International comparison of clinicians' ability to identify depression in primary care: meta-analysis and meta-regression of predictors

Thwarted Belongingness and Suicide Risk in Primary Care: Perceived Burdensomeness and Psychache as Mediators

Suicide is a significant public health concern, particularly among primary care patients, given that many individuals who die by suicide visit their primary care provider in the months prior to their death. We examined constructs from two prominent theories of suicide, the interpersonal and psychache theories, including thwarted belongingness, perceived burdensomeness, and psychache. Among our sample (n = 224) of patients, perceived burdensomeness and psychache, individually and in serial, mediated the relation between thwarted belongingness and suicidal behavior. Thwarted belongingness was associated with greater perceived burdensomeness and, in turn, with more psychache and increased suicide risk. Our results elucidate the associations between the interpersonal and psychache theories of suicide. Clinical strategies that may reduce thwarted interpersonal needs and psychache, and which are appropriate for medical settings, are discussed.

Developing interventions to improve detection of depression in primary healthcare settings in rural Ethiopia

BACKGROUND

The poor detection of depression in primary healthcare (PHC) in low- and middle-income countries continues to threaten the plan to scale up mental healthcare coverage.

AIMS

To describe the process followed to develop an intervention package to improve detection of depression in PHC settings in rural Ethiopia.

METHOD

The study was conducted in Sodo, a rural district in south Ethiopia. The Medical Research Council's framework for the development of complex interventions was followed. Qualitative interviews, observations of provider-patient communication, intervention development workshops and pre-testing of the screening component of the intervention were conducted to develop the intervention.

RESULTS

A multicomponent intervention package was developed, which included (a) manual-based training of PHC workers for 10 days, adapted from the World Health Organization's Mental Health Gap Action Programme Intervention Guide, with emphasis on depression, locally identified depressive symptoms, communication skills, training by people with lived experience and active learning methods; (b) screening for culturally salient manifestations of depression, using a four-item tool; (c) raising awareness among people attending out-patient clinics about depression, using information leaflets and health education; and (d) system-level interventions, such as supportive supervision, use of posters at health facilities and a decision support mobile app.

CONCLUSIONS

This contextualised, multicomponent intervention package may lead to meaningful impact on the detection of depression in PHC in rural Ethiopia and similar settings. The intervention will be pilot tested for feasibility, acceptability and effectiveness before its wider implementation.

Treatment-resistant depression: definition, prevalence, detection, management, and investigational interventions

Treatment-resistant depression (TRD) is common and associated with multiple serious public health implications. A consensus definition of TRD with demonstrated predictive utility in terms of clinical decision-making and health outcomes does not currently exist. Instead, a plethora of definitions have been proposed, which vary significantly in their conceptual framework. The absence of a consensus definition hampers precise estimates of the prevalence of TRD, and also belies efforts to identify risk factors, prevention opportunities, and effective interventions. In addition, it results in heterogeneity in clinical practice decision-making, adversely affecting quality of care. The US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have adopted the most used definition of TRD (i.e., inadequate response to a minimum of two antidepressants despite adequacy of the treatment trial and adherence to treatment). It is currently estimated that at least 30% of persons with depression meet this definition. A significant percentage of persons with TRD are actually pseudo-resistant (e.g., due to inadequacy of treatment trials or non-adherence to treatment). Although multiple sociodemographic, clinical, treatment and contextual factors are known to negatively moderate response in persons with depression, very few factors are regarded as predictive of non-response across multiple modalities of treatment. Intravenous ketamine and intranasal esketamine (co-administered with an antidepressant) are established as efficacious in the management of TRD. Some second-generation antipsychotics (e.g., aripiprazole, brexpiprazole, cariprazine, quetiapine XR) are proven effective as adjunctive treatments to antidepressants in partial responders, but only the olanzapine-fluoxetine combination has been studied in FDA-defined TRD. Repetitive transcranial magnetic stimulation (TMS) is established as effective and FDA-approved for individuals with TRD, with accelerated theta-burst TMS also recently showing efficacy. Electroconvulsive therapy is regarded as an effective acute and maintenance intervention in TRD, with preliminary evidence suggesting non-inferiority to acute intravenous ketamine. Evidence for extending antidepressant trial, medication switching and combining antidepressants is mixed. Manual-based psychotherapies are not established as efficacious on their own in TRD, but offer significant symptomatic relief when added to conventional antidepressants. Digital therapeutics are under study and represent a potential future clinical vista in this population.

Comparing Pruning and Thresholding with Continuous Shrinkage Polygenic Score Methods in a Large Sample of Ancestrally Diverse Adolescents from the ABCD Study®

Using individuals' genetic data researchers can generate Polygenic Scores (PS) that are able to predict risk for diseases, variability in different behaviors as well as anthropomorphic measures. This is achieved by leveraging models learned from previously published large Genome-Wide Association Studies (GWASs) associating locations in the genome with a phenotype of interest. Previous GWASs have predominantly been performed in European ancestry individuals. This is of concern as PS generated in samples with a different ancestry to the original training GWAS have been shown to have lower performance and limited portability, and many efforts are now underway to collect genetic databases on individuals of diverse ancestries. In this study, we compare multiple methods of generating PS, including pruning and thresholding and Bayesian continuous shrinkage models, to determine which of them is best able to overcome these limitations. To do this we use the ABCD Study, a longitudinal cohort with deep phenotyping on individuals of diverse ancestry. We generate PS for anthropometric and psychiatric phenotypes using previously published GWAS summary statistics and examine their performance in three subsamples of ABCD: African ancestry individuals (n = 811), European ancestry Individuals (n = 6703), and admixed ancestry individuals (n = 3664). We find that the single ancestry continuous shrinkage method, PRScs (CS), and the multi ancestry meta method, PRScsx Meta (CSx Meta), show the best performance across ancestries and phenotypes.

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.

GPs' identification of patients with mental distress: a coupled questionnaire and cohort study from norwegian urban general practice

BACKGROUND

Mental health problems are one of the leading causes of disease burden worldwide, and are mainly diagnosed and treated in general practice. It is unclear however, how general practitioners (GPs) identify mental health problems in their patients. The aim of this study was to explore how patients' self-reported levels of mental distress correspond with psychological diagnoses made by their GPs, and associations with sex, age, number of consultations, and somatic symptom diagnoses.

METHODS

A questionnaire study coupled with retrospective and prospective cohort data from 553 patients aged 16-65 years in six GP offices in Oslo, Norway during 21 months in 2014-2016.

RESULTS

We found that 73.3% of patients with self-reported high levels of mental distress versus only 13.3% of the patients with low levels of mental distress had received a psychological diagnosis (p < 0.01). We found an increase in number of consultations for the group with high levels of mental distress regardless of having received a psychological diagnosis (p < 0.01). There was also an increase in number of somatic symptoms (p = 0.04) and higher number of females (0.04) in this group. 35% of patients had received one or more psychological diagnosis by their GP. Mean CORE-10 score, being female and a high number of consultations was associated with having received a psychological diagnosis. In the adjusted analyses high CORE-10 score and a high number of consultations still predicted a psychological diagnosis.

CONCLUSIONS

We found a clear association between self-reported mental distress and having received a psychological diagnosis amongst the participants, and the probability for being identified increased with increasing levels of mental distress, and increasing number of visits to their doctor. This suggests that GPs can identify patients with high levels of mental distress in general practice in an adequate way, even though this can sometimes be a complex issue.

TRIAL REGISTRATION

Trial registration The main study was retrospectively registered in ClinicalTrials.gov on August 10 2019 with identification number NCT03624829.

Care pathways for people with major depressive disorder: a European Brain Council Value of Treatment study

Background

Despite well-established guidelines for managing major depressive disorder, its extensive disability burden persists. This Value of Treatment mission from the European Brain Council aimed to elucidate the nature and extent of “gaps” between best-practice and current-practice care, specifically to:Identify current treatment gaps along the care pathway and determine the extent of these gaps in comparison with the stepped-care model and Recommend policies intending to better meet patient needs (i.e., minimize treatment gaps).

Methods

After agreement upon a set of relevant treatment gaps, data pertaining to each gap were gathered and synthesized from several sources across six European countries. Subsequently, a modified Delphi approach was undertaken to attain consensus among an expert panel on proposed recommendations for minimizing treatment gaps.

Results

Four recommendations were made to increase the depression diagnosis rate (from ~50% episodes), aiming to both increase the number of patients seeking help, and the likelihood of a practitioner to correctly detect depression. These should reduce time to treatment (from ~1 to ~8 years after illness onset) and increase rates of treatment; nine further recommendations aimed to increase rates of treatment (from ~25 to ~50% of patients currently treated), mainly focused on targeting the best treatment to each patient. To improve follow-up after treatment initiation (from ~30 to ~65% followed up within 3 months), seven recommendations focused on increasing continuity of care. For those not responding, 10 recommendations focused on ensuring access to more specialist care (currently at rates of ~5–25% of patients).

Conclusions

The treatment gaps in depression care are substantial and concerning, from the proportion of people not entering care pathways to those stagnating in primary care with impairing and persistent illness. A wide range of recommendations can be made to enhance care throughout the pathway.

Validity of the Hospital Anxiety and Depression Scale (HADS) in primary care patients in Colombia

OBJECTIVE

To assess the validity of the Hospital Anxiety and Depression Scale (HADS) for depression and anxiety screening in primary care patients in Colombia.

METHODS

A criterion validity study was conducted with 243 adults that had completed the HADS and were later assessed using the MINI as a gold standard. Cronbach's alpha, McDonald's omega and factor structure were applied through confirmatory factor analysis (CFA). ROC curve analysis and Youden's statistic were used to determine the cut-off point.

RESULTS

Cronbach's α was reported to be 0.85 and 0.82 for McDonalds' ω. CFA supported a two-factor solution demonstrating satisfactory fit. Root mean square error of approximation = 0.04, Comparative Fix Index (CFI) and Tucker-Lewis Index (TLI) = 0.97. For HADS-A, the cut-off point was determined as 6 associated with a sensitivity of 0.76, a specificity of 0.72 and Youden's index of 0.50. The ABC was 0.81. For HADS-D, the cut-off point was determined as 4 associated with a sensitivity of 0.78, a specificity of 0.74 and Youden's index of 0.53. The ABC was 0.82.

CONCLUSION

The HADS is a valid and reliable instrument for anxiety and depression screening in adult patients of primary healthcare services in Colombia.

Toward an Extended Definition of Major Depressive Disorder Symptomatology: Digital Assessment and Cross-validation Study

Background

Diagnosing major depressive disorder (MDD) is challenging, with diagnostic manuals failing to capture the wide range of clinical symptoms that are endorsed by individuals with this condition.

Objective

This study aims to provide evidence for an extended definition of MDD symptomatology.

Methods

Symptom data were collected via a digital assessment developed for a delta study. Random forest classification with nested cross-validation was used to distinguish between individuals with MDD and those with subthreshold symptomatology of the disorder using disorder-specific symptoms and transdiagnostic symptoms. The diagnostic performance of the Patient Health Questionnaire–9 was also examined.

Results

A depression-specific model demonstrated good predictive performance when distinguishing between individuals with MDD (n=64) and those with subthreshold depression (n=140) (area under the receiver operating characteristic curve=0.89; sensitivity=82.4%; specificity=81.3%; accuracy=81.6%). The inclusion of transdiagnostic symptoms of psychopathology, including symptoms of depression, generalized anxiety disorder, insomnia, emotional instability, and panic disorder, significantly improved the model performance (area under the receiver operating characteristic curve=0.95; sensitivity=86.5%; specificity=90.8%; accuracy=89.5%). The Patient Health Questionnaire–9 was excellent at identifying MDD but overdiagnosed the condition (sensitivity=92.2%; specificity=54.3%; accuracy=66.2%).

Conclusions

Our findings are in line with the notion that current diagnostic practices may present an overly narrow conception of mental health. Furthermore, our study provides proof-of-concept support for the clinical utility of a digital assessment to inform clinical decision-making in the evaluation of MDD.

Depression screening using patient-targeted feedback in general practices: study protocol of the German multicentre GET.FEEDBACK.GP randomised controlled trial

INTRODUCTION

Approximately one out of six patients in primary care suffers from depression, which often remains undetected. Evidence regarding the efficacy of depression screening in primary care, however, is inconsistent. A previous single-centre randomised controlled trial (RCT) in cardiac patients, the DEPSCREEN-INFO trial, provided the first evidence that written feedback to patients following a positive depression screening reduces depression severity and leads to more comprehensive patient engagement in mental healthcare. To amplify these effects, the feedback should be tailored according to patients' needs and preferences. The GET.FEEDBACK.GP RCT will test the efficacy of this patient-targeted feedback intervention in primary care.

METHODS AND ANALYSIS

The multicentre three-arm GET.FEEDBACK.GP RCT aims to recruit a total of 1074 primary care patients from North, East and South Germany. Patients will be screened for depression using the Patient Health Questionnaire-9 (PHQ-9). In the case of a positive depression screening result (PHQ-9 score ≥10), the participant will be randomised into one of three groups to either receive (a) patient-targeted and general practitioner (GP)-targeted feedback regarding the depression screening results, (b) only GP-targeted feedback or (c) no feedback. Patients will be followed over a period of 12 months. The primary outcome is depression severity (PHQ-9) 6 months after screening. Secondary outcomes include patient engagement in mental healthcare, professional depression care and cost-effectiveness. According to a statistical analysis plan, the primary endpoint of all randomised patients will be analysed regarding the intention-to-treat principle.

ETHICS AND DISSEMINATION

The Ethics Committee of the Hamburg Medical Association approved the study. A clinical trial company will ensure data safety, monitoring and supervision. The multicentre GET.FEEDBACK.GP RCT is the first trial in primary care that tests the efficacy of a patient-targeted feedback intervention as an adjunct to depression screening. Its results have the potential to influence future depression guidelines and will be disseminated in scientific as well as patient-friendly language.

TRIAL REGISTRATION NUMBER

NCT03988985.

[Translation and cross-cultural adaptation into Spanish, Catalan and Galician of the Hopkins Symptom Checklist-25 to identify depression in Primary Care]

Objetivo

Describir el proceso de traducción y adaptación transcultural de la escala Hopkins Symptom Checklist-25 (HSCL-25) al español, catalán y gallego.

Diseño

Traducción, adaptación transcultural y análisis de la comprensibilidad mediante entrevistas cognitivas.

Emplazamiento

Unidades de Investigación de Atención Primaria de Barcelona y Vigo.

Participantes

Médicos de familia y pacientes de Atención Primaria.

Mediciones principales

Siguiendo las guías de la International Society for Pharmacoeconomics and Outcomes Research (ISPOR), se realizaron: 1) traducción directa; 2) estudio piloto basado en metodología Delphi con médicos de familia; 3) retrotraducción; 4) análisis de equivalencias; 5) análisis de comprensibilidad de las versiones obtenidas en español, catalán y gallego mediante entrevista cognitiva en una muestra de pacientes, y 6) armonización transcultural.

Resultados

En el estudio Delphi participaron 73 médicos de familia. El consenso se estableció en la primera ronda para la traducción española y catalana, y en la segunda ronda para la gallega. Las retrotraducciones fueron similares en los 3 idiomas. Todas las versiones fueron equivalentes entre ellas y respecto a la versión original inglesa. En la entrevista cognitiva participaron 10 pacientes por cada idioma, sin que se modificara la redacción de los ítems.

Conclusiones

Las traducciones de la escala HSCL-25 en español, catalán y gallego son equivalentes semántica y conceptualmente a la versión original. Las traducciones son comprensibles y bien aceptadas por los pacientes.

Factors influencing self-management of depression in older adults: a qualitative study

Objectives: A considerable body of work addresses prevalence and treatment options for depression in older adults. However, less is known about their capacity to self-manage their depression. Effective self-management of depression has the potential to improve individuals' quality of life through information, empowerment and perceived control, while enabling more efficient health service utilisation. The aim of this paper was to identify the barriers and facilitators to self-management of depression in older adults.Method: A qualitative study comprising in-depth, semi-structured interviews with 32 older adults with a diagnosis of moderate depression.Results: Three over-arching themes captured the barriers and facilitators to participants' capacity to self-manage their depression. Perspectives on age and depression represented how views of older age and mental health influenced the approach to self-management. Ability to access the health care system concerned the ability to identify and engage with different services and support. Individual capacity for self-management reflected participants' views on and the resources required for effective self-management.Conclusion: This study offers a better understanding of the factors that positively or negatively influence older adults' ability to self-manage their depression. Strategies to improve self-management should address misconceptions about age and depression, and older adults' interest in and capacity to embrace self-management practices.

Validity of the Patient Health Questionnaire-9 (PHQ-9) for depression screening in adult primary care users in Bucaramanga, Colombia

The patient health questionnaire-9 (PHQ-9) is one of the most widely used self-report instruments in primary care. There is no criterion validity of the PHQ-9 in Colombia. The objective was to validate the PHQ-9 as a screening tool in primary care. A cross-sectional, scale criterion validity study was performed using as reference criterion the mini neuropsychiatric interview (MINI) in male and female adult users of primary care centres. We calculated the internal consistency and convergent and criterion validity of the PHQ-9 by analysing the receiver operating characteristics (ROC) and the area under the curve (AUC). We analysed 243 participants; 184 (75.7%) were female. The average age was 34.05 (median of 31 and SD = 12.47). Cronbach's α was 0.80 and McDonald's ω was 0.81. Spearman's Rho was 0.64 for HADS-D (P <0.010) and 0.70 for PHQ-2 (P <0.010). The AUC was 0.92 (95% CI 0.880-0.963). The optimal cut-off point of PHQ-9 was ≥7: sensitivity of 90.38 (95% CI: 81.41-99.36); specificity of 81.68 (95% CI: 75.93-87.42); PPV 57.32 (95% CI: 46.00-68.63); NPV 96.89 (95% CI: 93.90-99.88); Youden index 0.72 (95% CI: 0.62-0.82); LR+ 4.93 (95% CI: 3.61-6.74); LR- 0.12 (95% CI: 0.005-0.270). In sum, the Colombian version of PHQ-9 is a valid and reliable instrument for depression screening in primary care in Bucaramanga, with a cut-off point ≥7.

[Educational intervention to improve diagnostic accuracy regarding psychological morbidity in general practice]

INTRODUCTION

The aim of this pilot study was to evaluate the effectiveness of a complex educational intervention to improve the diagnostic competencies of general practitioners (GPs) regarding the detection of depression, anxiety and somatization.

METHODS

Cluster-randomized controlled pilot study with six practices each in the intervention group and in the control group. Psychological morbidity was determined by patient self-report using the Patient Health Questionnaire (PHQ-D). GPs rated the extent of psychological morbidity on a numerical rating scale from 0 (no co-morbidity) to 10 (maximum) of the individual patient after the consultation, independent of the reason for encounter.

RESULTS

364 patients participated. There were moderate correlations between GP rating and the PHQ scales (Spearman correlation between 0.27 and 0.42). There was no significant difference between intervention and control group. Diagnostic accuracy of the GPs, as determined with areas under the curves (AUCs), ranged between 0.52 (95%KI 0.30-0.73) and 0.84 (95%KI 0.67-1.00). The AUCs showed significant heterogeneity (Cochran Q=25.0; p<0.01). The regression analysis with 'presence of psychological disorder' (in PHQ) as the dependent variable showed that longer duration of doctor-patient-relationship was negatively associated with psychological morbidity (OR 0.96; 95%KI 0.92-0.99; p=0.01). There was a significant interaction between the factors 'time of doctor-patient relationship' and 'GP rating' (ß=0.02; OR 1.02, 95%KI 1.01-1.03; p<0.001), pointing towards increasing diagnostic accuracy when patients are known for a longer time.

DISCUSSION

We found no significant effect regarding the educational intervention. The GPs' estimation regarding psychological morbidity correlated significantly with the self-rating of the patients on PHQ scales. However, there was a considerable inter-individual variation between the GPs' diagnostic accuracy. The diagnostic estimation improved with increasing duration of doctor-physician relationship.

CONCLUSION

A one-time educational intervention seems not to be sufficient to improve diagnostic competencies in the detection of psychological morbidity. The considerable variation of the diagnostic accuracy might explain why 'one-size-fits-all' educational interventions will not help improve diagnostic competencies.

Evaluation of the impacts of a district-level mental health care plan on contact coverage, detection and individual outcomes in rural Uganda: a mixed methods approach

Background

The burden of mental disorders in low- and middle-income countries is large. Yet there is a major treatment gap for these disorders which can be reduced by integrating the care of mental disorders in primary care.

Aim

We aimed to evaluate the impact of a district mental health care plan (MHCP) on contact coverage for and detection of mental disorders, as well as impact on mental health symptom severity and individual functioning in rural Uganda.

Results

For adults who attended primary care facilities, there was an immediate positive effect of the MHCP on clinical detection at 3 months although this was not sustained at 12 months. Those who were treated in primary care experienced significant reductions in symptom severity and functional impairment over 12 months. There was negligible change in population-level contact coverage for depression and alcohol use disorder.

Conclusion

The study found that it is possible to integrate mental health care into primary care in rural Uganda. Treatment by trained primary care workers improves clinical and functioning outcomes for depression, psychosis and epilepsy. Challenges remain in accessing the men for care, sustaining the improvement in detection over time, and creating demand for services among those with presumed need.

Depression in Emergency Department Patients and Association With Health Care Utilization

BACKGROUND

Depression is one of the most common illnesses in the United States, with increased prevalence among people with lower socioeconomic status and chronic mental illness who often seek care in the emergency department (ED). We sought to estimate the rate and severity of major depressive disorder (MDD) in a nonpsychiatric ED population and its association with subsequent ED visits and hospitalizations.

METHODS

This prospective cohort study enrolled a convenience sample of English-speaking adults presenting to an urban academic medical center ED without psychiatric complaints between January 1, 2015, and September 21, 2015. Patients completed a computerized adaptive depression diagnostic screen (CAD-MDD) and dimensional depression severity measurement test (CAT-DI) via tablet computer. Primary outcomes included number of ED visits and hospitalizations assessed from index visit until January 1, 2016. Negative binomial regression modeling was performed to assess associations between depression, depression severity, clinical covariates, and utilization outcomes.

RESULTS

Of 999 enrolled patients, 27% screened positive for MDD. The presence of MDD conveyed a 61% increase in the rate of ED visits (incidence rate ratio [IRR] = 1.61, 95% confidence interval [CI] = 1.27 to 2.03) and a 49% increase in the rate of hospitalizations (IRR = 1.49, 95% CI = 1.06-2.09). For each 10% increase in MDD severity, there was a 10% increase in the relative rate of subsequent ED visits (IRR = 1.10, 95% CI = 1.04 to 1.16) and hospitalizations (IRR = 1.10, 95% CI = 1.02 to 1.18). Across the range of the severity scale there was over a 2.5-fold increase in the rate of ED visits and hospitalization rates.

CONCLUSIONS

Rates of depression were high among a convenience sample of English-speaking adult ED patients presenting with nonpsychiatric complaints and independently associated with increased risk of subsequent ED utilization and hospitalization. Standardized assessment tools that provide rapid, accurate, and precise classification of MDD severity have the potential to play an important role in identifying ED patients in need of urgent psychiatric resource referral.

[How frequently are depressive disorders recognized in primary care patients? : A cross-sectional epidemiological study in Germany]

BACKGROUND

Primary care physicians (PCPs) play a crucial role for guideline-oriented intervention in patients with depression.

OBJECTIVES

Based on a diagnostic screening questionnaire, this study investigates the sensitivity of PCPs to recognize patients with depression as well as the factors facilitating recognition and concordant diagnostic decisions.

METHOD

In a cross-sectional epidemiological study in six regions of Germany, 3563 unselected patients filled in questionnaires on mental and physical complaints and were diagnostically evaluated by their PCP (N = 253). The patient reports on an established Depression-Screening-Questionnaire (DSQ), which allows the approximate derivation of an ICD-10 depression diagnosis, were compared with the physician diagnosis (N = 3211). In a subsample of discordant cases a comprehensive standardized clinical-diagnostic interview (DIA-X/CIDI) was applied.

RESULTS

On the study day, the prevalence of ICD-10 depression was 14.3% according to the DSQ and 10.7% according to the physician diagnosis. Half of the patients identified by DSQ were diagnosed with depression by their physician and two thirds were recognized as mental disorder cases. More severe depression symptomatology and the persistent presence of main depression symptoms were related to better recognition and concordant diagnostic decisions. Diagnostic validation interviews confirmed the DSQ diagnosis in the majority of the false-negative cases. Indications for at least a previous history of depression were found in up to 70% of false-positive cases.

CONCLUSION

Given the high prevalence of depression in primary care patients, there is continued need to improve the recognition and diagnosis of these patients to assure guideline-oriented treatment.

Tree analysis modeling of the associations between PHQ-9 depressive symptoms and doctor diagnosis of depression in primary care

BACKGROUND

The aim of this study was to explore the relationship between patient self-reported Patient Health Questionnaire-9 (PHQ-9) symptoms and doctor diagnosis of depression using a tree analysis approach.

METHODS

This was a secondary analysis on a dataset obtained from 10 179 adult primary care patients and 59 primary care physicians (PCPs) across Hong Kong. Patients completed a waiting room survey collecting data on socio-demographics and the PHQ-9. Blinded doctors documented whether they thought the patient had depression. Data were analyzed using multiple logistic regression and conditional inference decision tree modeling.

RESULTS

PCPs diagnosed 594 patients with depression. Logistic regression identified gender, age, employment status, past history of depression, family history of mental illness and recent doctor visit as factors associated with a depression diagnosis. Tree analyses revealed different pathways of association between PHQ-9 symptoms and depression diagnosis for patients with and without past depression. The PHQ-9 symptom model revealed low mood, sense of worthlessness, fatigue, sleep disturbance and functional impairment as early classifiers. The PHQ-9 total score model revealed cut-off scores of &gt;12 and &gt;15 were most frequently associated with depression diagnoses in patients with and without past depression.

CONCLUSIONS

A past history of depression is the most significant factor associated with the diagnosis of depression. PCPs appear to utilize a hypothetical-deductive problem-solving approach incorporating pre-test probability, with different associated factors for patients with and without past depression. Diagnostic thresholds may be too low for patients with past depression and too high for those without, potentially leading to over and under diagnosis of depression.

Diagnostic accuracy and treatment approach to depression in primary care: predictive factors

OBJECTIVE

The study assessed the predictive factors of diagnostic accuracy and treatment approach (antidepressants versus active monitoring) for depression in primary care.

METHODS

This is a cross-sectional study that uses information from a naturalistic prospective controlled trial performed in Barcelona (Spain) enrolling newly diagnosed patients with mild to moderate depression by GPs. Treatment approach was based on clinical judgement. Diagnosis was later assessed according to DSM-IV criteria using Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) interview by an external researcher. Patients (sociodemographic, psychiatric diagnosis, severity of depression and anxiety, health-related quality of life, disability, beliefs about medication and illness and comorbidities) and GP factors associated with diagnostic accuracy and treatment approach were assessed using multilevel logistic regression. Variables with missing data were imputed through multiple imputations.

RESULTS

Two hundred sixty-three patients were recruited by 53 GPs. Mean age was 51 years (SD = 15). Thirty percent met DSM-IV criteria for major depression. Mean depression symptomatology was moderate-severe. Using multivariate analyses, patients' beliefs about medicines were the only variable associated with the antidepressant approach. Specialization in general medicine and being a resident tutor were associated with a more accurate diagnosis.

CONCLUSIONS

Clinical depression diagnosis by GPs was not always associated with a formal diagnosis through a SCID-I. GPs' training background was central to an adequate depression diagnosis. Patients' beliefs in medication were the only factor associated with treatment approach. More resources should be allocated to improving the diagnosis of depression.

The Treatment of Depression in Primary Care

BACKGROUND

General practitioners play a key role in the care of patients with depressive disorders. We studied the frequency and type of treatment of depressive disorders in primary care.

METHODS

In a cross-sectional epidemiological study on a particular day in six different regions in Germany, 253 physicians and 3563 unselected patients were asked to fill in a questionnaire assessing the diagnosis and treatment of depression. A total of 3431 usable patient data sets and 3211 sets of usable data from both the patient and the physician were subjected to further analysis.

RESULTS

68.0% of the 490 patients in primary care who were classified as depressed according to the Depression Screening Questionnaire received treatment from their general practitioner or in other care settings; the probability of being treated by the general practitioner was higher for patients whose diagnosis was recognized by the general practitioner (92.8%) than for the remaining depressed patients (47.8%). On the day of data recording, 54.1% of the depressed patients were under treatment by the general practitioner and 21.2% had been referred to specialized treatment. Approximately 60% of the depressed patients were not being treated, as recommended in the guidelines, with antidepressant drugs, psychotherapy, or both. The likelihood of being treated in conformity with the guidelines depended on whether or not the general practitioner had made the diagnosis of depression (odds ratio [OR] = 7.5; 95% confidence interval = [4.9; 11.6]; p <0,001); it was also higher if the general practitioner had an additional qualification in psychotherapy (OR = 1.9; [1.1; 3.4]; p = 0.022).

CONCLUSION

The finding that a relevant proportion of patients with depressive disorders in primary care are inadequately treated indicates the need to improve general practitioners' ability to diagnose these conditions and determine the indication for treatment.

Exploring the feasibility of new Dutch mental health policy within a large primary health care centre: a case study

BACKGROUND

A reform of Dutch mental health care aimed to substitute care from specialized care to general practice. Since 1 January 2014, Dutch general practitioners (GPs) are no longer allowed to refer patients without a psychiatric disorder to mental health care. Patients with non-complex psychological problems should be treated within general practice.

OBJECTIVE

To explore the feasibility of the Dutch mental health policy.

METHODS

We conducted an observational case study in a primary health care centre in 2014. The health care centre was a convenience sample; the participating GPs reorganized mental health care in line with the upcoming policy, and invited the researchers to monitor their referrals. We assessed how many patients with mental health problems (n = 408) were allocated to policy-concordant treatment. Additionally, 137 patients (33%) completed a follow up assessment on mental health problems 3 months after baseline.

RESULTS

The majority of the patients were allocated to treatment in line with the policy. Almost half of the patients (42%) were treated in a setting that was exactly policy-concordant, while the other half (47%) was treated in a setting that was even less specialized than was allowed. In general, patients showed improvement after 3 months, regardless of (non) policy-concordant treatment. Attrition rate after 3 months was high, probably due to the practical study design.

CONCLUSION

There is potential for substitution of mental health care. Since the studied health care centre was specialized in mental health care, further research should explore if similar results can be found in other general practices.

Screening for psychiatric morbidity in the population - a comparison of the GHQ-12 and self-reported medication use

Introduction

Uptake of psychotropic medication has been previously used as a proxy for assessing the prevalence of population mental health morbidity. However, it is not known how this compares with estimates derived from population screening tools.

Objective

To compare estimates of psychiatric morbidity derived by a validated screening instrument of psychiatric morbidity and a self-reported medication uptake measure.

Methods

This study used data from two recent population-wide health surveys in Northern Ireland, a country (UK) with free health services and no prescription charges. The psychiatric morbidity of 7,489 respondents was assessed using the GHQ-12 and self-reported use of medication for stress, anxiety and depression (sDAS medication).

Results

Overall, 19% of respondents were defined as ‘cases’ and 14.3% were taking sDAS medication. Generally, the two methods identified the same population distributions of characteristics that were associated with psychiatric morbidity though nearly as many non-cases as cases received sDAS medication (46.4% vs. 53.6%). A greater proportion of women and older people were identified as cases according to sDAS medication use, while no such variation was observed between socio-economic status and method of assessment.

Conclusions

This study indicates that these two methods of assessing population psychiatric morbidity provide similar estimates, despite potentially identifying different individuals as cases. It is important to note that different health care systems might be linked to variations in obstacles when accessing and using health care services.

Highlights

Identification of major depressive disorder among the long-term unemployed

PURPOSE

Depression is a common mental health disorder among the unemployed, but research on identifying their depression in health care is scarce. The present study aimed to explore the identification of major depressive disorder (MDD) in health care on long-term unemployed and find out if the duration of unemployment correlates with the risk for unidentified MDD.

METHODS

The study sample consisted the patient files of long-term unemployed people (duration of unemployment 1-35 years, median 11 years), who in a screening project diagnosed with MDD (n = 243). The MDD diagnosis was found in the health care records of 101. Binomial logistic regression models were used to explore the effect of the duration of unemployment, as a discrete variable, to the identification of MDD in health care.

RESULTS

MDD was appropriately identified in health care for 42% (n = 101) of the participants with MDD. The odds ratio for unidentified MDD in health care was 1.060 (95% confidence interval 1.011; 1.111, p = 0.016) per unemployment year. When unemployment had continued, for example, for five years the odds ratio for having unidentified MDD was 1.336. The association remained significant throughout adjustments for the set of background factors (gender, age, occupational status, marital status, homelessness, criminal record, suicide attempts, number of health care visits).

CONCLUSIONS

This study among depressed long-term unemployed people indicates that the longer the unemployment period has lasted, the more commonly these people suffer from unidentified MDD. Health services should be developed with respect to sensitivity to detect signs of depression among the long-term unemployed.

The cost-effectiveness of PHQ screening and collaborative care for depression in New York City

BACKGROUND

Depression is under-diagnosed and under-treated in most areas of the US. New York City is currently looking to close gaps in identifying and treating depression through the adoption of a screening and collaborative care model deployed throughout the city.

METHODS

We examine the cost-effectiveness of universal two-stage screening with the 2- and 9-item Patient Health Questionnaires (PHQ-2 and PHQ-9) in New York City followed by collaborative care for those who screen positive. We conducted microsimulations on hypothetical adult participants between ages 20 and 70.

RESULTS

The incremental cost-effectiveness of the interventions over the average lifespan of a 20-year-old adult in NYC is approximately $1,726/QALY gained (95% plausible interval: cost-saving, $10,594/QALY gained).

CONCLUSIONS

Two-stage screening coupled with collaborative care for depression in the clinical setting appears to be significantly less expensive than most clinical preventive interventions, such as HIV screening in high-risk patients. However, effectiveness is dependent on the city's ability to manage scale up of collaborative care models.

The psychometric characteristics of the revised depression attitude questionnaire (R-DAQ) in Pakistani medical practitioners: a cross-sectional study of doctors in Lahore

Background

Depression is common mental health problem and leading contributor to the global burden of disease. The attitudes and beliefs of the public and of health professionals influence social acceptance and affect the esteem and help-seeking of people experiencing mental health problems. The attitudes of clinicians are particularly relevant to their role in accurately recognising and providing appropriate support and management of depression. This study examines the characteristics of the revised depression attitude questionnaire (R-DAQ) with doctors working in healthcare settings in Lahore, Pakistan.

Methods

A cross-sectional survey was conducted in 2015 using the revised depression attitude questionnaire (R-DAQ). A convenience sample of 700 medical practitioners based in six hospitals in Lahore was approached to participate in the survey. The R-DAQ structure was examined using Parallel Analysis from polychoric correlations. Unweighted least squares analysis (ULSA) was used for factor extraction. Model fit was estimated using goodness-of-fit indices and the root mean square of standardized residuals (RMSR), and internal consistency reliability for the overall scale and subscales was assessed using reliability estimates based on Mislevy and Bock (BILOG 3 Item analysis and test scoring with binary logistic models. Mooresville: Scientific Software, 55) and the McDonald’s Omega statistic. Findings using this approach were compared with principal axis factor analysis based on Pearson correlation matrix.

Results

601 (86%) of the doctors approached consented to participate in the study. Exploratory factor analysis of R-DAQ scale responses demonstrated the same 3-factor structure as in the UK development study, though analyses indicated removal of 7 of the 22 items because of weak loading or poor model fit. The 3 factor solution accounted for 49.8% of the common variance. Scale reliability and internal consistency were adequate: total scale standardised alpha was 0.694; subscale reliability for professional confidence was 0.732, therapeutic optimism/pessimism was 0.638, and generalist perspective was 0.769.

Conclusions

The R-DAQ was developed with a predominantly UK-based sample of health professionals. This study indicates that this scale functions adequately and provides a valid measure of depression attitudes for medical practitioners in Pakistan, with the same factor structure as in the scale development sample. However, optimal scale function necessitated removal of several items, with a 15-item scale enabling the most parsimonious factor solution for this population.

Recognition of depression by primary care clinicians in rural Ethiopia

Background

Depression is a common health condition affecting up to a third of patients attending primary care, where most of the care for people with depression is provided. Adequate recognition of depression is the critical step in the path to effective care, particularly in low income countries. As part of the Programme for Improving Mental healthcare (PRIME), a project supporting the implementation of integrated mental healthcare in primary care, we evaluated the level of recognition of depression by clinicians working in primary care in rural Ethiopia prior to in service training. We hypothesised that the detection rate of depression will be under 10% and that detection would be affected by gender, education and severity of depression.

Methods

Cross-sectional survey in eight health centres serving a population of over 160,000 people. A validated version of the 9-item patient health questionnaire (PHQ-9) was administered as an indicator of probable depression. In addition, primary care clinicians completed a clinician encounter form. Participants were consecutive primary care attendees aged 18 years and above.

Results

A total of 1014 participants were assessed. Primary care clinicians diagnosed 13 attendees (1.3%) with depression. The PHQ9 prevalence of depression at a cut-off score of ten was 11.5% (n = 117), of whom 5% (n = 6/117) had received a diagnosis of depression by primary care clinicians. Attendees with higher PHQ scores and suicidality were significantly more likely to receive a diagnosis of depression by clinicians. Women (n = 9/13) and participants with higher educational attainment were more likely to be diagnosed with depression, albeit non-significantly. All cases diagnosed with depression by the clinicians had presented with psychological symptoms.

Conclusion

Although not based on a gold standard diagnosis, over 98% of cases with PHQ-9 depression were undetected. Failure of recognition of depression may pose a serious threat to the scale up of mental healthcare in low income countries. Addressing this threat should be an urgent priority, and requires a better understanding of the nature of depression and its presentation in rural low-income primary care settings.

[Coping strategies of older people with low mood]

BACKGROUND

To gain new insights for support for older people with low mood, we explored the perceptions of 'screenpositive' older people on underlying causes and possible solutions.

DESIGN AND METHOD

We conducted two in-depth interviews with 38 participants (≥77 years) who screened positive for depressive symptoms in general practice. To investigate the influence of the presence of complex health problems, we included 19 persons with and 19 without complex problems. Complex problems were defined as a combination of functional, somatic, psychological or social problems.

RESULTS

All participants used several cognitive, social or practical coping strategies. Four patterns emerged: mastery, acceptance, ambivalence, and need for support. Some participants, especially those with complex problems, were ambivalent about possible interventions.

CONCLUSION

Most older participants perceived their coping strategies as sufficient. General practitioners can support self-management by exploring the (effectiveness of) personal coping strategies, providing information, elaborating on perceptions of risks and discussing alternative options with older persons.

Effectiveness of bright light therapy on depressive symptoms in older adults with non-seasonal depression: a systematic review protocol

REVIEW QUESTION

What is the effectiveness of bright light therapy (BLT) on depressive symptoms in older adults with non-seasonal depression?

REVIEW OBJECTIVE

The review objective is to determine the current evidence related to the effectiveness of BLT on depressive symptoms in older adults with non-seasonal depression.

Older people coping with low mood: a qualitative study

BACKGROUND

To gain new insight into support for older people with low mood, the perceptions, strategies, and needs of older people with depressive symptoms were explored.

METHODS

Two in-depth interviews were held with 38 participants (aged ≥77 years) who screened positive for depressive symptoms in general practice. To investigate the influence of the presence of complex health problems, 19 persons with and 19 without complex problems were included. Complex problems were defined as a combination of functional, somatic, psychological or social problems.

RESULTS

All participants used several cognitive, social or practical coping strategies. Four patterns emerged: mastery, acceptance, ambivalence, and need for support. Most participants felt they could deal with their feelings sufficiently, whereas a few participants with complex problems expressed a need for professional support. Some participants, especially those with complex problems, were ambivalent about possible interventions mainly because they feared putting their fragile balance at risk due to changes instigated by an intervention.

CONCLUSION

Most older participants with depressive symptoms perceived their coping strategies to be sufficient. The general practitioners (GPs) can support self-management by talking about the (effectiveness of) personal coping strategies, elaborating on perceptions of risks, providing information, and discussing alternative options with older persons.

Agreement for depression diagnosis between DSM-IV-TR criteria, three validated scales, oncologist assessment, and psychiatric clinical interview in elderly patients with advanced ovarian cancer

Background

Depression, a major outcome in cancer patients, is often evaluated by physicians relying on their clinical impressions rather than patient self-report. Our aim was to assess agreement between patient self-reported depression, oncologist assessment (OA), and psychiatric clinical interview (PCI) in elderly patients with advanced ovarian cancer (AOC).

Methods

This analysis was a secondary endpoint of the Elderly Women AOC Trial 3 (EWOT3), designed to assess the impact of geriatric covariates, notably depression, on survival in patients older than 70 years of age. Depression was assessed using the Geriatric Depression Scale-30 (GDS), the Hospital Anxiety Depression Scale, the distress thermometer, the mood thermometer, and OA. The interview guide for PCI was constructed from three validated scales: the GDS, the Hamilton Depression Rating Scale, and the Montgomery Asberg Depression Rating Scale (MADRS). The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, revised (DSM) criteria for depression were used as a gold standard.

Results

Out of 109 patients enrolled at 21 centers, 99 (91%) completed all the assessments. Patient characteristics were: mean age 78, performance status ≥2: 47 (47%). Thirty six patients (36%) were identified as depressed by the PCI versus 15 (15%) identified by DSM. We found moderate agreement for depression identification between DSM and GDS (κ=0.508) and PCI (κ=0.431) and high agreement with MADRS (κ=0.663). We found low or no agreement between DSM with the other assessment strategies, including OA (κ=−0.043). Identification according to OA (yes/no) resulted in a false-negative rate of 87%. As a screening tool, GDS had the best sensitivity and specificity (94% and 80%, respectively).

Conclusion

The use of validated tools, such as GDS, and collaboration between psychologists and oncologists are warranted to better identify emotional disorders in elderly women with AOC.

Presurgical assessment of bariatric patients with the Patient Health Questionnaire (PHQ)--a screening of the prevalence of psychosocial comorbidity

BACKGROUND

Bariatric surgery has gained increasing relevance due to the dramatic rise in morbid obesity prevalence. A sound body of scientific literature demonstrates positive long-term outcome of bariatric surgery in decreasing mental and physical health morbidity. Still, there is a need for a manageable presurgical screening to assess major mental disorders. The aim of this study was to assess the frequency of common psychiatric syndromes in bariatric surgery candidates using a computerized version of the Patient Health Questionnaire (PHQ).

METHODS

In a prospective cohort study from August 2009 to July 2011 morbidly obese individuals seeking bariatric treatment were evaluated for mental health disorders using the PHQ (computerized German version).

RESULTS

A total of 159 patients were included in this study. The median age of participants was 42 years, the median BMI was 49 kg/m(2). The PHQ revealed a prevalence of 84 % for mental health disorders, 50 % of the participants had three or more mental health disorders. A high somatic symptom burden (46 %), depressive syndromes (62 %) and anxiety disorders (29 %) were the most frequent psychiatric syndromes. The median number of psychiatric syndromes was 3 for women and 1 for men (p = 0.007). No correlation between BMI and a single syndrome or the sum of syndromes was observed.

CONCLUSION

84 % of the patients seeking bariatric treatment were screened positive for at least one mental health disorder. The computerized PHQ with automated reporting appears to be a useful instrument for presurgical assessment of bariatric patients in routine medical settings.

How do GP practices and patient characteristics influence the prescription of antidepressants? A cross-sectional study

BACKGROUND

Under-prescription of antidepressants (ADs) among people meeting the criteria for major depressive episodes and excessive prescription in less symptomatic patients have been reported. The reasons influencing general practitioners' (GPs) prescription of ADs remain little explored. This study aimed at assessing the influence of GP and patient characteristics on AD prescription.

METHODS

This cross-sectional study was based on a sample of 816 GPs working within the main health care insurance system in the Seine-Maritime district of France during 2010. Only GPs meeting the criteria for full-time GP practice were included. The ratio of AD prescription to overall prescription volume, a relative measure of AD prescription level, was calculated for each GP, using the defined daily dose (DDD) concept. Associations of this AD prescription ratio with GPs' age, gender, practice location, number of years of practice, number of days of sickness certificates prescribed, number of home visits and consultations, number and mean age of registered patients, mean patient income, and number of patients with a chronic condition were assessed using univariate and multivariate analysis.

RESULTS

The high prescribers were middle-aged (40-59) urban GPs, with a moderate number of consultations and fewer low-income and chronic patients. GPs' workload (e.g., volume of prescribed drug reimbursement and number of consultations) had no influence on the AD prescription ratio. GPs with more patients with risk factors for depression prescribed fewer ADs, however, which could suggest the medications were under-prescribed among the at-risk population.

CONCLUSIONS

Our study described a profile of the typical higher AD prescriber that did not include heavy workload. In future work, a more detailed assessment of all biopsychosocial components of the consultation and other influences on GP behavior such as prior training would be useful to explain AD prescription in GP's practice.

Accuracy of general practitioner unassisted detection of depression

OBJECTIVE

Primary care is an important setting for the treatment of depression. The aim of the study was to describe the accuracy of unassisted general practitioner judgements of patients' depression compared to a standardised depression-screening tool delivered via touch-screen computer.

METHOD

English-speaking patients, aged 18 or older, completed the Patient Health Questionnaire-9 (PHQ-9) when presenting for care to one of 51 general practitioners in Australia. General practitioners were asked whether they thought the patients were clinically depressed. General practitioner judgements of depression status were compared to PHQ-9 results.

RESULTS

A total of 1558 patients participated. Twenty per cent of patients were identified by the PHQ-9 as being depressed. General practitioners estimated a similar prevalence; however, when compared to the PHQ-9, GP judgement had a sensitivity of 51% (95% CI [32%, 66%]) and a specificity of 87% (95% CI [78%, 93%]).

CONCLUSIONS

General practitioner unassisted judgements of depression in their patients lacked sensitivity when compared to a standardised psychiatric measure used in general practice.

Stepped collaborative depression care: primary care results before and after implementation of a stepped collaborative depression programme

BACKGROUND

Numerous intensive research projects to assess the effects of stepped collaborative care (SCC) for depressed patients have been reported in primary care, yet it is unclear how SCC is sustained in usual care.

OBJECTIVE

To assess how SCC for depression is actually being used and how it performs in usual primary care by studying medical data that are routinely collected in family practice, outside the research setting.

METHODS

Retrospective before and after comparison of electronic medical records (EMR) regarding the implementation of an SCC depression programme in a large primary care organization from 2003 to 2012. Depression care parameters included prevalences, minimal interventions, Beck Depression Inventory-2 (BDI-2), antidepressants, referrals to psychologists and psychiatrists and primary health care consumption.

RESULTS

After programme implementation, differentiation between levels of depression severity increased, more patients were treated with minimal interventions and more patients were monitored with BDI-2. These effects occurred in both nonseverely and severely depressed patients, although they were larger for patients registered as nonseverely depressed. Antidepressant prescription rates and referral rates seemed not to have been influenced by the SCC programme. Health care consumption of the depressed patients increased significantly.

CONCLUSIONS

The depression care parameters changed to a different extent and at a different pace than after previous implementation initiatives. Future research should identify whether SCC uptake in primary care is best enhanced by intensive external guidance or by making care providers themselves responsible for the implementation. Analyses of EMR can be valuable in monitoring the implementation effects, especially after research projects are completed.

Health care costs before and after diagnosis of depression in patients with unexplained pain: a retrospective cohort study using the United Kingdom General Practice Research Database

Purpose

To assess the impact of pain severity and time to diagnosis of depression on health care costs for primary care patients with pre-existing unexplained pain symptoms who subsequently received a diagnosis of depression.

Patients and methods

This retrospective cohort study analyzed 4000 adults with unexplained pain (defined as painful physical symptoms [PPS] without any probable organic cause) and a subsequent diagnosis of depression, identified from the UK General Practice Research Database using diagnostic codes. Patients were categorized into four groups based on pain severity (milder or more severe; based on number of pain-relief medications and use of opioids) and time to diagnosis of depression (≤1 year or>1 year from PPS index date). Annual health care costs were calculated (2009 values) and included general practitioner (GP) consultations, secondary care referrals, and prescriptions for pain-relief medications for the 12 months before depression diagnosis and in the subsequent 2 years. Multivariate models of cost included time period as a main independent variable, and adjusted for age, gender, and comorbidities.

Results

Total annual health care costs before and after depression diagnosis for the four patient groups were higher for the groups with more severe pain (£819–£988 versus £565–£628; P < 0.001 for all pairwise comparisons) and highest for the group with more severe pain and longer time to depression diagnosis in the subsequent 2 years (P < 0.05). Total GP costs were highest in the group with more severe pain and longer time to depression diagnosis both before and after depression diagnosis (P < 0.05). In the second year following depression diagnosis, this group also had the highest secondary care referral costs (P < 0.01). The highest drug costs were in the groups with more severe pain (P < 0.001), although costs within each group were similar before and after depression diagnosis.

Conclusion

Among patients with unexplained pain symptoms, significant pain in combination with longer time from pain symptoms to depression diagnosis contribute to higher costs for the UK health care system.

[Integral Care Guide for Early Detection and Diagnosis of Depressive Episodes and Recurrent Depressive Disorder in Adults. Integral Attention of Adults with a Diagnosis of Depressive Episodes and Recurrent Depressive Disorder: Part I: Risk Factors, Screening, Suicide Risk Diagnosis and Assessment in Patients with a Depression Diagnosis]

INTRODUCTION

Depression is an important cause of morbidity and disability in the world; however, it is under-diagnosed at all care levels.

OBJECTIVE

The purpose here is to present recommendations based on the evidence gathered to answer a series of clinical questions concerning risk factors, screening, suicide risk diagnosis and evaluation in patients undergoing a depressive episode and recurrent depressive disorder. Emphasis has been made upon the approach used at the primary care level so as to grant adult diagnosed patients the health care guidelines based on the best and more updated evidence available thus achieving minimum quality standards.

METHODOLOGY

A practical clinical guide was elaborated according to standards of the Methodological Guide of the Ministry of Social Protection. Recommendation from guides NICE90 and CANMAT were adopted and updated so as to answer the questions posed while de novo questions were developed.

RESULTS

Recommendations 1-22 corresponding to screening, suicide risk and depression diagnosis were presented. The corresponding degree of recommendation is included.

The depression treatment cascade in primary care: a public health perspective

Major depressive disorder (MDD) is common and costly. Primary care remains a major access point for depression treatment, yet the successful clinical resolution of depression in primary care is uncommon. The clinical response to depression suffers from a "treatment cascade": the affected individual must access health care, be recognized clinically, initiate treatment, receive adequate treatment, and respond to treatment. Major gaps currently exist in primary care at each step along this treatment continuum. We estimate that 12.5% of primary care patients have had MDD in the past year; of those with MDD, 47% are recognized clinically, 24% receive any treatment, 9% receive adequate treatment, and 6% achieve remission. Simulations suggest that only by targeting multiple steps along the depression treatment continuum (e.g. routine screening combined with collaborative care models to support initiation and maintenance of evidence-based depression treatment) can overall remission rates for primary care patients be substantially improved.

Depression assessment by oncologists and palliative care physicians

Objective:

Depression is a frequent problem in cancer patients, which is known to reduce quality of life; however, many cancer patients with depression are not treated because of the difficulties in assessing depression in this population. Our aim was to evaluate and improve the depression assessment strategies of palliative care (PC) physicians and oncologists.

Method:

We invited all medical oncologists and PC physicians from three cancer centers to participate in this multicenter prospective study. They were asked to classify 22 symptoms (related and specific to depression in cancer patients, related but not specific, and unrelated) as “very important,” “important,” “less important,” or “not important” for the diagnosis of depression in cancer patients, at three different time points (at baseline, after a video education program, and after 4 weeks). They were also asked to complete a questionnaire exploring physicians' perceptions of depression and of their role in its systematic screening.

Results:

All 34 eligible physicians participated. Baseline performance was good, with >70% of participants correctly classifying at least seven of nine related and specific symptoms. We found no significant improvement in scores in the immediate and 4-week follow-up tests. Additionally, 24 (83%) and 23 (79%) participants expressed support for systematic depression screening and a role for oncologists in screening, respectively.

Significance of results:

Oncologists had good baseline knowledge about depression's main symptoms in cancer patients and a positive attitude toward being involved in screening. Underdiagnosis of depression is probably related to problems associated with the oncology working environment rather than the physicians' knowledge.

Clinical utility of screening for clinical depression and bipolar disorder

PURPOSE OF REVIEW

Screening for clinical depression and bipolar disorder remains controversial. Screening is usually based on finding discriminating symptoms, but not all tools perform equally well. Clinicians should be able to assess the clinical utility of screening tests as well as their accuracy and acceptability.

RECENT FINDINGS

Screening for depression using the Patient Health Questionnaire (PHQ) has been extensively examined. Four main versions of scoring the PHQ exist. The two-item PHQ2, the nine-item PHQ9, the PHQ DSM-IV algorithm, and the two-step PHQ2 then PHQ9. Recent results suggest that the PHQ9 is more accurate than the PHQ2, and that the algorithm scoring method is preferred to the linear cut-off score. The two-step procedure has promise, but it has not been adequately tested. Two screening questions may be a useful compromise in medical settings, as they take less than 2 min, but about a quarter of patients do not receive screening even when implemented systematically. Alternative customized questionnaires have been developed in medical settings such as the Depression Screening in Parkinson's Disease DESPAR and Neurological Disorders Depression Inventory for Epilepsy (NDDI-E). Screening for bipolar disorders is an even greater challenge than screening for unipolar depression. Screening in primary care and the community has low positive predictive value. Screening in high-risk samples, such as those with known depression is somewhat more successful, but not yet sufficiently accurate to be used alone.

SUMMARY

Screening for depression can bring added value to routine unassisted recognition, but only if followed by good-quality treatment. Screening for bipolar disorder is not yet sufficiently accurate to be used reliably in clinical practice.

The bidirectional relationship of depression and diabetes: a systematic review

Depression and diabetes are both serious chronic conditions common in Western cultures. These conditions impart a significant burden on the patients and society. Depression is often comorbid with chronic illness, and past research has found an increased prevalence of depressive symptoms in patients with Type 2 Diabetes Mellitus (T2DM). However, the exact nature and direction of this relationship are unknown. Depression is often thought to be a consequence of diabetes, perhaps due to the burden of chronic illness. Research has also suggested that depression may be a risk factor for development of diabetes, in part due to biochemical changes in depression and in part because of a reduction of health care behaviors in individuals with depression. This paper reviews the literature behind both lines of investigation and includes special diagnostic and clinical considerations for at risk populations. We discuss clinical implications, limitations of current research, and areas of interest for future research.

Screening for distress and depression in cancer settings: 10 lessons from 40 years of primary-care research

OBJECTIVE

There has been at least 40 years of active research on screening for depression and distress in primary care. Both successes and failures have been documented. The purpose of this focussed narrative review was to summarise this research and present the key lessons for clinicians and researchers working in psychosocial oncology.

METHODS

We searched for studies assessing the utility of screening in primary care in seven electronic bibliographic databases (CENTRAL, CINAHL, Embase, HMIC, Medline, PsycINFO, Web of Knowledge) from inception to December 2010. Results were reviewed and summarised into key areas.

RESULTS

We found that research could be distilled into the following key learning points. (1) Primary care is an important partner in psychosocial care. (2) Both over and under detection are problematic. (3) Barriers to identification involve patient and clinician factors. (4) Acceptability of screening is critical to implementation. (5) Underserved groups need special attention in screening. (6) Patient-clinician trust is an important modifiable variable. (7) Greater contact influences detection. (8) Clinician confidence/skills influence screening success and subsequent action. (9) Training may improve confidence but effects upon long-term outcomes are modest. (10) Screening is generally ineffective without aftercare.

CONCLUSIONS

Primary care has shown largely what does not work in relation to screening. Namely relying on clinicians' unassisted judgement without infrastructural support, using over-complex scales with low acceptability, looking for depression alone, using screening without linked treatment, treating in the absence of follow-up and failing to engage patients in their own care. These pitfalls can and should be avoided in psychosocial oncology.