Which DSM validated tools for diagnosing depression are usable in primary care research. A systematic literature review. (original) (raw)
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Identifying depression in primary care: a literature synthesis of case-finding instruments
General Hospital Psychiatry, 2002
We evaluated the usefulness of case-finding instruments for identifying patients with major depression or dysthymia in primary care settings using English language literature from Medline, a specialized trials registry and bibliographies of selected papers. Studies were done in primary care settings with unselected patients and compared case-finding instruments with accepted diagnostic criterion standards for major depression were selected. A total of 16 case-finding instruments were assessed in 38 studies. More than 32,000 patients received screening with a case-finding instrument; approximately 12,900 of these received criterion standard assessment. Case-finding instruments ranged in length from 1 to 30 questions. Average administration times ranged from less than 2 min to 6 min. Median sensitivity for major depression was 85% (range 50% to 97%); median specificity was 74% (range 51% to 98%). No significant differences between instruments were found. However for individual instruments, estimates of sensitivity and specificity varied significantly between studies. For the combined diagnoses of major depression or dysthymia, overall sensitivity was 79% (CI, 74% to 83%) and overall specificity 75% (CI, 70% to 81%). Stratified analyses showed no significant effects on overall instrument performance for study methodology, criterion standard choice, or patient characteristics. We found that multiple instruments with reasonable operating characteristics are available to help primary care clinicians identify patients with major depression. Because operating characteristics of these instruments are similar, selection of a particular instrument should depend on issues such as feasibility, administration and scoring times, and the instruments' ability to serve additional purposes, such as monitoring severity or response to therapy.
Clinical diagnosis of depression in primary care: a meta-analysis
The Lancet, 2009
Depression is a major burden for the health-care system worldwide. Most care for depression is delivered by general practitioners (GPs). We assessed the rate of true positives and negatives, and false positives and negatives in primary care when GPs make routine diagnoses of depression. We undertook a meta-analysis of 118 studies that assessed the accuracy of unassisted diagnoses of depression by GPs. 41 of these studies were included because they had a robust outcome standard of a structured or semi-structured interview. 50 371 patients were pooled across 41 studies and examined. GPs correctly identified depression in 47.3% (95% CI 41.7% to 53.0%) of cases and recorded depression in their notes in 33.6% (22.4% to 45.7%). 19 studies assessed both rule-in and rule-out accuracy; from these studies, the weighted sensitivity was 50.1% (41.3% to 59.0%) and specificity was 81.3% (74.5% to 87.3%). At a rate of 21.9%, the positive predictive value was 42.0% (39.6% to 44.3%) and the negative predictive value was 85.8% (84.8% to 86.7%). This finding suggests that for every 100 unselected cases seen in primary care, there are more false positives (n=15) than either missed (n=10) or identified cases (n=10). Accuracy was improved with prospective examination over an extended period (3-12 months) rather than relying on a one-off assessment or case-note records. GPs can rule out depression in most people who are not depressed; however, the modest prevalence of depression in primary care means that misidentifications outnumber missed cases. Diagnosis could be improved by re-assessment of individuals who might have depression. None.
Diagnostic accuracy and treatment approach to depression in primary care: predictive factors
Family Practice
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.
Journal of Affective Disorders, 2014
Background: The treatment of depression in primary care remains suboptimal for reasons that are complex and multifactorial. Typically GPs have to make difficult decisions in limited time and therefore, the aim of this study was to examine the management of depression of varying severity and the factors associated with treatment choices. Method: Nested within a primary care educational initiative we conducted a survey of 1760 GPs. The GPs each identified four patients with clinical depression whom they had treated recently and then answered questions regarding their diagnosis and management of each patient. Results: Comorbid anxiety, sadness and decreased concentration appeared to direct the management of depression toward psychological therapy, whereas comorbid pain and a patient's overall functioning, such as the ability to do simple everyday activities, directed the initiation of pharmacological treatment. The use of antidepressants with a broader spectrum of actions (acting on multiple neurotransmitters) increased from mild to severe depression, whereas this did not occur with the more selective agents. SSRIs were prescribed more frequently compared with all other antidepressants, irrespective of depression severity. Limitations: GPs chose the RADAR programme and therefore they were potentially more likely to have an interest in mental health compared to GPs who did not participate. Conclusions: GPs do not appear to be determining pharmacological treatment based on depression subtype and specificity, but rather on the basis of the total number of symptoms and overall severity. While acknowledging important differences between primary care and specialist practice, it is suggested that guidelines to assist GPs in matching treatment to depression subtype may be of practical assistance in decision-making, and the delivery of more effective treatments.
Managing depression in primary care
Quality in Health …, 1993
This review is based on Effective Care, Bulletin No 5 Depression is a common problem which ranges from a fluctuation in mood (minor depression or dysthymia) to episodes of major depression involving affective and biological signs. In any year general practitioners (GPs) diagnose an episode of major depression in around 30/O of their patients,' which places a major load on resources in primary care. Only around half of patients with major depression are recognised by GPs. Training" or the use of routine screening instruments' can improve the ability of GPs to detect major depression, and there is evidence that early detection and treatment may reduce the likelihood that the condition will persist. Major depression is an important concept in the recognition and appropriate treatment of patients who present with depressive signs. Episodes of major depression are more common among women than men (ratio of women to men about 2:1),8 and are strongly associated with social circumstances.9 Three main classification systems are currently used in research and clinical practice: Diagnostic and Statistical Maianal of Mental Disorders Third Edition, Revised (DSM-III-R),3 Research Diagnostic Criteria (RDC),'4 and ICD (tenth revision).'' The DSM-IJI-R classification is commonly used in trials and is appropriate for clinical practice; its criteria for major depression are summarised in the box. Depression and suicide There is a clear link between depression and suicide, but in primary care it is not possible to predict accurately which depressed patients
The detection of depression in medical setting: A study with PRIME-MD
Journal of Affective Disorders, 2006
Background: Studies investigating the performance of instruments to detect major depressive disorder (MDD) have reported inconsistent results. Subsyndromal depression (SD) has also been associated to increased morbidity, and little is known about its detection in primary care setting. This study aimed to investigate the performance of the Primary Care Evaluation of Mental Disorders (PRIME-MD) to detect MDD and any depression (threshold at SD) in an outpatient unit of a teaching general hospital. Methods: Nineteen primary care physicians using the PRIME-MD evaluated 577 patients, 240 of them (75% female; mean age, 40.0 F 14.4), including all with MDD and a randomly subset of those without MDD, were evaluated by 11 psychiatrists using the Structured Clinical Interview Axis I Disorders, Patient Version (SCIDI/P) for DSM-IV as the standard instrument. Results: The kappa between the PRIME-MD and the SCID was 0.42 for the diagnosis of any depression and 0.32 for MDD. The distribution of the number of depressive symptoms per patient suggested the existence of a continuum between SD and MDD, and a high frequency of subjects with 4-6 symptoms (close to the cutoff for the diagnosis of MDD). Limitations: The sample has a modest size and is a subset of an original one. Conclusion: A continuum between SD and MDD may in part explain the relatively low agreement for the diagnosis of MDD in our sample and possibly in other studies. Studies investigating the performance of screening instruments to detect MDD, should consider the relevance of identifying SD, and the influence of the distribution of the number of depressive symptoms in their results. D
General Hospital Psychiatry, 2002
General practitioners (GPs) are recommended to use DSM-IV criteria to diagnose major depression in daily clinical practice. This implies the assessment of nine depressive symptoms and four additional criteria. A short structured interview has been developed to assess these symptoms and criteria, and a study was carried out to investigate the reliability and validity with which GPs can assess these symptoms and criteria and the DSM-IV diagnosis of major depression. In 14 general practices, 52 patients with symptoms of distress and depression were interviewed twice by their GP, with an interval of one to four days. Furthermore, the patients filled out three depression questionnaires. The reproducibility of eight symptoms and three additional criteria was moderate to good (kappa Ͼ0.40). The reproducibility of the depressive symptom count, that is necessary to arrive at a diagnosis of major depression, was such that in 75 percent of the patients the test-retest difference did not exceed one symptom. The reproducibility of the diagnosis of major depression was good (kappa 0.63). The validity of the diagnosis of major depression assessed by the GPs, as compared to results of the self-report depression questionnaires, was satisfactory (r 0.35-0.61). Diagnosing major depression in patients with depressive symptomatology just above or below the threshold of major depression warrants a certain amount of caution in general practice.
Journal of Affective Disorders, 2004
Background: The aim of this study was to compare the validity of the Hospital Anxiety and Depression Scale (HADS), the WHO (five) Well Being Index (WBI-5), the Patient Health Questionnaire (PHQ), and physicians' recognition of depressive disorders, and to recommend specific cut-off points for clinical decision making. Methods: A total of 501 outpatients completed each of the three depression screening questionnaires and received the Structured Clinical Interview for DSM-IV (SCID) as the criterion standard. In addition, treating physicians were asked to give their psychiatric diagnoses. Criterion validity and Receiver Operating Characteristics (ROC) were determined. Areas under the curves (AUCs) were compared statistically. Results: All depression scales showed excellent internal consistencies (Cronbach's a: 0.85 -0.90). For 'major depressive disorder', the operating characteristics of the PHQ were significantly superior to both the HADS and the WBI-5. For 'any depressive disorder', the PHQ showed again the best operating characteristics but the overall difference did not reach statistical significance at the 5% level. Cut-off points that can be recommended for the screening of 'major depressive disorder' had sensitivities of 98% (PHQ), 94% (WBI-5), and 85% (HADS). Corresponding specificities were 80% (PHQ), 78% (WBI-5), and 76% (HADS). In contrast, physicians' recognition of 'major depressive disorder' was poor (sensitivity, 40%; specificity, 87%). Limitations: Our sample may not be representative of medical outpatients, but sensitivity and specificity are independent of disorder prevalence. Conclusions: All three questionnaires performed well in depression screening, but significant differences in criterion validity existed. These results may be helpful in the selection of questionnaires and cut-off points. D