Case-finding instruments for depression. Two questions are as good as many

Outcome measures and needs assessment tools for schizophrenia and related disorders

BACKGROUND

There has been a recent trend to encourage routine outcome measurement and needs assessment as an aid to decision making in clinical practice and patient care. Standardised instruments have been developed which measure clinical symptoms of disorders such as schizophrenia, wider health related quality of life and patients' needs. Such measures might usefully be applied to aid the recognition of psychosocial problems and to monitor the course of patients' progress over time in terms of disease severity and associated deficits in health related quality of life. They might also be used to help clinicians to make decisions about treatment and to assess subsequent therapeutic impact. Such an approach is not, however, without cost and the actual benefit of the adoption of routine outcome and needs assessment in the day-to-day care of those with schizophrenia remains unclear.

OBJECTIVES

To establish the value of the routine administration of outcome measures and needs assessment tools and the feedback they provide in improving the management and outcome of patients with schizophrenia and related disorders.

SEARCH STRATEGY

The reviewers undertook electronic searches of the British Nursing Index (1994 to Sept 1999), the Cochrane Library (Issue 2, 2002), the Cochrane Schizophrenia Group Trials Register (2002), EMBASE (1980-2002), MEDLINE (1966-2002), and PsycLIT (1887-2002), together with hand searches of key journals. References of all identified studies were searched for further trials, and the reviewers contacted authors of trials.

SELECTION CRITERIA

Randomised controlled trials comparing the feedback of routine standardised outcome measurement and needs assessment, to routine care for those with schizophrenia.

DATA COLLECTION AND ANALYSIS

Reviewers evaluated data independently. Studies which randomised clinicians or clinical teams (rather than individual patients) were considered to be the most robust. However only those which took account of potential clustering effects were considered further. Where possible and appropriate, risk ratios (RR) and their 95% confidence intervals (CI) were calculated. For continuous data Weighted Mean Differences (WMD) were calculated. Data were inspected for heterogeneity.

MAIN RESULTS

No randomised data were found which addressed the specified objectives. One unpublished and one ongoing trial was identified.

REVIEWER'S CONCLUSIONS

The routine use of outcomes measures and needs assessment tools is, as yet, unsupported by high quality evidence of clinical and cost effectiveness. Clinicians, patients and policy makers alike may wish to see randomised evidence before this strategy is routinely adopted.

Patients presenting with somatic complaints: epidemiology, psychiatric comorbidity and management

Somatic symptoms are the leading cause of outpatient medical visits and also the predominant reason why patients with common mental disorders such as depression and anxiety initially present in primary care. At least 33% of somatic symptoms are medically unexplained, and these symptoms are chronic or recurrent in 20% to 25% of patients. Unexplained or multiple somatic symptoms are strongly associated with coexisting depressive and anxiety disorders. Other predictors of psychiatric co-morbidity include recent stress, lower self-rated health and higher somatic symptom severity, as well as high healthcare utilization, difficult patient encounters as perceived by the physician, and chronic medical disorders. Antidepressants and cognitive-behavioural therapy are both effective for treatment of somatic symptoms, as well as for functional somatic syndromes such as irritable bowel syndrome, fibromyalgia, pain disorders, and chronic headache. A stepped care approach is described, which consists of three phases that may be useful in the care of patients with somatic symptoms.

Primary care pediatricians' roles and perceived responsibilities in the identification and management of maternal depression

OBJECTIVE

To describe the attitudes and approaches of primary care pediatricians in the identification and management of postpartum and other maternal depression.

METHODS

A national survey of randomly selected primary care pediatricians reported their management of the last recalled case of postpartum or other maternal depression, barriers to care, their attitudes about recognition and management, confidence in skills, and their willingness to implement new strategies to improve care.

RESULTS

Of 888 eligible primary care pediatricians, 508 (57%) completed surveys. Of these pediatricians, 57% felt responsible for recognizing maternal depression. In their last recalled case, respondents used an unstructured approach for identification based primarily on maternal appearance or complaints. When maternal depression was suspected, additional assessment of any kind was done by 48% of pediatricians. Although 7% perceived themselves to be responsible for treating maternal depression, pediatricians indicated they had an active role in 66% of cases in which they provided 1 or more brief interventions. The major barriers that were believed to limit their diagnosis or management were insufficient time for adequate history (70%) or education/counseling (73%) and insufficient training/knowledge to diagnose/counsel (64%) or treat (48%). Responses with cases involving maternal depression and the specific situation of postpartum depression were very similar. Forty-five percent were confident in their ability to diagnose maternal depression, whereas 32% were confident in their ability to diagnose postpartum depression. Nearly one fourth of pediatricians were willing to change their approach to identification. Pediatricians who felt responsible for recognizing maternal depression were more likely to assess more completely and intervene in cases as well as consider implementing change in their practice.

CONCLUSION

Pediatricians' current attitudes and skills that are relevant to maternal depression limit their ability to play an effective role in recognition and management. Future interventions need to address each of these issues. Educational efforts and new clinical approaches may be more effective with those who feel responsible and willing to change their approach to maternal depression.

Sadness predicts death in older people

OBJECTIVE

To determine if a question about symptoms of depression in a mail survey predicts mortality after adjusting for a large number of covariates.

DESIGN

National cross-sectional survey of 141,589 enrollees in Medicare, age 65 and older. Analyses used multivariate logistic regression models with death as the outcome.

RESULTS

Response to a question about sadness or anhedonia was associated with death in 2 years (OR = 1.32; 95% CI = 1.2, 1.4). Results were consistent across age, gender, and presence/absence of known heart disease. Other responses associated with death were older age, male gender, and self-reported cancers, shortness of breath, heart failure, smoking, and other characteristics. Higher education and being married appeared to protect from death.

DISCUSSION

A single survey question about feelings of sadness or anhedonia is predictive of death in 2 years.

Depression and public health: an overview

Depressive disorders are a significant public health issue. They are prevalent, disabling, often chronic illnesses, which cause a high economic burden for society, related to both direct and indirect costs. Depressive disorders also influence significantly the outcome of comorbid medical illnesses such as cardiac diseases, diabetes, and cancer. In primary care, underrecognition and undertreatment of depressive disorders are common, despite their relatively high prevalence, which accounts typically for more than 10% of patients. Primary care physicians should be aware of the common risk factors for depressive disorders such as gender, neuroticism, life events and adverse childhood experiences, and they should be familiar with associated features such as a positive psychiatric family history and prior depressive episodes. In primary care settings, depressive disorders should be considered with patients with multiple medical problems, unexplained physical symptoms, chronic pain or use of medical services that is more frequent than expected. Management of depressive disorders in primary care should include treatment with the newer antidepressant agents (given the fact they are typically well tolerated and safe) and focus on concomitant unhealthy behaviors as well as treatment adherence, which may both affect patient outcome. Programs aimed at improving patient follow-up and the coordination of the primary care intervention with that of specialists have been found to improve patient outcomes and to be cost effective.

Identifying depression in primary care: a literature synthesis of case-finding instruments

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.

Coordination and advocacy for rural elders (CARE): a model of rural case management with veterans

PURPOSE

To describe a pilot initiative sponsored by the Veterans Health Administration (VHA) to improve the health and community tenure of frail older veterans living in rural counties 50-100 miles from two host VHA medical centers.

DESIGN AND METHODS

Veterans aged 75 and older who scored at risk of repeated hospital admission on the PRA-Plus telephone questionnaire were targeted and visited by evaluators who administered a comprehensive health questionnaire prior to being assessed at home by the Coordination and Advocacy for Rural Elders (CARE) program clinical teams. Guided by current state-of-the-art practices, the nurse-social worker teams performed in-home standardized assessments using the MDS-HC, developed patient-specific care plans, and mobilized family, community, and VHA resources to implement plans.

RESULTS

On average, eight problems were identified for each patient, most commonly falls risk, social needs, pain, and needs related to IADL disability. As a result of initial assessment, two thirds of CARE participants received referral/linkage to formal services, more than half to medical providers.

IMPLICATIONS

Through CARE, the VHA is learning more about the unmet needs of older rural veterans. Further development and evaluation should guide the VHA toward providing efficient, effective community-based services to all frail older veterans.

Child neglect: outcomes in high-risk urban preschoolers

BACKGROUND

Limited longitudinal research has been conducted on the impact of neglect on children's health and well-being. There is a need to consider the impact of specific subtypes of neglect on children's functioning. In addition, there is interest in examining the cumulative effect of experiencing >1 subtype of neglect.

OBJECTIVE

To examine the individual and cumulative relationships among physical, psychological, and environmental neglect and children's behavior and development at age 3, and the impact on changes in children's behavior and development between ages 3 and 5.

METHODS

One hundred thirty-six children and their primary caregivers participating in a prospective longitudinal study of children's development and maltreatment were assessed when the children were aged 3 and 5 years. The children were recruited from primary care clinics because of failure to thrive, risk for human immunodeficiency virus, or as a comparison group. Evaluations were conducted in laboratory and home settings using observations, maternal self-report, and standardized testing of the children. Scores on physical, psychological, and environmental neglect were combined into a Cumulative Neglect Index. Regression analyses were run to examine the association of specific subtypes of neglect and of cumulative neglect with children's functioning at age 3, controlling for group, sociodemographic risk, and maternal depression. The analyses were repeated examining the impact on child outcomes at age 5, controlling for the above 3 variables as well as the children's cognitive development and behavior at age 3.

RESULTS

Of the subtypes of neglect at age 3, only psychological neglect was significantly associated with increased internalizing and externalizing behavior problems at age 3; the Cumulative Neglect Index was associated with internalizing problems. None of the neglect subtypes or cumulative neglect were predictive of changes in children's behavior and development between ages 3 and 5. Cognitive development of the entire sample was impaired at age 5, averaging 0.85 standard deviations below the norm, and their average externalizing behavior score was significantly problematic with an average of 0.60 standard deviations above the norm.

CONCLUSIONS

In the context of poverty where many preschool children have poor cognitive development and increased behavior problems, psychological neglect is significantly related to reported behavior problems. Children who experienced multiple types of neglect had increased internalizing problems. Neglect did not explain changes in children's behavior or development between ages 3 and 5. There is a need for pediatricians to identify and address child neglect, particularly psychological neglect, as early as possible. Pediatricians should also screen for maternal depression.

Screening for depression in middle-aged and older puerto rican primary care patients

BACKGROUND

Brief depression screens have recently been developed, but their use in older or minority populations has not been studied. To date, optimal depression screens and optimal cutpoints have not been identified for middle-aged and older Hispanic primary care patients.

METHODS

This study compares multiple versions of four depression screening tools--Center for Epidemiologic Studies-Depression Scale (CES-D), Geriatric Depression Scale, Yale 1-question screen, and PRIME-MD 2-question screen--to the Composite International Diagnostic Interview (CIDI), the World Health Organization's diagnostic interview, which has been validated in adult Latino populations, to assess convergent validity. Three hundred and three Puerto Rican primary care patients age 50 and older completed all screens and the CIDI in a face-to-face interview. Sensitivity and specificity for each screen were calculated, and receiver operator characteristic curves were generated.

RESULTS

Between 34% and 61% of patients screened positive for depression, depending on the measure, with 12% meeting DSM-IV criteria for major depression (CIDI). The 10-item CES-D worked best to identify major depression in this population, with a sensitivity of 84% and specificity of 64% using a cutpoint of 3.

CONCLUSIONS

The 10-item CES-D, which takes about 2 minutes to administer, is a useful tool for identifying Puerto Rican patients in need of an in-depth mental health evaluation in a primary care setting. A lower cutpoint of 3 (instead of the conventional cutpoint of 4) is recommended for optimal sensitivity and specificity.

Survey of psychological health in women with infertility

The aims of this study were to assess mental well-being in women undergoing investigation and initial management of infertility and to determine any specific factors, such as the duration or type of infertility, that might be associated with an increased risk of psychological morbidity. A postal survey was sent to 1080 women with infertility attending gynecology outpatient departments in 12 Scottish centres. The survey included the Twelve-Item General Health Questionnaire (GHQ-12) and three multi-item scales from the Short Form Health Survey Questionnaire (SF-36). The response rate was 47.4% (512/1080) of which 507 completed the GHQ-12. Of the 507 GHQ-12 responders, 32.5% had a GHQ-12 score of > or = 8/12 suggesting they were at risk of clinically significant psychological disturbance. There were no significant associations between GHQ-12 scores and duration of infertility, the presence of existing children, or the cause of infertility. GHQ-12 scores significantly increased with the number of clinic attendances and decreased as the patient's age increased. Responders scored significantly lower on all aspects of the selected SF-36 questions as compared to published population data, suggesting poorer mental health. These standardized psychological instruments suggest that approximately 32% of women in the early stages of infertility management may be at risk of developing clinically relevant mental health problems. Psychological aspects of infertility should be addressed as part of a more holistic approach to management of these patients.

Evaluation of a guided protocol for quality improvement in identifying common geriatric problems

OBJECTIVES

Many common geriatric problems are underrecognized and undertreated. A simple and reliable tool to facilitate a standard approach to evaluating geriatric patients might improve the quality of medical care delivered to geriatric patients. The objective of this study was to evaluate a standardized, semistructured quality-improvement protocol (the guided geriatric care protocol) for the assessment of common geriatric problems.

DESIGN

Sequential comparison cohorts, with chart review to evaluate study measures before and after introduction of the guided geriatric care protocol.

SETTING

The outpatient consultative geriatric assessment center of Yale-New Haven Hospital in New Haven, Connecticut.

PARTICIPANTS

One hundred consecutive new patients before and 100 consecutive new patients after introduction of the guided geriatric care protocol.

MEASUREMENTS

Number and type of problems identified and recommendations made during the clinical encounter, duration of the clinical encounter, clinician acceptance.

RESULTS

The two patient groups were similar in sociodemographics, cognitive and functional status, and reasons for evaluation. Significantly more problems were identified after (mean 5.51) than before (mean 3.49) introduction of the guided geriatric care protocol (P< .001); likewise, significantly more recommendations were made after (mean 10.45) than before (mean 8.48) introduction of the protocol (P< .001). The duration of the clinical encounter did not differ significantly between the two groups. The protocol was well accepted by participating clinicians.

CONCLUSIONS

Use of the guided geriatric care protocol assured a standard approach to evaluating common geriatric problems and may have led to the identification and treatment of more problems than usual care without increasing the duration of the clinical encounter. A quality-improvement tool that standardizes the evaluation of common geriatric problems, if validated in other clinical settings, holds the potential to improve the quality of care for vulnerable older patients.

Assessing the performance of a new depression screener for primary care (PC-SAD)

As many as 50% of patients with major depression seen in primary care settings are not diagnosed. To facilitate efficient identification of primary care patients with depression, we developed a new patient-administered depression screening instrument (PC-SAD) that produces a DSM-IV diagnosis, and compared its performance to other screeners that yield DSM-IV diagnoses. To assess validity, the diagnostic accuracy of the PC-SAD was compared with the Inventory to Diagnose Depression (IDD) and the PRIME-MD-PHQ (PHQ) in a convenience sample (N = 312) of health plan members, primary care outpatients, and psychiatric patients (with diagnoses). The screeners were compared with each other and with psychiatric diagnoses to assess their relative performance. Disagreement among the three screeners was formally tested using a triangulation approach that incorporates a statistical likelihood model. Of patients diagnosed as depressed using the IDD, 84.2% were also depressed by the PC-SAD (sensitivity). Of patients not diagnosed as depressed by the IDD, 94.7% were not depressed by the PC-SAD (specificity). Using the triangulation method the sensitivities were 87.2% (PC-SAD), 88.4% (IDD), and 60.7% (PHQ). The specificities were 95.0% (PC-SAD), 92.7% (IDD), and 98.3% (PHQ). The performance of the PC-SAD and the IDD was comparable. The PHQ was less sensitive than either of those. The PC-SAD respondent burden strikes a balance between the very short PHQ, and the longer IDD, and has the lowest (easiest) Flesch-Kincaid reading level. Investigators, clinicians, and health plans that want a DSM-IV-based depression screener can choose from among these three instruments, with known tradeoffs in sensitivity, respondent burden, and readability.

The early stages of schizophrenia: speculations on pathogenesis, pathophysiology, and therapeutic approaches

Schizophrenia is commonly considered a neurodevelopmental disorder that is associated with significant morbidity; however, unlike other neurodevelopmental disorders, the symptoms of schizophrenia often do not manifest for decades. In most patients, the formal onset of schizophrenia is preceded by prodromal symptoms, including positive symptoms, mood symptoms, cognitive symptoms, and social withdrawal. The proximal events that trigger the formal onset of schizophrenia are not clear but may include developmental biological events and environmental interactions or stressors. Treatment with antipsychotic drugs clearly ameliorates psychotic symptoms, and maintenance therapy may prevent the occurrence of relapse. The use of atypical antipsychotic agents may additionally ameliorate the pathophysiology of schizophrenia and prevent disease progression. Moreover, if treated properly early in the course of illness, many patients can experience a significant remission of their symptoms and are capable of a high level of recovery following the initial episode. Because the clinical deterioration that occurs in schizophrenia may actually begin in the prepsychotic phase, early identification and intervention may favorably alter the course and outcome of schizophrenia.

The PHQ-9: validity of a brief depression severity measure

OBJECTIVE

While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity.

MEASUREMENTS

The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as "0" (not at all) to "3" (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients.

RESULTS

As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score > or =10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples.

CONCLUSION

In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.

The PHQ-9: validity of a brief depression severity measure

OBJECTIVE

While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity.

MEASUREMENTS

The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as "0" (not at all) to "3" (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients.

RESULTS

As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score > or =10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples.

CONCLUSION

In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.

The PHQ-9: validity of a brief depression severity measure

OBJECTIVE

While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity.

MEASUREMENTS

The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as "0" (not at all) to "3" (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients.

RESULTS

As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score > or =10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples.

CONCLUSION

In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.

The PHQ-9: validity of a brief depression severity measure

OBJECTIVE

While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity.

MEASUREMENTS

The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as "0" (not at all) to "3" (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients.

RESULTS

As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score > or =10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples.

CONCLUSION

In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.

The PHQ-9: validity of a brief depression severity measure

OBJECTIVE

While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity.

MEASUREMENTS

The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as "0" (not at all) to "3" (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients.

RESULTS

As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score > or =10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples.

CONCLUSION

In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.

Validation and utility of the patient health questionnaire in diagnosing mental disorders in 1003 general hospital Spanish inpatients

OBJECTIVE

To determine whether the Spanish version of the patient health questionnaire (PHQ) has validity and utility for diagnosing mental disorders in general hospital inpatients.

METHODS

Participants in the study were 1003 general hospital inpatients, randomly selected from all admissions over an 18-month period. All of them completed the PHQ, the Beck Depression Inventory (BDI), and measures of functional status, disability days, and health care use, including length of hospital stay. They also had a structured interview with a mental health professional.

RESULTS

A total of 416 (42%) of the 1003 general hospital inpatients had a PHQ diagnosis. There was good agreement between PHQ diagnoses and those of an independent mental health professional (for the diagnosis of any PHQ disorder, kappa = 0.74; overall accuracy, 88%; sensitivity, 87%; specificity, 88%), similar to the original English version of the PHQ in primary care patients. Patients with PHQ diagnoses had more functional impairment, disability days, and health care use than did patients without PHQ diagnoses (group main effects for functional status measures and disability days, p < .001; group main effects for health care use, p < .01). The group main effect for hospital length of stay was not significant. An index of depression symptom severity calculated from the PHQ correlated significantly both with the number of depressive symptoms detected at interview and the total BDI score. PHQ administration was well accepted by patients.

CONCLUSIONS

The Spanish version of the PHQ has diagnostic validity in general hospital inpatients comparable to the original English version in primary care.

Treatments for late life depression in primary care--a systematic review

BACKGROUND

Depression is common among older people. It is associated with increased mortality and use of health services. We could identify no prior systematic review of treatment for depression in either primary care attenders or population samples of older people.

OBJECTIVES

The aim of this study was to carry out a systematic review of trials of treatments for depression of patients over 60 years of age in primary care or population samples.

METHODS

We searched Medline, Embase, Cinahl, the Cochrane Library, Psyclit, BIDS--Social Science and BIDS--Science Citation Indices for trials of drug treatment, interpersonal psychotherapy, cognitive behavioural psychotherapy, counselling and social interventions for late life depression in English, French or German published between 1980 and June 1999.

RESULTS

Of the studies identified, only two were of patients over 60 years of age and met all inclusion criteria for content and quality. Three further studies that were not restricted to but included patients over the age of 60 years also fulfilled our criteria. We found no studies of psychological therapies for depression in older people. With few exceptions, studies were limited to older people who reached a diagnostic threshold and excluded those with 'subcase level depression'.

CONCLUSION

There is little evidence of effectiveness for a variety of treatment approaches for depression in older people in primary care, particularly in those with less severe depression. As older people take more medication, making contra-indications to the use of antidepressant drugs more likely, there is a pressing need for studies of the efficacy of non-pharmacological interventions in primary care settings.

A health services perspective on delivery of psychiatric services in primary care including internal medicine

Serious problems persist in the recognition and treatment of psychiatric problems in primary care despite multiple interventions directed at correcting these problems. Improved outcomes depend on improved recognition, and screening instruments need to be streamlined tremendously to be accepted by primary care providers. Publication of guidelines and physician education, although essential for improved care, are probably insufficient to implement guidelines-based care. Improvements in psychiatric outcome appear to depend on the level of intensity of the intervention employed. Continued research is needed to determine the most effective type of educational intervention and more widely applicable quality improvement processes. Broad-based changes in health service delivery focusing on the true integration of mental health services with general medical care are required to bring about meaningful, effective change. Ongoing changes in physician training programs (combined primary care/psychiatry programs) may facilitate implementation of guideline-based psychiatric care in medical settings, but the full impact of these changes is not likely to be felt for several years.

The depression in primary care tool kit

OBJECTIVE

A tool kit was developed to help primary care physicians overcome some of the barriers to recognition and management of depression.

METHOD

Tools were collected from a variety of sources, categorized by function, and evaluated on the basis of previously established criteria, with the best tools selected for inclusion in the tool kit. New tools were developed when an adequate tool for a desired function was not available. The tool kit was reviewed and then revised based on the feedback from eleven experts on depression in primary care, five medical directors from health care systems or managed care companies, and eighteen primary care physicians. All eighteen primary care physicians completed a questionnaire after reviewing the tool kit as part of the evaluation process.

RESULTS

Only five of the eighteen physicians were using any kind of tool for depression prior to reviewing the tool kit. All eighteen physicians indicated that they were likely to use one or more of the components of the tool kit. On average, physicians indicated they were likely to use 6.5 of the ten types of tools included in the kit.

CONCLUSIONS

A depression tool kit containing screening, diagnostic, management planning, and outcomes assessment questionnaires as well as treatment and counseling guidelines, information tables, flow charts, and patient education materials is likely to be well received by primary care physicians. However, its effectiveness may have as much to do with how its use is organized and implemented as it does with the intrinsic value of its components.

Validation of dizziness as a possible geriatric syndrome

OBJECTIVE

While dizziness has traditionally been considered solely as a symptom of discrete diseases, recent findings from population-based studies of older persons suggest that it may often be a geriatric syndrome with multiple predisposing risk factors, representing impairments in diverse systems. To validate these findings, we identified predisposing risk factors for dizziness in a clinic-based population.

DESIGN

Cross-sectional study.

SETTING

Geriatric assessment center.

PARTICIPANTS

262 consecutive, eligible patients.

MEASUREMENTS

Medical history and physical examination data were ascertained and characteristics of patients with and without a report of dizziness were compared.

RESULTS

Seven factors were independently associated with a report of dizziness, namely depressive symptoms, cataracts, abnormal balance or gait, postural hypotension, diabetes, past myocardial infarction, and the use of three or more medications. Of patients with none of these risk factors, none reported dizziness. This proportion rose from 6% among patients with one factor, to 12%, 26%, and 51% among patients with two, three, and four or more factors, respectively.

CONCLUSIONS

The finding of similar factors associated with dizziness in previous community-based cohorts and the present clinic-based cohort supports the possibility of a multifactorial etiology of dizziness in many older persons. A multifactorial intervention targeting the factors identified in these studies may be effective at reducing the frequency or severity of dizziness in older patients.

Prevalence and determinants of intimate partner abuse among public hospital primary care patients

OBJECTIVE

To determine the prevalence, sociodemographic determinants, and depression correlates of intimate partner abuse among an ethnically diverse population of women patients.

DESIGN

Cross-sectional telephone survey in English and Spanish of a random sample of women patients aged 18 to 46 years.

SETTING

Three public hospital primary care clinics (general internal medicine, family medicine, and obstetrics/gynecology) in San Francisco, Calif.

PARTICIPANTS

We interviewed 734 (74%) of the 992 eligible participants. Thirty-one percent were non-Latina white, 31% African American, and 36% Latina.

MEASUREMENTS AND MAIN RESULTS

Using questions adapted from the Abuse Assessment Screen, we determined recent and lifetime history of physical, sexual, and psychological abuse. Overall, 15% reported recent abuse by an intimate partner (in the preceding 12 months); lifetime prevalence was 51%. Recent abuse was more common among women aged 18 to 29 years (adjusted odds ratio [OR] 2.1; 95% confidence interval [CI], 1.2 to 3.7), non-Latinas (adjusted OR, 1.7; 95% CI, 1.0 to 2.9), and unmarried women (adjusted OR, 1.65; 95% CI, 1.0 to 2.7). The prevalence of abuse did not differ by education, employment, or medical insurance status of the women. Compared with women with no history of abuse, a greater proportion of recently abused women reported symptoms of depression (adjusted OR, 3.5; 95% CI, 2.2 to 5.5).

CONCLUSIONS

Because a substantial proportion of women patients in primary care settings are abused, screening for partner abuse and depression is indicated. In contrast to other studies, lower socioeconomic status was not associated with partner abuse history.

Depressive symptoms and risks of coronary heart disease and mortality in elderly Americans. Cardiovascular Health Study Collaborative Research Group

BACKGROUND

Several epidemiological studies have associated depressive symptoms with cardiovascular disease. We investigated whether depressive symptoms constituted a risk for coronary heart disease (CHD) and total mortality among an apparently healthy elderly cohort.

METHODS AND RESULTS

In a prospective cohort of 5888 elderly Americans (>/=65 years) who were enrolled in the Cardiovascular Health Study, 4493 participants who were free of cardiovascular disease at baseline provided annual information on their depressive status, which was assessed using the Depression Scale of the Center for Epidemiological Studies. These 4493 subjects were followed for 6 years for the development of CHD and mortality. The cumulative mean depression score was assessed for each participant up to the time of event (maximum 6-year follow-up). Using time-dependent, proportional-hazards models, the unadjusted hazard ratio associated with every 5-unit increase in mean depression score for the development of CHD was 1.15 (P:=0.006); the ratio for all-cause mortality was 1.29 (P:<0.0001). In multivariate analyses adjusted for age, race, sex, education, diabetes, hypertension, cigarette smoking, total cholesterol, triglyceride level, congestive heart failure, and physical inactivity, the hazard ratio for CHD was 1.15 (P:=0.006) and that for all-cause mortality was 1.16 (P:=0.006). Among participants with the highest cumulative mean depression scores, the risk of CHD increased by 40% and risk of death by 60% compared with those who had the lowest mean scores.

CONCLUSIONS

Among elderly Americans, depressive symptoms constitute an independent risk factor for the development of CHD and total mortality.

Preventive care in the emergency department, Part I: Clinical preventive services--are they relevant to emergency medicine? Society for Academic Emergency Medicine Public Health and Education Task Force Preventive Services Work Group

In 1998 the Society for Academic Emergency Medicine's (SAEM's) Board of Directors asked the SAEM Public Health and Education Task Force to develop recommendations for prevention, screening, and counseling activities to be conducted in emergency departments (EDs). The Task Force's work was divided into two phases: 1) a discussion of the rationale for preventive services in the ED, along with generation of a preliminary list of prevention activities that could be studied for ED implementation; and 2) a formal evidence-based review of topics chosen from the preliminary list, along with recommendations for ED implementation and further study. This paper represents Phase I of the project. Phase II, the formal evidence-based review and recommendations, is published separately in this issue.

Randomized trial of case-finding for depression in elderly primary care patients

OBJECTIVE

To determine the effect of case-finding for depression on frequency of depression diagnoses, prescriptions for antidepressant medications, prevalence of depression, and health care utilization during 2 years of follow-up in elderly primary care patients.

DESIGN

Randomized controlled trial.

SETTING

Thirteen primary care medical clinics at the Kaiser Permanente Medical Center, an HMO in Oakland, Calif, were randomly assigned to intervention conditions (7 clinics) or control conditions (6 clinics).

PARTICIPANTS

A total of 2,346 patients aged 65 years or older who were attending appointments at these clinics and completed the 15-item Geriatric Depression Scale (GDS). GDS scores of 6 or more were considered suggestive of depression.

INTERVENTIONS

Primary care physicians in the intervention clinics were notified of their patients' GDS scores. We suggested that participants with severe depressive symptoms (GDS score >/= 11) be referred to the Psychiatry Department and participants with mild to moderate depressive symptoms (GDS score of 6 -10) be evaluated and treated by the primary care physician. Intervention group participants with GDS scores suggestive of depression were also offered a series of organized educational group sessions on coping with depression led by a psychiatric nurse. Primary care physicians in the control clinics were not notified of their patients' GDS scores or advised of the availability of the patient education program (usual care). Participants were followed for 2 years.

MEASUREMENTS AND MAIN RESULTS

Physician diagnosis of depression, prescriptions for antidepressant medications, prevalence of depression as measured by the GDS at 2-year follow-up, and health care utilization were determined. A total of 331 participants (14%) had GDS scores suggestive of depression (GDS >/= 6) at baseline, including 162 in the intervention group and 169 in the control group. During the 2-year follow-up period, 56 (35%) of the intervention participants and 58 (34%) of the control participants received a physician diagnosis of depression (odds ratio [OR], 1.0; 95% confidence interval [CI], 0.6 to 1.6; P =.96). Prescriptions for antidepressants were received by 59 (36%) of the intervention participants and 72 (43%) of the control participants (OR, 0.8; 95% CI, 0.5 to 1.2; P =.3). Two-year follow-up GDS scores were available for 206 participants (69% of survivors): at that time, 41 (42%) of the 97 intervention participants and 54 (50%) of the 109 control participants had GDS scores suggestive of depression (OR, 0.7; 95% CI, 0.4 to 1.3; P =.3). Comparing participants in the intervention and control groups, there were no significant differences in mean GDS change scores (-2.4 +/- SD 3.7 vs -2.1 SD +/- 3.6; P =.5) at the 2-year follow-up, nor were there significant differences in mean number of clinic visits (1.8 +/- SD 3.1 vs 1.6 +/- SD 2.8; P =.5) or mean number of hospitalizations (1.1 +/- SD 1.6 vs 1.0 +/- SD 1.4; P =.8) during the 2-year period. In participants with initial GDS scores > 11, there was a mean change in GDS score of -5.6 +/- SD 3.9 for intervention participants (n = 13) and -3.4 +/- SD 4.5 for control participants (n = 21). Adjusting for differences in baseline characteristics between groups did not affect results.

CONCLUSIONS

We were unable to demonstrate any benefit from case-finding for depression during 2 years of follow-up in elderly primary care patients. Studies are needed to determine whether case-finding combined with more intensive patient education and follow-up will improve outcomes of primary care patients with depression.

Development of a brief screening instrument: the HANDS

BACKGROUND

The present study was designed to develop a briefer screening scale of approximately 10 items which maintained the validity of the Zung Self-Rating Depression Scale in a sample similar to that attending National Depression Screening Day (NDSD), as well as a more general audience.

METHODS

We first administered 70 items from a variety of existing rating scales to 40 subjects who answered an ad for depressed subjects and 55 who answered an ad for non-depressed subjects, all of whose diagnoses were confirmed by the Structured Clinical Interview for DSM-IV (SCID). Based on the correlation between each item and the diagnostic criterion, we reduced the number of items to 17 which we then administered to another 45 subjects who answered an ad similar to that used for NDSD and also underwent a SCID interview. Based on these results, we arrived at the final 10-item Harvard Department of Psychiatry/NDSD scale (HANDS) with the assistance of the item-response theory. The items are scored for frequency of occurrence of each symptom over the past 2 weeks. Total scores range from 0 to 30.

RESULTS

The 10-item scale (HANDS) has good internal consistency and validity: a cutpoint score of 9 or greater gave sensitivity of at least 95% in both studies. Although specificity was lower for all scales in the self-selected population, the HANDS performed at least as well as the 20-item Zung Scale, the 21-item Beck Depression Inventory-II and the 15-item Hopkins Symptom Depression Checklist.

CONCLUSION

The 10-item HANDS performs as well as other widely used longer self-report scales and has the advantage of briefer administration time.

Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 1993 British Association for Psychopharmacology guidelines. British Association for Psychopharmacology

A revision of the British Association for Psychopharmacology guidelines for treating depressive disorders with antidepressants was undertaken in order to specify the scope and target of the guidelines and to update the recommendations based explicitly on the available evidence. A consensus meeting, involving experts in depressive disorders and their treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is given which identifies the quality of evidence followed by recommendations, the strength of which are based on the level of evidence. The guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing, management when initial treatment fails, continuation treatment, maintenance treatment to prevent recurrence and stopping treatment.

Psychometric properties of the General Health Questionnaire (GHQ-12) in a German primary care sample

OBJECTIVE

The aim of this investigation was to examine the psychometric properties of the German 12-item General Health Questionnaire (GHQ-12) in a primary care sample.

METHOD

A sample (n = 421) of adult out-patients was screened using the GHQ-12. A standardized clinical interview (SCID) was conducted with all screened patients. Reliability, validity and factor analysis of the GHQ-12 were evaluated. Item characteristics were examined using item characteristics curves. Item bias analysis was performed using contingency tables.

RESULTS

The German version of the GHQ-12 is a reliable instrument and performed well in detecting cases of psychological disorders. Factor analysis replicated the findings of earlier studies. Item characteristics curves and item bias analysis indicated that the individual items should be assessed carefully. One item was biased in relation to age, while another item showed a low positive response rate.

CONCLUSION

The GHQ-12 as a whole is a reliable questionnaire and can be a useful screening tool in primary care.

Evaluating dizziness

PURPOSE

To conduct a structured literature synthesis on the etiology, prognosis, and diagnostic evaluation of dizziness, and to suggest a primary-care approach to evaluating this symptom.

METHODS

Studies were identified from MEDLINE searches (1966 through 1996) and a manual search of bibliographies from retrieved articles. Two investigators independently abstracted study data.

RESULTS

The most common etiologies for dizziness were peripheral vestibulopathies (35% to 55% of patients) and psychiatric disorders (10% to 25% of patients). Cerebrovascular disease (5%) and brain tumors (<1%) were infrequent. The history and physical examination led to a diagnosis in about 75% of patients. At least 10% of patients eluded diagnosis. Symptoms were usually self-limited and not associated with an increased risk of mortality. The diagnostic testing literature, which was often methodologically flawed, suggested that routine laboratory tests as well as cardiovascular and neurologic testing had a low yield in unselected patients. We could not derive evidence-based guidelines for using specialized vestibular function tests such as electronystagmography.

CONCLUSIONS

Dizziness is usually a benign, self-limited complaint. When a diagnosis can be made, a careful history and physical examination will usually identify the probable cause. Cardiovascular, neurologic, and laboratory testing should be guided by the clinical evaluation. Rigorous studies are needed to determine the accuracy and utility of specialized vestibular testing.

Association of low serum total cholesterol with major depression and suicide

BACKGROUND

It has been suggested that low serum total cholesterol is associated with an increased risk of suicide.

AIMS

To study the association between serum total cholesterol, depression and suicide using versatile, prospective data.

METHOD

A total of 29,133 men aged 50-69 years were followed up for 5-8 years. Baseline blood samples were analysed for serum total and high-density lipoprotein cholesterol concentrations. Self-reported depression was recorded, data on hospital treatments due to depressive disorders were derived from the National Hospital Discharge Register and deaths from suicide were identified from death certificates.

RESULTS

Low serum total cholesterol was associated with low mood and subsequently a heightened risk of hospital treatment due to major depressive disorder and of death from suicide.

CONCLUSIONS

Our results suggest that low serum total cholesterol appears to be associated with low mood and thus to predict its serious consequences.

Diagnostic errors of primary care screens for depression and panic disorder

OBJECTIVE

As the health care reimbursement system has changed, brief screens for detecting mental disorders in primary care have been developed. These efforts have faced the formidable task of identifying patients with mental disorders, while at the same time minimizing the number of misclassified cases. Here we consider the balance between sensitivity and positive predictive value. Primary care patients with false positive and false negative results on screens for depression and panic disorder are compared with regard to comorbidity and functional impairment.

METHODS

This was a cross-sectional psychometric study. The study sample included 1001 primary care patients from the Department of Internal Medicine at Kaiser Permanente in Oakland, California. The Symptom-Driven Diagnostic System for Primary Care (SDDS-PC) screens and Sheehan Disability Scale were completed by the subjects. The SDDS-PC diagnostic interviews were administered to all subjects.

RESULTS

Patients with false positive results on the panic disorder screen did not differ from patients with false negatives results with regard to rates of other psychiatric disorders, functional impairment, or mental health service utilization. In contrast, patients with false negative depression screen results had significantly more psychiatric disorders and functional impairment than those with false positive depression results.

CONCLUSIONS

A substantial number of patients with either false positive or false negative screen results met diagnostic criteria for other mental disorders. Given the nominal burden of follow-up assessments for patients with positive screens, these data suggest that erring on the side of sensitivity may have been preferable when algorithms for these screens were selected.

Psychiatric disorders in older primary care patients

OBJECTIVE

Most older people with psychiatric disorders are never treated by mental health specialists, although they visit their primary care physicians regularly. There are no published studies describing the broad array of psychiatric disorders in such patients using validated diagnostic instruments. We therefore characterized Axis I psychiatric diagnoses among older patients seen in primary care.

DESIGN

Survey of psychopathology using standardized diagnostic methods.

SETTING

The private practices of three board-certified general internists, and a free-standing family medicine clinic.

PARTICIPANTS

All patients aged 60 years or older who gave informed consent were eligible.

MEASUREMENTS AND MAIN RESULTS

For the 224 subjects completing the study, psychiatric diagnoses were based on the Structured Clinical Interview for DSM-III-R. Point prevalence estimates used weighted averages based on the stratified sampling method. For the combined sites, 31.7% of the patients had at least one active psychiatric diagnosis. Prevalent current disorders included major depression (6.5%), minor depression (5.2%), dementia (5.0%), alcohol abuse or dependence (2. 3%), and psychotic disorders (2.0%). Dysthymic disorder and primary anxiety and somatoform disorders were less common and frequently comorbid with major depression.

CONCLUSIONS

Mental disorders, particularly depression, are common among older persons seen in these primary care settings. Clinicians should be particularly vigilant about depression when evaluating older patients with anxiety or putative somatoform symptoms, given the relatively low prevalences of primary anxiety and somatoform disorders.

Use of the Beck Depression Inventory for Primary Care to screen for major depression disorders

To ascertain how effective the Beck Depression Inventory for Primary Care (BDI-PC) was in screening for DSM-IV major depression disorders (MDD) in outpatients who were scheduled for routine office visits with physicians specializing in internal medicine, the BDI-PC was administered to 60 male and 60 female outpatients. The internal consistency of the BDI-PC was high (alpha 0.85), and the Mood Module from the Primary Care Evaluation of Mental Disorders was used to diagnose MDD. The BDI-PC scores were not significantly correlated with sex, age, ethnicity, or total number of medical diagnoses. A BDI-PC cutoff score of 4 and above yielded 98% maximum clinical efficiency with 97% (95% CI 82%-99%) sensitivity and 99% (95% CI 94%-99%) specificity rates, respectively, for identifying patients with and without MDD. The BDI-PC is discussed as an effective case-finding instrument for screening primary care patients for MDD.

Case-finding for depression in primary care: a randomized trial

PURPOSE

Depression is a highly prevalent, morbid, and costly illness that is often unrecognized and inadequately treated. Because depression questionnaires have the potential to improve recognition, we evaluated the accuracy and effects on primary care of two case-finding instruments compared to usual care.

SUBJECTS AND METHODS

The study was conducted at three university-affiliated and one community-based medical clinics. Consecutive patients were randomly assigned to be asked a single question about mood, to fill out the 20-item Center for Epidemiologic Studies Depression Screen, or to usual care. Within 72 hours, patients were assessed for Diagnostic and Statistical Manual of Mental Disorders Third Revised Edition (DSM-III-R) disorders by an assessor blinded to the screening results. Process of care was assessed using chart audit and administrative databases; patient and physician satisfaction was assessed using Likert scales. At 3 months, depressed patients and a random sample of nondepressed patients were re-assessed for DSM-III-R disorders and symptom counts.

RESULTS

We approached 1,083 patients, of whom 969 consented to screening and were assigned to the single question (n = 330), 20-item questionnaire (n = 323), or usual care (n = 316). The interview for DSM-III-R diagnosis was completed in 863 (89%) patients; major depression, dysthymia, or minor depression was present in 13%. Both instruments were sensitive, but the 20-item questionnaire was more specific than the single question (75% vs 66%, P = 0.03). The 20-item questionnaire was less likely to be self-administered (54% vs 90%) and took significantly more time to complete (15 vs 248 seconds). Case-finding with the 20-item questionnaire or single question modestly increased depression recognition, 30/77 (39%) compared with 11/38 (29%) in usual care (P = 0.31) but did not affect treatment (45% vs 43%, P = 0.88). Effects on DSM-III-R symptoms were mixed. Recovery from depression was more likely in the case-finding than usual care groups, 32/67 (48%) versus 8/30 (27%, P = 0.03), but the mean improvement in depression symptoms did not differ significantly (1.6 vs 1.5 symptoms, P = 0.21).

CONCLUSIONS

A simple question about depression has similar performance characteristics as a longer 20-item questionnaire and is more feasible because of its brevity. Case-finding leads to a modest increase in recognition rates, but does not have consistently positive effects on patient outcomes.

Use of the Zung Self-Rating Depression Scale in cancer patients: feasibility as a screening tool

The feasibility, utility and reliability of the Zung Self-Rating Depression Scale (ZSDS) was examined in a large sample of ambulatory cancer patients. This tool and a brief 11-item version of the ZSDS (excluding nine items concerning somatic symptoms), which was developed during the course of the survey, were used to estimate the prevalence of self-reported depressive symptoms. Patient characteristics that may be associated with an increased risk of clinically significant depressive symptoms were also explored. Twenty-five ambulatory oncology clinics affiliated with Community Cancer Care, Inc. enrolled and surveyed 1109 subjects. The alpha coefficients for the ZSDS (0.84) and the Brief ZSDS (0.84) indicated high levels of internal consistency. The overall prevalence of clinically significant depressive symptoms as defined by the ZSDS was 35.9% and by the Brief ZSDS was 31.1%. The ZSDS and the Brief ZSDS were highly correlated (r = 0.92). The medical and demographic variables most associated with clinically significant depressive symptoms were more advanced stage of disease at time of diagnosis, lung cancer as primary tumor type, higher ECOG rating (greater degree of physical disability), and having been prescribed antidepressant medications. The high prevalence of depressive symptoms observed in this study is consistent with rates found in other studies of self-report depression instruments in cancer patients. The initial indicators of internal consistency and validity suggest that the Zung SDS or the brief version may be useful screening tools to identify depressive symptoms in oncology patients.

Clinical predictors of mental disorders among medical outpatients. Validation of the "S4" model

The authors previously reported four clinical cues that predicted a subgroup of ambulatory patients likely to have depressive and anxiety disorders. The authors' purpose in this study was to validate this model in another cohort of 185 consecutive adult referrals to a rheumatology clinic. The authors found 4 variables important in predicting mental disorders: recent stress (odds ratio [OR]: 3.3, 95% confidence interval [CI]: 1.5-7.1); > 5 somatic symptoms (OR: 4.5, 95% CI: 1.1-9.5); only fair or poor health status (OR: 3.4, 95% CI: 1.6-7.4); and symptom severity (OR: 1.6, 95% CI: 0.8-3.6). There was a stepwise increase in the likelihood of a mental disorder with an increasing number of predictors. The authors conclude that these clinical cues may allow clinicians to select patients in which formal screening for mental disorders would be particularly fruitful.

Depressive and anxiety disorders in patients presenting with physical complaints: clinical predictors and outcome

PURPOSE

To identify the predictors of depressive and anxiety disorders in general medical patients presenting with physical complaints and to determine the effect of these mental disorders on patient outcome.

PATIENTS AND METHODS

In this cohort study, 500 adults presenting to a general medicine clinic with a chief complaint of a physical symptom were interviewed with PRIME-MD to diagnose DSM-IV depressive and anxiety disorders. Clinical predictors were identified by logistic regression analysis. Outcomes were assessed immediately postvisit and at 2 weeks and 3 months. These included symptomatic improvement, functional status, unmet expectations, satisfaction with care, clinician-perceived patient difficulty, and health care utilization and costs.

RESULTS

A depressive or anxiety disorder was present in 146 (29%) of the patients. Independent predictors of a mental disorder included recent stress, multiple physical symptoms (ie, 6 or more), higher patient ratings of symptom severity, lower patient ratings of their overall health, physician perception of the encounter as difficult, and patient age less than 50. Patients with depressive or anxiety disorders were more likely to have unmet expectations postvisit (20% versus 8%, P < 0.001), be considered difficult (26% versus 11%, P < 0.0001), and report persistent psychiatric symptoms and ongoing stress even 3 months following the initial visit. Psychiatric status was not associated with symptomatic improvement, health care utilization, or costs.

CONCLUSION

Simple clinical clues in patients with physical complaints identify a subgroup who may warrant further evaluation for a depressive or anxiety disorder. Such disorders are associated with unmet patient expectations and increased provider frustration.