correlates were assessed using generalized estimating equations.

RESULTS

Among 824 enrolled women, 14.6% ever had MSD during pregnancy or postpartum; 8.6% of WLWH had MSD in pregnancy and 9.0% any postpartum MSD. MSD was associated with abuse [RR: 3.8, 95% confidence interval (CI): 2.6 to 5.4], stigma (RR: 4.4, 95% CI: 3.1 to 6.3), and food insecurity (RR: 2.7, 95% CI: 1.9 to 3.8). Unintended pregnancy (RR: 1.6, 95% CI: 1.1 to 2.3) and recent HIV diagnosis (RR: 1.8, 95% CI: 1.2 to 2.6) were associated with higher MSD risk, whereas HIV status disclosure to partner (RR: 0.3, 95% CI: 0.2 to 0.6) and social support (RR: 0.97, 95% CI: 0.96 to 0.98) were associated with lower risk. Trajectory modeling identified 4 phenotypes of peripartum depressive symptoms: persistent no/low symptoms (38.5%), mild symptoms resolving postpartum (12.6%), low symptoms increasing slightly in postpartum (47.9%), and persistent moderate-severe symptoms throughout (1.1%).

CONCLUSIONS

WLWH attending PMTCT services had varied patterns of depressive symptoms, which were associated with stressors (recent diagnosis and food insecurity) and factors reflecting low social power (abuse, stigma, and unintended pregnancy). Women experiencing concurrent abuse, stigma, and food insecurity should be prioritized for interventions to prevent persistent depression.

Sample size and precision of estimates in studies of depression screening tool accuracy: A meta-research review of studies published in 2018-2021

OBJECTIVES

Depression screening tool accuracy studies should be conducted with large enough sample sizes to generate precise accuracy estimates. We assessed the proportion of recently published depression screening tool diagnostic accuracy studies that reported sample size calculations; the proportion that provided confidence intervals (CIs); and precision, based on the width and lower bounds of 95% CIs for sensitivity and specificity. In addition, we assessed whether these results have improved since a previous review of studies published in 2013-2015.

METHODS

MEDLINE was searched from January 1, 2018, through May 21, 2021.

RESULTS

Twelve of 106 primary studies (11%) described a viable sample size calculation, which represented an improvement of 8% since the last review. Thirty-six studies (34%) provided reasonably accurate CIs. Of 103 studies where 95% CIs were provided or could be calculated, seven (7%) had sensitivity CI widths of ≤10%, whereas 58 (56%) had widths of ≥21%. Eighty-four studies (82%) had lower bounds of CIs <80% for sensitivity and 77 studies (75%) for specificity. These results were similar to those reported previously.

CONCLUSION

Few studies reported sample size calculations, and the number of included individuals in most studies was too small to generate reasonably precise accuracy estimates.

The role of rurality on factors associated with major depressive episode screening among Brazilian adults in a national household survey

BACKGROUND

Worldwide, depression is one of the leading causes of disability, contributing significantly to the global burden of disease. The aim of this study was to evaluate in Brazil the effect of living in rural or urban areas on the prevalence of major depressive episode (MDE), as well as the differences among associated factors in both contexts.

METHODS

Data from 60,202 adult residents from a household-based cross-sectional survey conducted in Brazil were analyzed. The prevalence of MDE, evaluated using PHQ-9, as well as the prevalence ratios between the categories of the independent variables were estimated. Multiple hierarchical Poisson regression analyses based on a theoretical model were reproduced for both rural and urban areas.

RESULTS

Residents of rural areas showed lower MDE prevalence (3.3% [95% CI: 2.9-3.9] vs. 4.2% [95% CI: 3.9-4.6], p < .05) and the effect of rurality remained even adjusted by potential confounders (PR = 0.8 [95% CI: 0.7-0.9]). Better education, social network, and access to health services were protective factors for both rural and urban areas, while previous diagnosis of depression, chronic diseases, and obesity were risk factors. Living in the northern region, being indigenous, presenting higher income and number of goods were protective factors only in rural areas. In urban areas, being younger and having an occupation were protective factors, whereas female sex and having some disability were risk factors.

CONCLUSIONS

Rural and urban areas differ not only in the prevalence of depression, but also in the way in which different factors influence its occurrence.

Inclusion of currently diagnosed or treated individuals in studies of depression screening tool accuracy: a meta-research review of studies published in 2018-2021

OBJECTIVES

Screening is done to improve health outcomes by identifying and effectively treating individuals with unrecognized conditions. Depression screening has been proposed to identify previously unrecognized depression cases. Including individuals already diagnosed or treated for depression in screening test accuracy studies could exaggerate accuracy and the yield of new cases from screening. The present study investigated (1) the proportion of depression screening tool accuracy primary studies published in 2018-2021 that excluded individuals with a confirmed depression diagnosis or who were already undergoing treatment; and (2) whether this has improved since the last review of studies published in 2013-2015, which found that five of 89 (5.6%) primary studies appropriately excluded such individuals.

METHODS

MEDLINE was searched from January 1, 2018 through May 21, 2021 for primary studies on depression screening tool accuracy.

RESULTS

Eighteen of 106 (17.0%; 95% Confidence Interval [CI], 11.0% to 25.3%) primary studies excluded currently diagnosed or treated individuals. This was 11.4% (95% CI, 2.8% to 20.0%) greater than in similar studies published in 2013-2015.

CONCLUSION

There has been an improvement since 2015, but the proportion of studies that exclude individuals already known to have depression remains low. This may bias research findings intended to inform clinical practice.

The cost-effectiveness of depression screening for the general adult population

BACKGROUND

Depression is a treatable disease, and untreated depression can lead to serious health complications and decrease the quality of life. Therefore, prevention, early identification, and treatment efforts are essential. Screening has an essential role in preventive medicine in the general population. Ideally, screening tools detect patients early enough to manage the disease and reduce symptoms. We aimed to determine the cost-effectiveness of routine screening schedules.

METHODS

We used a discrete-time nonstationary Markov model to simulate the progression of depression. We used Monte Carlo techniques to simulate the stochastic model for 20 years or during the lifetime of individuals. Baseline and screening scenario models with screening frequencies of annual, 2-year, and 5-year strategies were compared based on incremental cost-effectiveness ratios (ICER). Monte Carlo (MC) simulation and one-way sensitivity analysis were conducted to manage uncertainties.

RESULTS

In the general population, all screening strategies were cost-effective compared to the baseline. However, male and female populations differed based on cost over quality-adjusted life years (QALY). Females had lower ICERs, and annual screening had the highest ICER for females, with 11,134$/QALY gained. In contrast, males had around three times higher ICER, with annual screening costs of 34,065$/QALY gained.

LIMITATIONS

We assumed that the screening frequency was not changing at any time during the screening scenario. In our calculations, false-positive cases were not taking into account.

CONCLUSIONS

Considering the high lifetime prevalence and recurrence rates of depression, detection and prevention efforts can be one critical cornerstone to support required care. Our analysis combined the expected benefits and costs of screening and assessed the effectiveness of screening scenarios. We conclude that routine screening is cost-effective for all age groups of females and young, middle-aged males.

Depression screening and clinical outcomes among adults initiating maintenance hemodialysis

Background

Transitioning to maintenance hemodialysis (HD) is a vulnerable period for persons with end-stage renal disease (ESRD), punctuated by high rates of depression, hospitalizations and death. Screening for depression during this time may help to improve patient outcomes but formal inquiry has yet to be conducted. Among a national Veteran cohort, we examined whether depression screening in the year prior to HD initiation led to improved outcomes in the year thereafter.

Methods

Associations between pre-ESRD depression screening and post-ESRD outcomes were examined with Cox proportional hazards models (mortality) and Poisson regression models (hospitalization). Hierarchal adjustment models accounted for sociodemographic, clinical, pre-ESRD care and dialysis characteristics.

Results

The final analytic cohort of the study was 30 013 Veterans of whom 64% underwent pre-ESRD depression screening. During the 12 months post-transition, the crude all-cause mortality rate was 0.32 person-year for those screened and 0.35 person-year for those not screened, while the median (interquartile range) hospitalizations were 2 (2, 2) per year for both groups. In fully adjusted models, pre-ESRD depression screening was associated with a lower risk of mortality [hazard ratio (95% confidence interval): 0.94 (0.90-0.99)] and hospitalization [incidence rate ratio (95% confidence interval): 0.97 (0.9-0.99)].

Conclusion

Depression screening among adults prior to maintenance HD transition may be associated with better outcomes during the following year.

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.

Somatic Versus Cognitive Depressive Symptoms as Predictors of Coronary Artery Disease among Women with Suspected Ischemia: The Women's Ischemia Syndrome Evaluation

BACKGROUND

Depression is an established predictor of coronary artery disease (CAD) progression and mortality. "Somatic" symptoms of depression such as fatigue and sleep impairment overlap with symptoms of CAD and independently predict CAD events. Differentiating between "somatic" and "cognitive" depressive symptoms in at-risk patients may improve our understanding of the relationship between depression and CAD.

METHODS

The study utilized data from the Women's Ischemia Syndrome Evaluation. Participants (N = 641; mean age = 58.0 [11.4] years) were enrolled to evaluate chest pain or suspected myocardial ischemia. They completed a battery of symptom and psychological questionnaires (including the Beck Depression Inventory [BDI]) at baseline, along with quantitative coronary angiography and other CAD diagnostic procedures. The BDI provided scores for total depression and for cognitive and somatic depressive symptom subscales.

RESULTS

Two hundred and fourteen (33.4%) women met criteria for obstructive CAD. Logistic regression models were used to examine relationships between depression symptoms and obstructive CAD. Neither BDI total scores (odds ratio [OR] =1.02, 95% confidence interval [CI], 0.99-1.05, P = 0.053) nor BDI cognitive scores (OR = 1.02, 95% CI, 1.00-1.04, P = 0.15) predicted CAD status. BDI somatic symptom scores, however, significantly predicted CAD status and remained statistically significant after controlling for age, race, and education (OR = 1.06, 95% CI, 1.01-1.12, P = 0.02).

CONCLUSION

Among women with suspected myocardial ischemia, somatic but not cognitive depressive symptoms predicted an increased risk of obstructive CAD determined by coronary angiography. Consistent with prior reports, these results suggest a focus on somatic rather than cognitive depressive symptoms could offer additional diagnostic information.

Measuring mental health in humanitarian crises: a practitioner's guide to validity

Background

There are ongoing methodological advances in measuring mental health in humanitarian crises. This Special Section describes numerous innovations. Here we take a practitioner's view in understanding the key issues related to assessment of mental health in humanitarian contexts and how the innovations contribute to the field.

Main body

In this guide for practitioners, we address the following issues: (1) clarifying the intended purpose of conducting mental health assessment in humanitarian crises: why is this information collected and for what intended purposes?; (2) determining what type of tool should be selected and the types of psychometric properties that are important for tools serving this particular purpose; (3) when a validated tool is not available, considering how qualitative and quantitative methods should be used to generate information on validity; and finally, (4) how to report on validity and its implications for interpreting information for humanitarian practitioners, governments, care providers, and other stakeholders supporting people affected by humanitarian emergencies.

Conclusion

Ultimately, mental health assessment tools are not independent of the group with which they were designed, nor are the psychometric properties of the tools or their utility universal across purposes. Therefore, organizations and stakeholders will optimize their positive impact when choosing tools wisely, appropriately adapting and validating tools, and providing guidance on how to interpret those findings to best serve populations in need.

Are guided internet-based interventions for the indicated prevention of depression in green professions effective in the long run? Longitudinal analysis of the 6- and 12-month follow-up of a pragmatic randomized controlled trial (PROD-A)

OBJECTIVE

Evidence of long-term stability for positive mental health effects of internet-based interventions (IBIs) for depression prevention is still scarce. We evaluate long-term effectiveness of a depression prevention program in green professions (i.e. agriculture, horticulture, forestry).

METHODS

This pragmatic RCT (n = 360) compares a tailored IBI program to enhanced treatment as usual (TAU+) in green professions with at least subthreshold depression (PHQ ≥ 5). Intervention group (IG) received one of six IBIs shown previously to efficaciously reduce depressive symptoms. We report 6- and 12-month follow-up measures for depression, mental health and intervention-related outcomes. Intention-to-treat and per-protocol regression analyses were conducted for each measurement point and complemented by latent growth modeling.

RESULTS

After 6 months, depression severity (β = -0.30, 95%-CI: -0.52; -0.07), insomnia (β = -0.22, 95%-CI: -0.41; -0.02), pain-associated disability (β = -0.26, 95%-CI: -0.48; -0.04) and quality of life (β = 0.29, 95%-CI: 0.13; 0.45) in IG were superior to TAU+. Onset of possible depression was not reduced. After 12 months, no intervention effects were found. Longitudinal modeling confirmed group effects attenuating over 12 months for most outcomes. After 12 months, 55.56% of IG had completed at least 80% of their IBI.

CONCLUSIONS

Stability of intervention effects along with intervention adherence was restricted. Measures enhancing long-term effectiveness of IBIs for depression health promotion are indicated in green professions.

TRIAL REGISTRATION

German Clinical Trial Registration: DRKS00014000. Registered: 09 April 2018.

Clinical effectiveness of patient-oriented depression feedback in primary care: The empirical method of the GET.FEEDBACK.GP multicenter randomized controlled trial

GET.FEEDBACK.GP₁ is a multicenter randomized controlled trial testing the efficacy of patient-oriented depression feedback in primary care. This paper describes the complex methods and procedures of the trial. The primary outcome is depression severity six months after feedback, and we vary who is the target of the feedback as follows: no one receives feedback, only general practitioners receive feedback, and both patients and general practitioners receive feedback. The procedure includes a baseline assessment in primary care practices and three telephone follow-up interviews after one, six, and twelve months. The patients completed a baseline assessment, which determined their depression severity. Those with at least a moderate depression severity (PHQ-9₅ ≥ 10) were randomly allocated to three groups stratified by depression severity. A standardized mean difference of d = 0.25 with power 1 - β = 0.80 required a total sample size of N = 699. The patients provided responses regarding the primary and secondary outcomes at follow-up. The extensive planning for GET.FEEDBACK.GP involved experts from diverse medical specialties and external corporations. Of particular importance were (a) blinding in the study inclusion and random assignment with data capture software, (b) representative and unbiased patient selection in practice waiting rooms, (c) a data management and safety plan supplied by a specialized trial center, and (d) the use of participant pseudonyms supplied by a specialized service (Mainzelliste). The data collection started in July 2019 and will continue until June 2022. Five university study centers in Germany are participating in the trial.

Characteristics of Patients Presenting to a Psycho-Oncology Outpatient Clinic

OBJECTIVE

We aimed to determine the overall profile of patients in a psycho-oncology clinic and the differences in their characteristics according to the cancer site.

METHODS

The charts of 740 patients aged under 81 years were reviewed. The data from 586 completed questionnaires were subjected to multiple comparison analyses using one-way analysis of variance to examine the demographic and clinical differences according to the cancer site.

RESULTS

Most (n=532, 71.9%) patients were referred. Most new patients (n=426, 96.6%) received a psychiatric diagnosis; the most common diagnosis was depressive disorder (n=234, 31.6%). Likewise, depressive disorder accounted for the majority of diagnoses in all groups except for the digestive system cancer group in which sleep-wake disorder was the most prevalent. The female genital cancer group showed a higher level of anxiety symptoms than other groups, except for breast and haematolymphoid cancer groups, and psychological distress than all other groups.

CONCLUSION

There appear to be delays in the referral of cancer patients seeking psychiatric help to a psycho-oncology clinic. Along with tailoring approaches by cancer site, thorough evaluation and appropriate management of sleep-wake and anxiety symptoms are important for digestive system and female genital cancer patients, respectively.

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.

Prevalence of depressive symptoms in urban primary care settings: Botswana

BACKGROUND

The prevalence of depression is estimated to be high in primary care settings, especially amongst people with chronic diseases. Early identification and management of depression can improve chronic disease outcomes and quality of life, however, there are many missed opportunities in primary care.

AIM

This study aimed to determine the prevalence and correlates of depression and depressive symptoms in two urban primary care settings.

SETTING

The study was conducted at two primary care facilities in the capital city of Botswana.

METHODS

We administered a demographic questionnaire and the Patient Health Questionnaire-9 (PHQ-9) to adults attending two primary care facilities. The association between depressive symptoms and demographic variables was determined using Chi-square; level of significance was set at 0.05. We carried out a multivariate analysis using Kruskal-Wallis test to determine the association between demographic characteristics and depression.

RESULTS

A sample of 259 participants were recruited (66.8% women, median age 32). The mean PHQ-9 score was 8.71. A total of 39.8% of participants screened positive for depression at a cut-off of 9.0% and 35.1% at a cut-off of 10. Depressive symptoms were significantly associated with employment status and income using the Kruskal-Wallis test, χ2 (1) = 5.649, p = 0.017.

CONCLUSION

The high rates of depressive symptoms amongst the study population highlight the need for depression screening in primary care settings. The association between unemployment and income underscore the impact of socio-economic status on mental health in this setting.

Assessing Suicidal Ideation Using a Brief Self-Report Measure

Accurate assessment of suicidal thoughts is a challenge for researchers and clinicians. There is evidence that self-report and clinical interview assessment methods can result in different endorsement numbers when used to assess suicidal ideation. This study investigates endorsement rates and psychometric properties of a two-item self-report measure of suicidal ideation that distinguishes active from passive suicidal ideation, when compared with a clinical interview. Individuals presenting at an outpatient psychiatry clinic completed a measure of depression severity containing two items assessing passive and active suicidal ideation before undergoing a structured clinical interview. Self-report and clinical interview items demonstrated a low level of agreement. Self-report items were more strongly correlated with same-domain clinical interviewer ratings than different-domain ratings. These items demonstrated high negative predictive value and moderate-to-low positive predictive value for interviewer ratings. A two-item measure of suicidal ideation did not highly align with corresponding interviewer ratings, though such a measure may be useful in determining the absence of suicidal ideation, as well as distinguishing between passive and active suicidal ideation.

Resource allocation for depression management in general practice: A simple data-based filter model

Background

This study aimed to illustrate the potential utility of a simple filter model in understanding the patient outcome and cost-effectiveness implications for depression interventions in primary care.

Methods

Modelling of hypothetical intervention scenarios during different stages of the treatment pathway was conducted.

Results

Three scenarios were developed for depression related to increasing detection, treatment response and treatment uptake. The incremental costs, incremental number of successes (i.e., depression remission) and the incremental costs-effectiveness ratio (ICER) were calculated. In the modelled scenarios, increasing provider treatment response resulted in the greatest number of incremental successes above baseline, however, it was also associated with the greatest ICER. Increasing detection rates was associated with the second greatest increase to incremental successes above baseline and had the lowest ICER.

Conclusions

The authors recommend utility of the filter model to guide the identification of areas where policy stakeholders and/or researchers should invest their efforts in depression management.

Maximizing maternal health and value for money in postpartum depression screening: a cost-effectiveness analysis using the All Our Families cohort and administrative data in Alberta, Canada

BACKGROUND

Postpartum depression (PPD) affects 10-15% of women, is costly and debilitating, yet often remains undiagnosed. Within Alberta, Canada, screening is conducted at public health well child clinics using the Edinburgh Postnatal Depression Scale. If screened high-risk, women are offered referral to their family physicians for follow up diagnosis and treatment.

METHODS

We developed a decision tree to estimate the cost-effectiveness of PPD screening versus not screening in Alberta over a two-year time horizon using a public healthcare payer perspective. Both the current practice (51% attending referral) and a scenario analysis (100% attending referral) are presented.

RESULTS

Current practice results suggest screening leads to an incremental cost-effectiveness ratio (ICER) of $17,644 USD per quality adjusted life year (QALY). At a population-level, this resulted in an annual 813 (11%) additional cases diagnosed, 120 additional QALYs gained, and an additional cost of $2.1 million relative to not screening. With 100% attending referral, the ICER fell to $13,908 per QALY, resulting in an annual 1997 (27%) additional cases diagnosed, 249 additional QALYs gained, and an additional cost of $3.5 million relative to not screening.

LIMITATIONS

We were unable to explore the cost-effectiveness of PPD screening versus not screening for secondary populations, including children.

CONCLUSIONS

The results suggest screening may be most valuable when participation and compliance are maximized, where all women screened high-risk attend referral. This leads to greater value for money and increased maternal health gains across the population. Collaboration among public health and primary care services is encouraged to improve outcomes.

Screening for depression at the primary care level: Evidence for policy decision-making from a facility in Pretoria, South Africa

Background

Depression is a serious public health issue that has clinical, social and economic implications. Adult patients attending a primary healthcare (PHC) facility were screened in order to estimate the prevalence of depressive features and identify potential risk factors for screening positive.

Methods

This was an analytical cross-sectional study conducted at a clinic in Pretoria, South Africa. A self-administered questionnaire, which included the Patient Health Questionnaire-9 (PHQ-9) screening tool, was completed by patients attending the clinic. A PHQ-9 score of less than five was deemed as a negative screen for depressive features; with a score of five or more being considered a positive screen. A multivariate logistic regression model was developed to identify factors associated with a positive screen for depressive features.

Results

A total of 199 patients participated and the proportion screened positive for depressive features using the PHQ-9 tool was 46.23% (n = 92). Employed participants had significantly lower odds (odds ratio [OR] = 0.48; 95% confidence interval [CI]: 0.25 – 0.94) of screening positive, whilst the participants with significantly higher odds were those with co-morbidities (OR = 2.12; 95% CI: 1.08 – 4.17) and a history of stressful life events (OR = 3.21; 95% CI: 1.64 – 6.28).

Conclusion

Depression appears to be a significant problem in PHC settings in South Africa. Screening for depressive features at primary level, targeting those with chronic medical conditions, history of recent stressful life events and other known risk factors may improve detection rates, lead to earlier diagnosis and improved health outcomes.

Protocol for assessing feasibility, acceptability and fidelity of screening for antenatal depression (FAFSAD) by midwives in Blantyre District, Malawi

Background

Depression is often underdiagnosed by treating health professionals. This is a situation in Malawi where there is no routine screening of depression at antenatal clinics. Recently, a Screening Protocol for Antenatal Depression (SPADe) that can be used by midwives to screen for antenatal depression was developed in Blantyre District. SPADe proposes multistage screening of antenatal depression by midwives which may enable early detection and treatment of pregnant women with depression. Proper treatment of antenatal depression can assist in achieving Sustainable Development Goals (SDGs). However, utilisation of SPADe in clinical practice to screening for depression in antenatal clinics has not been established yet. Therefore, the primary aim of this study is to assess feasibility of screening for depression by midwives using SPADe in antenatal clinics in Blantyre District. The secondary aim was to assess acceptability and fidelity of screening for depression by midwives using SPADe in antenatal clinics in Blantyre District.

Methods

This will be a feasibility study which will consist of scientific investigations that will support movement of evidence-based, effective health care approach, SPADe, from the clinical knowledge base into routine use. This study will consist three phases: phase 1 will introduce SPADe in antenatal clinics in Blantyre District where screening of depression is almost none existent; phase 2 will implement screening of depression using SPADe in antenatal clinics in Blantyre District; and phase 3 will evaluate the screening of antenatal depression using SPADe to establish its feasibility, acceptability and fidelity in antenatal clinics in Blantyre District.

Discussion

This study will establish and document feasibility, acceptability and fidelity of screening for depression by midwives using SPADe in antenatal clinics in Blantyre District. It is expected that midwives will develop more confidence in detecting and dealing with antenatal depression. Consequently, there will be increased numbers of pregnant women detected with depression by midwives and increased accessibility to mental health care by pregnant women in antenatal clinics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00775-6.

Validity, Reliability, and Optimal Cut-off Scores of the WHO-5, PHQ-9, and PHQ-2 to Screen Depression Among University Students in Iran

This study aimed to investigate the validity, reliability, and optimal cut-off points for the Patient Health Questionnaire-2 (PHQ-2), Patient Health Questionnaire-9 (PHQ-9), and Well-being Index (WHO-5) to screen mild depression among 400 Iranian students who completed these tools and Beck Depression Inventory (BDI-13). Further, a psychiatrist diagnosed the depression by using the "Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders." The validity and internal consistency of tools assessed and the accuracy were computed using the receiver operating characteristic (ROC) and area under the curve (AUC). The internal consistency values of PHQ-2, PHQ-9, and WHO-5 were .73, .88, and .94, respectively. The PHQ-2 (.53), PHQ-9 (.60), and WHO-5 (.54) were significantly associated with the BDI. The PHQ-2, PHQ-9, and WHO-5 had optimal cut-off points of 2, 5, and 9 with an AUC of .809, .851, and .823, respectively. Based on these findings, it is recommended to use the PHQ-9 for mild depression screening among medical university students in Iran because of its high sensitivity and specificity.

Screening for depression in primary care with Patient Health Questionnaire-9 (PHQ-9): A systematic review

BACKGROUND

Depression is a leading cause of disability. International guidelines recommend screening for depression and the Patient Health Questionnaire 9 (PHQ-9) has been identified as the most reliable screening tool. We reviewed the evidence for using it within the primary care setting.

METHODS

We retrieved studies from MEDLINE, Embase, PsycINFO, CINAHL and the Cochrane Library that carried out primary care-based depression screening using PHQ-9 in populations older than 12, from 1995 to 2018.

RESULTS

Forty-two studies were included in the systematic review. Most of the studies were cross-sectional (N=40, 95%), conducted in high-income countries (N=27, 71%) and recruited adult populations (N=38, 90%). The accuracy of the PHQ-9 was evaluated in 31 (74%) studies with a two-stage screening system, with structured interview most often carried out by primary care and mental health professionals. Most of the studies employed a cut-off score of 10 (N=24, 57%, total range 5 - 15). The overall sensitivity of PHQ-9 ranged from 0.37 to 0.98, specificity from 0.42 to 0.99, positive predictive value from 0.09 to 0.92, and negative predictive value from 0.8 to 1.

LIMITATIONS

Lack of longitudinal studies, small sample size, and the heterogeneity of primary-care settings limited the generalizability of our results.

CONCLUSIONS

PHQ-9 has been widely validated and is recommended in a two-stage screening process. Longitudinal studies are necessary to provide evidence of long-term screening effectiveness.

Feasibility of implementing a culturally adapted Prolonged Grief Disorder scale in the mental healthcare system in Nepal

BACKGROUND

Nepali widows have a high prevalence of mental disorders, including prolonged grief disorder (PGD). Despite the considerable needs that Nepali widows have for mental health services, resources for mental health in Nepal are limited, amplifying the importance of accurate screening and diagnosis. The objective of this study was to explore the feasibility of implementing a culturally adapted Prolonged Grief Scale (PG-12/17-N) and provide actionable recommendations for its implementation.

METHODS

Twenty-five mental health service providers in Kathmandu and Chitwan, Nepal were interviewed using a semi-structured guide based on selected constructs from the Consolidated Framework for Implementation Research. Qualitative data were inductively and deductively coded and analyzed to identify prominent themes.

RESULTS

Providers reported that the main advantages of the scale were the need to identify widows at risk, cultural relevance, easy language, and inclusion of detailed and specific symptoms. Perceived weaknesses included the complexity in response options and scoring, length, item redundancy, overlap with depression symptoms, and lack of somatic symptoms. Providers discussed the need for training, supervision, and a referral and detection system required to implement the scale in Nepal. Further development of a brief version of the scale as a routine screener may facilitate detection and referral to care.

CONCLUSION

Based on the results showing need to address PGD in Nepali widows, further efforts are needed to increase awareness about PGD and develop evidence-supported treatments for PGD, after which screening could be made routine for widows.

Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis of individual participant data

OBJECTIVE

To evaluate the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression in pregnant and postpartum women.

DESIGN

Individual participant data meta-analysis.

DATA SOURCES

Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, and Web of Science (from inception to 3 October 2018).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Eligible datasets included EPDS scores and major depression classification based on validated diagnostic interviews. Bivariate random effects meta-analysis was used to estimate EPDS sensitivity and specificity compared with semi-structured, fully structured (Mini International Neuropsychiatric Interview (MINI) excluded), and MINI diagnostic interviews separately using individual participant data. One stage meta-regression was used to examine accuracy by reference standard categories and participant characteristics.

RESULTS

Individual participant data were obtained from 58 of 83 eligible studies (70%; 15 557 of 22 788 eligible participants (68%), 2069 with major depression). Combined sensitivity and specificity was maximised at a cut-off value of 11 or higher across reference standards. Among studies with a semi-structured interview (36 studies, 9066 participants, 1330 with major depression), sensitivity and specificity were 0.85 (95% confidence interval 0.79 to 0.90) and 0.84 (0.79 to 0.88) for a cut-off value of 10 or higher, 0.81 (0.75 to 0.87) and 0.88 (0.85 to 0.91) for a cut-off value of 11 or higher, and 0.66 (0.58 to 0.74) and 0.95 (0.92 to 0.96) for a cut-off value of 13 or higher, respectively. Accuracy was similar across reference standards and subgroups, including for pregnant and postpartum women.

CONCLUSIONS

An EPDS cut-off value of 11 or higher maximised combined sensitivity and specificity; a cut-off value of 13 or higher was less sensitive but more specific. To identify pregnant and postpartum women with higher symptom levels, a cut-off of 13 or higher could be used. Lower cut-off values could be used if the intention is to avoid false negatives and identify most patients who meet diagnostic criteria.

REGISTRATION

PROSPERO (CRD42015024785).