Detection of depression in primary care: comparison of two self-administered scales

Effects of Qigong Exercise on Physical and Psychological Health among African Americans

Interventions are needed to address physical and psychological health in middle-aged and older African Americans (AAs). The purpose of this pilot study was to evaluate the feasibility and potential benefits of an eight-week Qigong exercise on physical ability and function, balance, frailty, depression and anxiety, and spiritual well-being in AAs using a single-group design. Fifteen AAs with a mean age of 64 years received Qigong exercise over 16 semi-weekly, one-hour sessions. The majority were female (93.3%) and college-level educated (53.3%). Repeat chair stands, physical function, and spiritual well-being improved significantly (p < .05) with effect sizes ranging from .45 to .87. Over 52% of participants showed improved depression scores, fast gait speed, and standing balance. Nearly 42% demonstrated some frailty improvement over baseline. No adverse events were reported. Qigong exercise potentially improves the physical ability and function, and spiritual well-being of AAs and needs further testing in a randomized clinical trial.

Case identification of depression in patients with chronic physical health problems: a diagnostic accuracy meta-analysis of 113 studies

BACKGROUND

Depression is more likely in patients with chronic physical illness, and is associated with increased rates of disability and mortality. Effective treatment of depression may reduce morbidity and mortality. The use of two stem questions for case finding in diabetes and coronary heart disease is advocated in the Quality and Outcomes Framework, and has become normalised into primary care.

AIM

To define the most effective tool for use in consultations to detect depression in people with chronic physical illness.

DESIGN

Meta-analysis.

METHOD

The following data sources were searched: CENTRAL, CINAHL, Embase, HMIC, MEDLINE, PsycINFO, Web of Knowledge, from inception to July 2009. Three authors selected studies that examined identification tools and used an interview-based ICD (International Classification of Diseases) or DSM (Diagnostic and statistical Manual of Mental Disorders) diagnosis of depression as reference standard. At least two authors independently extracted study characteristics and outcome data and assessed methodological quality.

RESULTS

A total of 113 studies met the eligibility criteria, providing data on 20,826 participants. It was found that two stem questions, PHQ-9 (Patient Health Questionnaire), the Zung, and GHQ-28 (General Health Questionnaire) were the optimal measures for case identification, but no method was sufficiently accurate to recommend as a definitive case-finding tool. Limitations were the moderate-to-high heterogeneity for most scales and the facts that few studies used ICD diagnoses as the reference standard, and that a variety of methods were used to determine DSM diagnoses.

CONCLUSION

Assessing both validity and ease of use, the two stem questions are the preferred method. However, clinicians should not rely on the two-questions approach alone, but should be confident to engage in a more detailed clinical assessment of patients who score positively.

Ethnic Minority Status, Depression, and Cognitive Failures in Relation to Marital Adjustment in Ethnically Diverse Older Women

The authors investigated the relationship between marital adjustment and ethnic minority status, depressive symptomatology, and cognitive failures among 78 married, community-dwelling, and predominantly non-European-American older women (ages 57-89). Respondents were screened to rule out dementia. Level of depressive symptoms, self-report of cognitive failures, and marital adjustment were obtained. As hypothesized, higher depressive symptomatology and cognitive failures were associated with worse marital adjustment (p < .05 for both). The same was true for membership in a non-dominant ethnic group, albeit only when ethnic status was considered outside the context of the other two independent variables. These results have clinical implications and fit within the theoretical framework of the socioemotional selectivity theory (Carstensen, 1992) applied to marriage in older age, a conceptualization formulated by Bookwala and Jacobs in 2004.

The Hospital Anxiety and Depression Scale: a diagnostic meta-analysis of case-finding ability

OBJECTIVE

To quantify the accuracy of the Hospital Anxiety and Depression Scale (HADS) as a case-finding instrument for anxiety and depressive disorders.

METHOD

MEDLINE, PSYCHINFO, EMBASE, CINAHL, BNI, and AMED were searched from January 1983 to June 2006. Studies were included that administered the HADS, used a standardized psychiatric interview to establish a diagnosis of anxiety or depression, and provided sufficient data on sensitivity and specificity (N=41). Summary sensitivity, specificity, likelihood ratios, and diagnostic odds ratios were calculated for each study. Random effects meta-analytic pooling across studies at the recommended clinical (7/8) and research (10/11) cutoff points was undertaken and summary receiver operating characteristic curves constructed.

RESULTS

For major depressive disorders, a cut point of ≥8 gave a sensitivity of 0.82 (95% CI, 0.73-0.89) and a specificity of 0.74 (95% CI, 0.60-0.84) and a cut point ≥11 gave a sensitivity of 0.56 (95% CI, 0.40-0.71) and a specificity of 0.92 (95% CI, 0.79-0.97).

CONCLUSIONS

Many studies have shown that the HADS is a useful screening tool to identify emotional distress in nonpsychiatric patients. However, it does not appear to be superior to other screening instruments in terms of identifying specific mental disorders in physical health settings.

The ineffectiveness of the Hospital Anxiety and Depression Scale for diagnosis in an Omani traumatic brain injured population

BACKGROUND

The rehabilitation of the traumatic brain injury (TBI) patient is especially challenging in non-western populations as the phenotypic indicators as well as the neurobehavioral assessments for the survivors of brain injury are limited.

OBJECTIVE

The study screened for the prevalence of anxiety and depressive states among patients with TBI and examined the validity of the Hospital Anxiety and Depression Scale (HADS) to identify TBI patients with comorbid affective dysfunctions, specifically anxiety and depressive disorders, in an Omani population.

METHODS

Sixty-eight survivors of TBI were screened with the semi-structured, Composite International Diagnostic Interview (CIDI) and the HADS. A receiver operating characteristics (ROC) curve was calculated to discriminate the power of the HADS for every possible threshold score.

RESULTS

The semi-structured interview revealed the prevalence rate of 57.4% for depressive disorder and 50% for anxiety disorder. The sensitivity (53.8%) and specificity 75.9%, gave the best compromise using the cut-off score of 4, suggesting HADS is not a useful screening tool for this particular population.

CONCLUSIONS

Phenotypic indicators as detected by CIDI revealed that prevalence of affective dysfunctionality is common among this TBI population. Although the HADS is the most widely used screening instrument in other clinical populations, it does not appear to be a reliable resource in identifying depression and anxiety in people with traumatic brain injury in Oman.

Depression in general practice

The aim of this study was to examine the prevalence of depression and to investigate factors related to depression in a multi-ethnic healthcare practice population. The Primary Care Evaluation of Mental Disorders (PRIME-MD) was used to assess mental disorders in Jordbro Health District, Haninge municipality (JHC), Sweden; 470 adult patients were consecutively examined. A two-stage-screening questionnaire was applied to identify patients reporting five or more of the nine criteria for major depression listed in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). This procedure was combined with a patient questionnaire (PQ) dealing with questions on socio-demographic characteristics, lifestyle, health status and medicine use. Major depression is common and in this population 18.1% met the criteria for major depression. Also, minor depression was common, with 12.1% of subjects falling into this category. Only 21.2% of the patients with major depression were being treated with anti-depressant medication. Co-morbidity was more common among depressed than among non-depressed patients. Depression seems to be under-recognized in primary care practice. The recognition and treatment of depressive disorders could be improved by using DSM-IV criteria to detect depressive disorders in daily clinical practice in primary care.

The Geriatric Mental State Examination in the 21st century

The Geriatric Mental State Examination (GMS) is now established as one of the most commonly used mental health assessments for older people. Its strengths lie in extensive validity studies, high inter-rater reliability, accessibility to trained raters, irrespective of professional background and its continual evolution and adaptation. Its computerisation, association with supplementary instruments and support by a diagnostic algorithm provides a comprehensive diagnostic system and syndrome profile for each subject. The instrument has been validated against most major diagnostic systems and has been used as outcome measures in intervention studies. It has been translated into numerous languages and validated as a diagnostic instrument in various cultures. Such studies have exposed weaknesses, including the over diagnoses of organic states in populations with poorly developed education. On-going studies continue to address these issues, providing a culture sensitive instrument enabling unique trans-cultural research in a relatively under-researched field.

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.

Mental health in older adult recipients of primary care services: is depression the key issue? Identification, treatment and the general practitioner

OBJECTIVES

Mental health services for older people in primary care are relatively underdeveloped. This study has sought to determine the nature and extent of mental health problems in older people presenting to primary care and to compare this with the detection and management of mental health problems by the primary health care team (PHCT).

METHOD

Participants were patients aged 65 years and above attending a representative inner city general practice. Screening tools included the General Health Questionnaire (GHQ-28), Hospital Anxiety and Depression Scale (HADS), Mini Mental State Examination (MMSE). The PHCT used a brief checklist to rate participants for the presence of mental health problems. Follow-up interviews using the Geriatric Mental State (GMSA), Cambridge Examination for Mental Disorders in the Elderly (CAMDEX)-cognitive subscale (CAMCOG), National Adult Reading Test (NART), were carried out.

RESULTS

A high level of psychological morbidity was identified at screening (48.1%). There was a considerable degree of agreement between the HADS and GMSA, and the MMSE and GMSA at follow-up. Agreement rates between the PHCT and initial screening tools were low suggesting under-recognition of mental health problems at primary care level by the PHCT. Contributory factors included: short consultation times with a concentration on physical symptoms; few patients presenting explicitly with mental health problems; few decisions to treat or refer patients; and the general practitioners tended to monitor, or defer decisions.

CONCLUSIONS

This study found lower levels of severe mental health problems, especially depression, than reported elsewhere, but higher prevalence of psychological distress. High levels of physical and mental health co-morbidity were found. These findings suggest that planning for primary care services needs to adopt a flexible assessment model. The development of effective, time-limited protocols and screening tools to assist the PHCT in improving their identification rates is recommended. This needs to be supported by the availability of appropriate treatments for the psychological distress.