1
|
Brinck-Claussen UØ, Curth NK, Christensen KS, Davidsen AS, Mikkelsen JH, Lau ME, Lundsteen M, Csillag C, Hjorthøj C, Nordentoft M, Eplov LF. Improving the precision of depression diagnosis in general practice: a cluster-randomized trial. BMC FAMILY PRACTICE 2021; 22:88. [PMID: 33962564 PMCID: PMC8105936 DOI: 10.1186/s12875-021-01432-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 04/05/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Methods to enhance the accuracy of the depression diagnosis continues to be of relevance to clinicians. The primary aim of this study was to compare the diagnostic precision of two different diagnostic strategies using the Mini International Neuropsychiatric Interview (MINI) as a reference standard. A secondary aim was to evaluate accordance between depression severity found via MINI and mean Major Depression Inventory (MDI) sum-scores presented at referral. METHODS This study was a two-armed, cluster-randomized superiority trial embedded in the Collabri trials investigating collaborative care in Danish general practices. GPs performing case-finding were instructed always to use MDI when suspecting depression. GPs performing usual clinical assessment were instructed to detect depression as they would normally do. According to guidelines, GPs would use MDI if they had a clinical suspicion, and patients responded positively to two or three core symptoms of depression. We compared the positive predictive value (PPV) in the two groups. RESULTS Fifty-one GP clusters were randomized. In total, 244 participants were recruited in the case-finding group from a total of 19 GP clusters, and 256 participants were recruited in the usual clinical assessment group from a total of 19 GP clusters. The PPV of the GP diagnosis, when based on case-finding, was 0.83 (95% CI 0.78-0.88) and 0.93 (95% CI 0.89-0.96) when based on usual clinical assessment. The mean MDI sum-scores for each depression severity group indicated higher scores than suggested cut-offs. CONCLUSIONS In this trial, systematic use of MDI on clinical suspicion of depression did not improve the diagnostic precision compared with the usual clinical assessment of depression. TRIAL REGISTRATION The trial was retrospectively registered on 07/02/2016 at ClinicalTrials.gov. No. NCT02678845 .
Collapse
Affiliation(s)
- Ursula Ødum Brinck-Claussen
- Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
| | - Nadja Kehler Curth
- Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark.
| | - Kaj Sparle Christensen
- Research Unit for General Practice, Institute of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark
| | - Annette Sofie Davidsen
- The Research Unit for General Practice and Section of General Practice, University of Copenhagen, Oester Farimagsgade 5, Postbox 2099, 1014, Copenhagen K, Denmark
| | - John Hagel Mikkelsen
- Mental Health Center Frederiksberg, Nordre Fasanvej 57-59, 2000, Frederiksberg, Denmark
| | | | | | - Claudio Csillag
- Mental Health Center North Zealand, Dyrehavevej 48, 3400, Hilleroed, Denmark
| | - Carsten Hjorthøj
- Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
| | - Merete Nordentoft
- Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
| | - Lene Falgaard Eplov
- Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
| |
Collapse
|
2
|
Abstract
Depression is a common and heterogeneous condition with a chronic and recurrent natural course that is frequently seen in the primary care setting. Primary care providers play a central role in managing depression and concurrent physical comorbidities, and they face challenges in diagnosing and treating the condition. In this two part series, we review the evidence available to help to guide primary care providers and practices to recognize and manage depression. In this first of two reviews, we outline an approach to screening and diagnosing depression in primary care that evaluates current evidence based guidelines and applies the recommendations to clinical practice. The second review presents an evidence based approach to the treatment of depression in primary care, detailing the recommended lifestyle, drug, and psychological interventions at the individual level. It also highlights strategies that are being adopted at an organizational level to manage depression more effectively in primary care.
Collapse
Affiliation(s)
- Erin K Ferenchick
- Center for Family and Community Medicine, Columbia University Medical Center, New York, NY, USA
| | | | - Harold Alan Pincus
- Department of Psychiatry, Columbia University, New York State Psychiatric Institute, New York, NY, USA
- Irving Institute for Clinical and Translational Research, Columbia University, New York, NY, USA
- RAND Corporation, Pittsburgh, PA, USA
| |
Collapse
|
3
|
Xu T, Jiao J, Zhu C, Li F, Guo X, Li J, Zhu M, Li Z, Wu X. Prevalence and Potential Associated Factors of Depression among Chinese Older Inpatients. J Nutr Health Aging 2019; 23:997-1003. [PMID: 31781730 DOI: 10.1007/s12603-019-1270-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Little is known about the current representative depression situation among Chinese older inpatients. The aim of this study is to examine prevalence of depression and associated risk factors among Chinese older inpatients by a large-scale cross-sectional national survey. METHODS This study is based on baseline survey data from a large-scale cohort study in a representative sample of Chinese older inpatients. The procedure of this study involves physical examination and face-to-face questionnaire interviews. Depression was assessed based on the Geriatric Depression Scale 15. Mixed-effect Poisson regression model was used to examine the relationship between depression and covariates by controlling the cluster effect of hospital wards. RESULTS Of all 9727 respondents, the mean age of all respondents was 72.4±5.7 years, from 65 to 97. The average GDS score was 2 (1, 4). The prevalence rate of depression was 16.7% (95%CI: 15.8-17.4%) among older inpatients. The prevalence rates were 14.6% for males and 19.5% for females respectively. After controlling the cluster effect of hospital wards, age, gender, ADL score, educational level, BMI, frail, marriage, falls, alcohol drinking, cognitive function, living conditions, vision, hearing, sleep and defecation function were associated with depression. Emaciation (OR=1.176, 95%CI: 1.107-1.249), frail (OR=1.562, 95%CI: 1.489-1.639), divorced or widowed (OR=1.083 95%CI: 1.017-1.153), living in the bungalow (OR=1.075, 95%CI: 1.023-1.130), falls (OR=1.078, 95%CI: 1.030-1.128), cognitive function (OR=1.142, 95%CI: 1.091-1.195), vision dysfunction (OR=1.125, 95%CI: 1.076-1.177), hearing dysfunction (OR=1.061, 95%CI: 1.011-1.113), sleep dysfunction (OR=1.237, 95%CI: 1.194-1.282), defecation dysfunction (OR=1.160, 95%CI: 1.103-1.221) could increase prevalence risk of depression. CONCLUSIONS There was a high prevalence of depression among Chinese older inpatients. Demographic characteristics, physical and mental conditions indicators have strong effect on prevalence and strength of depression. Therefore, it is essential to assess depression and perform comprehensive measures to improve physical and mental conditions in order to manage depressive symptoms in older inpatients.
Collapse
Affiliation(s)
- T Xu
- Xinjuan Wu, Department of Nursing, Peking Union Medical College Hospital, Beijing, 100730, China,
| | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Factors contributing to the recognition of anxiety and depression in general practice. BMC FAMILY PRACTICE 2018; 19:99. [PMID: 29935537 PMCID: PMC6015659 DOI: 10.1186/s12875-018-0784-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 05/31/2018] [Indexed: 11/24/2022]
Abstract
Background Adequate recognition of anxiety and depression by general practitioners (GPs) can be improved. Research on factors that are associated with recognition is limited and shows mixed results. The aim of this study was to explore which patient and GP characteristics are associated with recognition of anxiety and depression. Methods We performed a secondary analysis on data from 444 patients who were recruited for a randomized trial. Recognition of anxiety and depression was defined in terms of information in the medical records, in patients who screened positive on the extended Kessler 10 (EK-10). A total of 10 patient and GP characteristics, measured at baseline, were tested and included in a multilevel regression model to examine their impact on recognition. Results Patients who reported a perceived need for psychological care (OR = 2.54, 95% CI 1.60–4.03) and those with higher 4DSQ distress scores (OR = 1.03; 95% CI 1.00–1.07) were more likely to be recognized. In addition, patients’ anxiety or depression was less likely to be recognized when GPs were less confident in their abilities to identify depression (OR = 0.97; 95% CI 0.95–0.99). Patients’ age, chronic medical condition, somatisation, severity of anxiety and depression, and functional status were not associated with the recognition of anxiety and depression. Conclusions There is room for improvement of the recognition of anxiety and depression. Quality improvement activities that focus on increasing GPs’ confidence in the ability to identify symptoms of distress, anxiety and depression, as part of care according to guidelines, may improve recognition. Electronic supplementary material The online version of this article (10.1186/s12875-018-0784-8) contains supplementary material, which is available to authorized users.
Collapse
|
5
|
Cosgrove L, Karter JM, Vaswani A, Thombs BD. Unexamined assumptions and unintended consequences of routine screening for depression. J Psychosom Res 2018; 109:9-11. [PMID: 29773154 DOI: 10.1016/j.jpsychores.2018.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 03/14/2018] [Accepted: 03/14/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Lisa Cosgrove
- University of Massachusetts Boston, Department of Counselling and School Psychology, Boston, MA, USA
| | - Justin M Karter
- University of Massachusetts Boston, Department of Counselling and School Psychology, Boston, MA, USA.
| | - Akansha Vaswani
- University of Massachusetts Boston, Department of Counselling and School Psychology, Boston, MA, USA
| | - Brett D Thombs
- Departments of Psychiatry, McGill University, Montréal, Québec, Canada; Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Québec, Canada; Medicine, McGill University, Montréal, Québec, Canada; Psychology, McGill University, Montréal, Québec, Canada; Educational and Counselling Psychology, McGill University, Montréal, Québec, Canada
| |
Collapse
|
6
|
The Mini-International Neuropsychiatric Interview is useful and well accepted as part of the clinical assessment for depression and anxiety in primary care: a mixed-methods study. BMC FAMILY PRACTICE 2018; 19:19. [PMID: 29368585 PMCID: PMC5781342 DOI: 10.1186/s12875-017-0674-5] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 11/28/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Psychiatric complaints are common among primary care patients, with depression and anxiety being the most frequent. Diagnosis of anxiety and depression can be difficult, potentially leading to over- as well as under-diagnosis. The diagnostic process can be facilitated by incorporating structured interviews as part of the assessment. One such instrument, the Mini-International Neuropsychiatric Interview (MINI), has been established and accepted in psychiatric care. The purpose of this study was to explore the experiences and perceptions of the paper-and-pen version of MINI version 6.0 among patients and staff in primary care centers in Sweden. METHODS The MINI was introduced at three primary care centers and was conducted by either therapists or general practitioners. Patients presented with symptoms that could suggest depression or anxiety disorders. The duration of the interview was recorded. The experiences and perceptions of 125 patients and their interviewers were collected using a structured questionnaire. Global satisfaction was measured with a visual-analog scale (0-100). Semi-structured interviews were conducted with 24 patients and three therapists, and focus groups were held with 17 general practitioners. Qualitative content analysis was used for the interviews and focus groups. The findings across the groups were triangulated with results from the questionnaires. RESULTS The median global satisfaction with the MINI was 80 for patients and 86 for interviewers. General practitioners appreciated that the MINI identified comorbidities, as one-third of the patients had at least two psychiatric diagnoses. The MINI helped general practitioners attain a more accurate diagnosis. Patients appreciated that the MINI helped them recognize and verbalize their problems and did not find it intrusive. Patients and interviewers had mixed experiences with the yes-no format of the MINI, and the risk of subjective interpretations was acknowledged. Patients, general practitioners and therapists stated that the MINI contributed to appropriate treatment. The MINI assessment lasted 26 min on average (range 12 to 60 min). CONCLUSIONS The paper-and-pen version of the MINI could be useful in primary care as part of the clinical assessment of patients with problems suggestive of depression or anxiety disorders. The MINI was well accepted by patients, general practitioners and therapists.
Collapse
|
7
|
Brinck-Claussen UØ, Curth NK, Davidsen AS, Mikkelsen JH, Lau ME, Lundsteen M, Csillag C, Christensen KS, Hjorthøj C, Nordentoft M, Eplov LF. Collaborative care for depression in general practice: study protocol for a randomised controlled trial. Trials 2017; 18:344. [PMID: 28732523 PMCID: PMC5521147 DOI: 10.1186/s13063-017-2064-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 06/24/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Depression is a common illness with great human costs and a significant burden on the public economy. Previous studies have indicated that collaborative care (CC) has a positive effect on symptoms when provided to people with depression, but CC has not yet been applied in a Danish context. We therefore developed a model for CC (the Collabri model) to treat people with depression in general practice in Denmark. Since systematic identification of patients is an "active ingredient" in CC and some literature suggests case finding as the best alternative to standard detection, the two detection methods are examined as part of the study. The aim is to investigate if treatment according to the Collabri model has an effect on depression symptoms when provided to people with depression in general practice in Denmark, and to examine if case finding is a better method to detect depression in general practice than standard detection. METHODS/DESIGN The trial is a cluster-randomised, clinical superiority trial investigating the effect of treatment according to the Collabri model for CC, compared to treatment as usual for 480 participants diagnosed with depression in general practice in the Capital Region of Denmark. The primary outcome is depression symptoms (Beck's Depression Inventory (BDI-II)) after 6 months. Secondary outcomes include depression symptoms (BDI-II) after 15 months, anxiety symptoms (Beck's Anxiety Inventory (BAI)), level of functioning (Global Assessment of Function (GAF)) and psychological stress (Symptom Checklist-90-Revised (SCL-90-R)). In addition, case finding (with the recommended screening tool Major Depression Inventory (MDI)) and standard detection of depression is examined in a cluster-randomized controlled design. Here, the primary outcome is the positive predictive value of referral diagnosis. DISCUSSION If the Collabri model is shown to be superior to treatment as usual, the study will contribute with important knowledge on how to improve treatment of depression in general practice, with major benefit to patients and society. If case finding is shown to be superior to standard detection, it will be recommended as the detection method in future treatment according to the Collabri model. TRIAL REGISTRATION ClinicalTrials.gov. NCT02678845 . Retrospectively registered on 7 February 2016.
Collapse
Affiliation(s)
- Ursula Ødum Brinck-Claussen
- Mental Health Center Copenhagen, Mental Health Services, Kildegårdsvej 28, DK- 2900 Hellerup, Capital Region of Denmark Denmark
| | - Nadja Kehler Curth
- Mental Health Center Copenhagen, Mental Health Services, Kildegårdsvej 28, DK- 2900 Hellerup, Capital Region of Denmark Denmark
| | - Annette Sofie Davidsen
- The Research Unit for General Practice and Section of General Practice, University of Copenhagen, Øster Farimagsgade 5, Postboks 2099, 1014 Copenhagen K, Denmark
| | - John Hagel Mikkelsen
- Mental Health Center Copenhagen, Mental Health Services, Kildegårdsvej 28, DK- 2900 Hellerup, Capital Region of Denmark Denmark
- Mental Health Center Frederiksberg, Mental Health Services, Nordre Fasanvej 57-59, 2000 Frederiksberg, Capital Region of Denmark Denmark
| | - Marianne Engelbrecht Lau
- Mental Health Center Copenhagen, Mental Health Services, Kildegårdsvej 28, DK- 2900 Hellerup, Capital Region of Denmark Denmark
- Stolpegård Psychotherapy Center, Mental Health Services, Stolpegårdsvej 20, 2820 Gentofte, Capital Region of Denmark Denmark
| | | | - Claudio Csillag
- Mental Health Center Copenhagen, Mental Health Services, Kildegårdsvej 28, DK- 2900 Hellerup, Capital Region of Denmark Denmark
- Mental Health Center North Zealand, Mental Health Services, Dyrehavevej 48, 3400 Hillerød, Capital Region of Denmark Denmark
| | - Kaj Sparle Christensen
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Research Unit for General Practice, Institute of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark
| | - Carsten Hjorthøj
- Mental Health Center Copenhagen, Mental Health Services, Kildegårdsvej 28, DK- 2900 Hellerup, Capital Region of Denmark Denmark
| | - Merete Nordentoft
- Mental Health Center Copenhagen, Mental Health Services, Kildegårdsvej 28, DK- 2900 Hellerup, Capital Region of Denmark Denmark
- Institute for Clinical Medicine, University of Copenhagen, Mental Health Center Copenhagen, Mental Health Services, Kildegårdsvej 28, DK-2900 Hellerup, Capital Region of Denmark Denmark
| | - Lene Falgaard Eplov
- Mental Health Center Copenhagen, Mental Health Services, Kildegårdsvej 28, DK- 2900 Hellerup, Capital Region of Denmark Denmark
| |
Collapse
|
8
|
Stoop CH, Nefs G, Pop VJ, Pouwer F. Screening for and subsequent participation in a trial for depression and anxiety in people with type 2 diabetes treated in primary care: Who do we reach? Prim Care Diabetes 2017; 11:273-280. [PMID: 28330680 DOI: 10.1016/j.pcd.2017.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 02/26/2017] [Indexed: 01/28/2023]
Abstract
AIMS This study investigated (factors related to) (a) the response to a screening procedure for depression and anxiety in people with type 2 diabetes in primary care, and (b) participation in a subsequent randomised controlled trial targeting depressive or anxiety symptoms. METHODS People with type 2 diabetes (n=1837) received a screening questionnaire assessing depressive symptoms (PHQ-9) and anxiety symptoms (GAD-7). Eligible persons who scored above the cut-off score (PHQ-9≥7 or GAD-7≥8) were offered to participate in the trial. RESULTS In total, 798 people (43%) returned the screening questionnaire. Non-responders were more often female (53% vs 44%, p<0.001), had higher LDL cholesterol levels (Cohen's d=0.17, p=0.001) and a higher albumin/creatinine ratio (Cohen's d=0.08, p=0.01). In total, 130 people (18%) reported elevated depressive or anxiety symptoms. Twenty-seven persons agreed to participate in the trial. Factors related to participation were a high education level, a higher level of diabetes distress and a history of psychological problems. CONCLUSIONS Using screening as recruitment resulted in a small number of participants in a treatment trial for anxiety and depression. Research is needed to investigate whether screening is also followed by a low uptake of treatment in primary care outside a RCT setting.
Collapse
Affiliation(s)
- Corinne H Stoop
- Department of Medical and Clinical Psychology, Center of Research on Psychological and Somatic disorders (CoRPS), Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands; PoZoB, PO Box 312, 5500 AH Veldhoven, The Netherlands
| | - Giesje Nefs
- Department of Medical and Clinical Psychology, Center of Research on Psychological and Somatic disorders (CoRPS), Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands.
| | - Victor J Pop
- Department of Medical and Clinical Psychology, Center of Research on Psychological and Somatic disorders (CoRPS), Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands
| | - François Pouwer
- Department of Medical and Clinical Psychology, Center of Research on Psychological and Somatic disorders (CoRPS), Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands
| |
Collapse
|
9
|
Thombs BD, Ziegelstein RC. Primary care doctors should not screen their patients for depression. Expert Rev Neurother 2017; 17:645-647. [DOI: 10.1080/14737175.2017.1327356] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Brett D. Thombs
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Canada
- Department of Psychiatry, McGill University, Montréal, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Canada
- Department of Medicine, McGill University, Montréal, Canada
- Department of Counselling and Educational Psychology, McGill University, Montréal, Canada
| | - Roy C. Ziegelstein
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
10
|
Developing a brief depression screen and identifying associations with comorbid physical and psychological illness in Australian Gulf War veterans. J Psychosom Res 2015; 79:566-73. [PMID: 26477979 DOI: 10.1016/j.jpsychores.2015.08.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 08/10/2015] [Accepted: 08/11/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Major depression occurs frequently in veterans, and is associated with comorbid psychological and physical disorders and poorer quality of life. Depression can be difficult to detect in primary care, while lengthy assessment instruments can deter use. Our study aimed to develop a brief depression screen that could be used by veterans and caregivers, and then to compare the association between the brief screen and comorbidities and quality of life with that of a longer instrument. METHODS Our dataset comprised 1204 male Royal Australian Navy veterans of the 1990/91 Gulf War. Depressive symptoms were assessed using the General Health Questionnaire (GHQ-12), health-related quality of life by the Short-Form Health Survey (SF-12), major depression and comorbid psychiatric diagnoses such as posttraumatic disorder (PTSD) using Diagnostic and Statistical Manual (DSM-IV) criteria. Comorbid physical illnesses including musculoskeletal disorders, chronic fatigue and diabetes were examined. RESULTS A brief depression screen of three key self-reported symptoms was identified. Veterans with major depression present according to the screen were over four times more likely to have multisymptom illness or PTSD, and almost twice as likely to have musculoskeletal disorders. Having depression according to the brief screen and having at least one other physical or psychological condition was associated with poorer quality of life. Similar results were obtained for a longer screen based on all GHQ-12 items. CONCLUSION A 3 item depression screen performed as well as a 12 item one in identifying major depression, comorbid physical and psychological illness and poorer quality of life in veterans.
Collapse
|
11
|
Stoop CH, Nefs G, Pommer AM, Pop VJM, Pouwer F. Effectiveness of a stepped care intervention for anxiety and depression in people with diabetes, asthma or COPD in primary care: A randomized controlled trial. J Affect Disord 2015; 184:269-76. [PMID: 26118755 DOI: 10.1016/j.jad.2015.05.063] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 05/22/2015] [Accepted: 05/22/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Depression and anxiety are common in people with a chronic somatic disease. Although guidelines recommend stepped care, the effectiveness of this approach has not been evaluated in people with diabetes, asthma, or COPD in primary care. METHODS 3559 People were sent screening questionnaires (41% response). Of 286 persons with anxiety and/or depression (Generalized Anxiety Disorder questionnaire, GAD-7, cut-off ≥ 8 and/or Patient Health Questionnaire, PHQ-9, cut-off ≥ 7), 46 were randomized into the intervention (stepped care and monitoring of symptoms; n = 23) or control (usual care) group (n = 23). Main outcomes were symptoms of anxiety and depression after the 12-months intervention and six months post intervention. Analysis of covariance was first adjusted for condition and baseline GAD-7/PHQ-9 scores and additionally for age, sex and education. RESULTS The intervention group had a significantly lower level of anxiety symptoms at the end of the program (GAD-7 6 ± 6 vs. 9 ± 6; Cohen's d = 0.61). This effect was still present six months post intervention. The effect on depression was statistically significant in the first model (PHQ-9 6 ± 4 vs. 9 ± 6; p = 0.035), but not in the fully adjusted model (p = 0.099), despite a large effect size (d = 0.63). At six months post intervention there was no statistically significant difference in symptoms of depression between the two groups although the difference in symptoms was still clinically significant (Cohen's d = 0.61). LIMITATIONS Many people were screened, but relatively few participated in the randomized controlled trial. CONCLUSIONS Stepped care with monitoring resulted in a lower level of symptoms of anxiety and depression in people with a chronic condition.
Collapse
Affiliation(s)
- C H Stoop
- Department of Medical and Clinical Psychology, Center of Research on Psychology in Somatic diseases (CoRPS), Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands
| | - G Nefs
- Department of Medical and Clinical Psychology, Center of Research on Psychology in Somatic diseases (CoRPS), Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands
| | - A M Pommer
- Department of Medical and Clinical Psychology, Center of Research on Psychology in Somatic diseases (CoRPS), Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands
| | - V J M Pop
- Department of Medical and Clinical Psychology, Center of Research on Psychology in Somatic diseases (CoRPS), Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands
| | - F Pouwer
- Department of Medical and Clinical Psychology, Center of Research on Psychology in Somatic diseases (CoRPS), Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands.
| |
Collapse
|
12
|
Smits FT, Brouwer HJ, Zwinderman AH, Mohrs J, Schene AH, van Weert HCPM, ter Riet G. Why do they keep coming back? Psychosocial etiology of persistence of frequent attendance in primary care: a prospective cohort study. J Psychosom Res 2014; 77:492-503. [PMID: 25217448 DOI: 10.1016/j.jpsychores.2014.08.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 07/21/2014] [Accepted: 08/12/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients who visit their General Practitioner (GP) very frequently over extended periods of time often have multimorbidity and are costly in primary and specialist healthcare. We investigated the impact of patient-level psychosocial and GP-level factors on the persistence of frequent attendance (FA) in primary care. METHODS Two-year prospective cohort study in 623 incident adult frequent attenders (>90th attendance centile; age and sex-adjusted) in 2009. Information was collected through questionnaires (patients, GPs) and GPs' patient data. We used multilevel, ordinal logistic regression analysis, controlling for somatic illness and demographic factors with FA in 2010 and/or 2011 as the outcome. RESULTS Other anxiety (odds ratio (OR) 2.00; 95% confidence interval from 1.29 to 3.10) over 3years and the number of life events in 3years (OR 1.06; 1.01-1.10 per event; range of 0 to 12) and, at baseline, panic disorder (OR 5.40; 1.67-17.48), other anxiety (OR 2.78; 1.04-7.46), illness behavior (OR 1.13; 1.05-1.20 per point; 28-point scale) and lack of mastery (OR 1.08; 1.01-1.15 per point; 28-point scale) were associated with persistence of FA. We found no evidence of synergistic effects of somatic, psychological and social problems. We found no strong evidence of effects of GP characteristics. CONCLUSION Panic disorder, other anxiety, negative life events, illness behavior and lack of mastery are independently associated with persistence of frequent attendance. Effective intervention at these factors, apart from their intrinsic benefits to these patients, may reduce attendance rates, and healthcare expenditures in primary and specialist care.
Collapse
Affiliation(s)
- Frans T Smits
- Department of General Practice, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands.
| | - Henk J Brouwer
- Department of General Practice, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Jacob Mohrs
- Department of General Practice, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Aart H Schene
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands; Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Henk C P M van Weert
- Department of General Practice, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Gerben ter Riet
- Department of General Practice, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| |
Collapse
|
13
|
van der Waerden JEB, Hoefnagels C, Hosman CMH, Jansen MWJ. Defining subgroups of low socioeconomic status women at risk for depressive symptoms: the importance of perceived stress and cumulative risks. Int J Soc Psychiatry 2014; 60:772-82. [PMID: 24599903 DOI: 10.1177/0020764014522751] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Most disadvantaged women are exposed to risk factors for depression, but not all necessarily have an identical risk for this mental health problem. A better prediction of which low socioeconomic status (SES) women are most at risk for depressive symptoms can help target preventive interventions at high-risk subgroups most in need of support. AIMS Exploring which demographic, socioeconomic and psychological risk factors are associated with self-reported depressive symptoms in a sample of low-SES women and whether the number of risk factors might expose them to an accumulated risk. METHODS Between April 2005 and November 2007, 519 disadvantaged women from urban neighbourhoods in Maastricht, a southern Dutch city, participated in a cross-sectional survey on stress and depressive symptoms. RESULTS Lower education levels, no current employment and lower net monthly family incomes were socioeconomic risk factors associated with higher scores for depressive symptoms. The psychological risk factor 'perceived stress' had the highest explained variance and was most strongly associated with depressive symptoms. Women exposed to multiple risk factors across domains had a cumulated risk for depressive symptomatology. CONCLUSION Low-SES women who seem most eligible for targeted preventive action are those with cumulative risks. Depression prevention strategies for this population may benefit from focusing on perceived stress since this is an important modifiable risk factor.
Collapse
Affiliation(s)
- Judith E B van der Waerden
- INSERM, UMR_S 1136, Department of Social Epidemiology, Pierre Louis Institute of Epidemiology and Public Health, Paris, France Department of Health Promotion, Maastricht University, Maastricht, The Netherlands CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Cees Hoefnagels
- Department of Health Promotion, Maastricht University, Maastricht, The Netherlands CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands Trimbos Institute, Netherlands Institute for Mental Health and Addiction, Utrecht, The Netherlands
| | - Clemens M H Hosman
- Department of Health Promotion, Maastricht University, Maastricht, The Netherlands CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands Behavioral Science Institute, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Maria W J Jansen
- Department of Health Promotion, Maastricht University, Maastricht, The Netherlands CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands Public Health Services South Limburg, Geleen, The Netherlands
| |
Collapse
|
14
|
Depression screening and patient outcomes in pregnancy or postpartum: a systematic review. J Psychosom Res 2014; 76:433-46. [PMID: 24840137 DOI: 10.1016/j.jpsychores.2014.01.006] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 01/17/2014] [Accepted: 01/18/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Clinical practice guidelines disagree on whether health care professionals should screen women for depression during pregnancy or postpartum. The objective of this systematic review was to determine whether depression screening improves depression outcomes among women during pregnancy or the postpartum period. METHODS Searches included the CINAHL, EMBASE, ISI, MEDLINE, and PsycINFO databases through April 1, 2013; manual journal searches; reference list reviews; citation tracking of included articles; and trial registry reviews. RCTs in any language that compared depression outcomes between women during pregnancy or postpartum randomized to undergo depression screening versus women not screened were eligible. RESULTS There were 9,242 unique titles/abstracts and 15 full-text articles reviewed. Only 1 RCT of screening postpartum was included, but none during pregnancy. The eligible postpartum study evaluated screening in mothers in Hong Kong with 2-month-old babies (N=462) and reported a standardized mean difference for symptoms of depression at 6 months postpartum of 0.34 (95% confidence interval=0.15 to 0.52, P<0.001). Standardized mean difference per 44 additional women treated in the intervention trial arm compared to the non-screening arm was approximately 1.8. Risk of bias was high, however, because the status of outcome measures was changed post-hoc and because the reported effect size per woman treated was 6-7 times the effect sizes reported in comparable depression care interventions. CONCLUSION There is currently no evidence from any well-designed and conducted RCT that screening for depression would benefit women in pregnancy or postpartum. Existing guidelines that recommend depression screening during pregnancy or postpartum should be re-considered.
Collapse
|
15
|
Thombs BD, Ziegelstein RC, Roseman M, Kloda LA, Ioannidis JPA. There are no randomized controlled trials that support the United States Preventive Services Task Force Guideline on screening for depression in primary care: a systematic review. BMC Med 2014; 12:13. [PMID: 24472580 PMCID: PMC3922694 DOI: 10.1186/1741-7015-12-13] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 12/02/2013] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The United States Preventive Services Task Force (USPSTF) recommends screening adults for depression in primary care settings when staff-assisted depression management programs are available. This recommendation, however, is based on evidence from depression management programs conducted with patients already identified as depressed, even though screening is intended to identify depressed patients not already recognized or treated. The objective of this systematic review was to evaluate whether there is evidence from randomized controlled trials (RCTs) that depression screening benefits patients in primary care, using an explicit definition of screening. METHODS We re-evaluated RCTs included in the 2009 USPSTF evidence review on depression screening, including only trials that compared depression outcomes between screened and non-screened patients and met the following three criteria: determined patient eligibility and randomized prior to screening; excluded patients already diagnosed with a recent episode of depression or already being treated for depression; and provided the same level of depression treatment services to patients identified as depressed in the screening and non-screening trial arms. We also reviewed studies included in a recent Cochrane systematic review, but not the USPSTF review; conducted a focused search to update the USPSTF review; and reviewed trial registries. RESULTS Of the nine RCTs included in the USPSTF review, four fulfilled none of three criteria for a test of depression screening, four fulfilled one of three criteria, and one fulfilled two of three criteria. There were two additional RCTs included only in the Cochrane review, and each fulfilled one of three criteria. No eligible RCTs were found via the updated review. CONCLUSIONS The USPSTF recommendation to screen adults for depression in primary care settings when staff-assisted depression management programs are available is not supported by evidence from any RCTs that are directly relevant to the recommendation. The USPSTF should re-evaluate this recommendation. Please see related article: http://www.biomedcentral.com/1741-7015/12/14 REGISTRATION: PROSPERO (#CRD42013004276).
Collapse
Affiliation(s)
- Brett D Thombs
- Department of Psychiatry, McGill University, Montréal, Québec, Canada.
| | | | | | | | | |
Collapse
|
16
|
Uijen AA, Schers HJ, Schene AH, Schellevis FG, Lucassen P, van den Bosch WJHM. Experienced continuity of care in patients at risk for depression in primary care. Eur J Gen Pract 2013; 20:161-6. [PMID: 24033228 DOI: 10.3109/13814788.2013.828201] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Existing studies about continuity of care focus on patients with a severe mental illness. OBJECTIVES Explore the level of experienced continuity of care of patients at risk for depression in primary care, and compare these to those of patients with heart failure. METHODS Explorative study comparing patients at risk for depression with chronic heart failure patients. Continuity of care was measured using a patient questionnaire and defined as ( 1 ) number of care providers contacted (personal continuity); ( 2 ) collaboration between care providers in general practice (team continuity) (six items, score 1-5); and ( 3 ) collaboration between GPs and care providers outside general practice (cross-boundary continuity) (four items, score 1-5). RESULTS Most patients at risk for depression contacted several care providers throughout the care spectrum in the past year. They experienced high team continuity and low cross-boundary continuity. In their general practice, they contacted more different care providers for their illness than heart failure patients did (P < 0.01). Patients at risk for depression experienced a slightly better collaboration between these care providers in their practice: a mean score of 4.3 per item compared to 4.0 for heart failure patients (P = 0.03). The perceived cross-boundary continuity, however, was reversed: a mean score of 3.5 per item for patients at risk for depression, compared to 4.0 for heart failure patients (P = 0.01). CONCLUSION The explorative comparison between patients at risk for depression and heart failure patients shows small differences in experienced continuity of care. This should be analysed further in a more robust study.
Collapse
Affiliation(s)
- Annemarie A Uijen
- Department of Primary and Community Care 117, Radboud University Nijmegen Medical Centre , Nijmegen , The Netherlands
| | | | | | | | | | | |
Collapse
|
17
|
Muntingh ADT, De Heer EW, Van Marwijk HWJ, Adèr HJ, Van Balkom AJLM, Spinhoven P, Van der Feltz-Cornelis CM. Screening high-risk patients and assisting in diagnosing anxiety in primary care: the Patient Health Questionnaire evaluated. BMC Psychiatry 2013; 13:192. [PMID: 23865984 PMCID: PMC3723551 DOI: 10.1186/1471-244x-13-192] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 07/10/2013] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Questionnaires may help in detecting and diagnosing anxiety disorders in primary care. However, since utility of these questionnaires in target populations is rarely studied, the Patient Health Questionnaire anxiety modules (PHQ) were evaluated for use as: a) a screener in high-risk patients, and/or b) a case finder for general practitioners (GPs) to assist in diagnosing anxiety disorders. METHODS A cross-sectional analysis was performed in 43 primary care practices in the Netherlands. The added value of the PHQ was assessed in two samples: 1) 170 patients at risk of anxiety disorders (or developing them) according to their electronic medical records (high-risk sample); 2) 141 patients identified as a possible 'anxiety case' by a GP (GP-identified sample). All patients completed the PHQ and were interviewed using the Mini International Neuropsychiatric interview to classify DSM-IV anxiety disorders. Psychometric properties were calculated, and a logistic regression analysis was performed to assess the diagnostic value of the PHQ. RESULTS Using only the screening questions of the PHQ, the area under the curve was 83% in the high-risk sample. In GP-identified patients the official algorithm showed the best characteristics with an area under the curve of 77%. Positive screening questions significantly increased the odds of an anxiety disorder diagnosis in high-risk patients (odds ratio = 23.4; 95% confidence interval 6.9 to 78.8) as did a positive algorithm in GP-identified patients (odds ratio = 13.9; 95% confidence interval 3.8 to 50.6). CONCLUSIONS The PHQ screening questions can be used to screen for anxiety disorders in high-risk primary care patients. In GP-identified patients, the benefit of the PHQ is less evident.
Collapse
Affiliation(s)
- Anna DT Muntingh
- Netherlands Institute of Mental Health and Addiction (Trimbos Institute), PO box 725, Utrecht 3500AS, The Netherlands
- Faculty of Social Sciences, Tranzo department, Tilburg University, PO Box 90153, Tilburg 5000 LE, The Netherlands
- Department of Psychiatry, VU University Medical Centre and GGZ inGeest, A.J. Ernststraat 1187, Amsterdam 1081 HL, The Netherlands
| | - Eric W De Heer
- Netherlands Institute of Mental Health and Addiction (Trimbos Institute), PO box 725, Utrecht 3500AS, The Netherlands
- Faculty of Social Sciences, Tranzo department, Tilburg University, PO Box 90153, Tilburg 5000 LE, The Netherlands
| | - Harm WJ Van Marwijk
- EMGO Institute for Health and Care Research (EMGO+), PO Box 7057, Amsterdam 1007 MB, The Netherlands
- Department of General Practice and Elderly Care Medicine, VU University Medical Centre, Van der Boechorststraat 7, Amsterdam 1081BT, The Netherlands
| | - Herman J Adèr
- Johannes van Kessel Advising, Wederkuil 11, Huizen 1273SB, The Netherlands
| | - Anton JLM Van Balkom
- EMGO Institute for Health and Care Research (EMGO+), PO Box 7057, Amsterdam 1007 MB, The Netherlands
- Department of Psychiatry, VU University Medical Centre and GGZ inGeest, A.J. Ernststraat 1187, Amsterdam 1081 HL, The Netherlands
| | - Philip Spinhoven
- Institute of Psychology, Leiden University, PO Box 9555, Leiden 2300 RB, The Netherlands
- Department of Psychiatry, Leiden University Medical Centre, PO Box 9600, Leiden 2300 RC, The Netherlands
| | - Christina M Van der Feltz-Cornelis
- Netherlands Institute of Mental Health and Addiction (Trimbos Institute), PO box 725, Utrecht 3500AS, The Netherlands
- Faculty of Social Sciences, Tranzo department, Tilburg University, PO Box 90153, Tilburg 5000 LE, The Netherlands
- Clinical Centre for Body, Mind and Health, GGZ Breburg, Lage Witsiebaan 4, Tilburg 5042 DA, The Netherlands
| |
Collapse
|
18
|
Sinnema H, Franx G, Spijker J, Ruiter M, van Haastrecht H, Verhaak P, Nuyen J. Delivering stepped care for depression in general practice: results of a survey amongst general practitioners in the Netherlands. Eur J Gen Pract 2013; 19:221-9. [PMID: 23577662 DOI: 10.3109/13814788.2013.780018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Revised guidelines for depression recommend a stepped care approach. Little is known about the implementation of the stepped care model by general practitioners (GPs) in daily practice. OBJECTIVES To evaluate the performance of Dutch GPs in their general practice regarding important elements of the stepped care model (identification, severity assessment and stepped care treatment allocation) shortly before the revised Dutch multidisciplinary guideline for Depressive Disorders was published. METHODS Data was collected through a self-report questionnaire sent to 500 randomly selected GPs. Multivariate logistic regression analyses were employed to investigate whether GP-related characteristics were associated with GPs' self-reported performance. RESULTS The study involved 194 GPs (response rate: 39%). Responses indicated that 37% paid systematic attention to depression identification, 33% used a screening instrument, and 63% determined the severity of newly diagnosed depression, generally without using an instrument. Most GPs (72%) indicated to allocate stepped care treatment to the majority of their patients newly diagnosed with depression. However, more than 40% indicated to start with antidepressants, either alone or in combination with psychotherapy. Assessing the severity of newly diagnosed depression and clinical experience were positively associated with allocating stepped care treatment. Structural collaboration with mental health professionals was positively associated with assessing severity. CONCLUSION Delivering stepped care for depression in daily general practice could be further improved. Collaboration with mental health professionals and routine severity assessment of diagnosed depression are positively associated with allocating stepped care.
Collapse
Affiliation(s)
- Henny Sinnema
- Trimbos Institute, Netherlands Institute of Mental Health and Addiction , The Netherlands
| | | | | | | | | | | | | |
Collapse
|
19
|
Romera I, Montejo ÁL, Aragonés E, Arbesú JÁ, Iglesias-García C, López S, Lozano JA, Pamulapati S, Yruretagoyena B, Gilaberte I. Systematic depression screening in high-risk patients attending primary care: a pragmatic cluster-randomized trial. BMC Psychiatry 2013; 13:83. [PMID: 23497463 PMCID: PMC3602032 DOI: 10.1186/1471-244x-13-83] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 02/12/2013] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Systematic screening for depression in high-risk patients is recommended but remains controversial. The aim of this study was to assess the effectiveness of such screening in everyday clinical practice on depression recognition. METHODS A pragmatic, cluster randomized, controlled study that randomized primary care physicians (PCPs) in Spain either to an intervention or control group. The intervention group (35-PCPs) received training in depression screening and used depression screening routinely for at least 6 months. The control group (34-PCPs) managed depression in their usual manner. Adherence to (1-6; never-very frequently), feasibility (1-4; unfeasible-very feasible), and acceptance (1-5; very poor-very good) of the screening were evaluated. Underrecognition (primary outcome) and undertreatment rates of major depressive disorder (MDD) in the two groups were compared 6 months after randomization in a random sample of 3737 patients assigned to these PCPs using logistic regression adjusting for the clustering effect. RESULTS No significant differences were found for recognition rates (58.0% vs. 48.1% intervention vs. control; OR [95%CI] 1.40 [0.73-2.68], p = 0.309). The undertreatment rate did not differ significantly either (p = 0.390). The mean adherence to depression screening was 4.4 ± 1.0 ('occasionally'), the mean feasibility was 3.1 ± 0.5 ('moderately feasible'), and the mean acceptance was 4.2 ± 0.6 ('good'). CONCLUSIONS This research was not able to show effectiveness of the systematic screening for MDD in high-risk patients on depression recognition in primary care. The poor adherence to screening implementation could partially explain the results. These reflect the difficulties of putting into practice the clinical guidelines usually based on interventional research. TRIAL REGISTRATION Clinicaltrials.gov NCT01662817.
Collapse
Affiliation(s)
- Irene Romera
- Clinical Research Department, Lilly, S.A., Avenida de la Industria, 30. Alcobendas, E-28108, Madrid, Spain
- Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Ángel L Montejo
- University Hospital of Salamanca. IBSAL. Department of Psychiatry, University of Salamanca, Salamanca, Spain
| | | | | | | | - Silvia López
- Atención Primaria, Área 7 de Madrid, Madrid, Spain
| | | | - Sireesha Pamulapati
- European Statistics, Lilly UK, Erl Wood Manor, Windlesham, Surrey, United Kingdom
| | - Belen Yruretagoyena
- Clinical Research Department, Lilly, S.A., Avenida de la Industria, 30. Alcobendas, E-28108, Madrid, Spain
| | - Inmaculada Gilaberte
- Clinical Research Department, Lilly, S.A., Avenida de la Industria, 30. Alcobendas, E-28108, Madrid, Spain
| |
Collapse
|
20
|
Stafford L, Judd F, Gibson P, Komiti A, Mann GB, Quinn M. Screening for depression and anxiety in women with breast and gynaecologic cancer: course and prevalence of morbidity over 12 months. Psychooncology 2013; 22:2071-8. [DOI: 10.1002/pon.3253] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 01/13/2013] [Accepted: 01/15/2013] [Indexed: 01/06/2023]
Affiliation(s)
| | | | - Penny Gibson
- Centre for Women's Mental Health; Royal Women's Hospital; Parkville; Australia
| | - Angela Komiti
- Centre for Women's Mental Health; Royal Women's Hospital; Parkville; Australia
| | | | | |
Collapse
|
21
|
Response to an unsolicited intervention offer to persons aged ≥ 75 years after screening positive for depressive symptoms: a qualitative study. Int Psychogeriatr 2012; 24:270-7. [PMID: 21846427 DOI: 10.1017/s1041610211001530] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Screening can increase detection of clinically relevant depressive symptoms, but screen-positive persons are not necessarily willing to accept a subsequent unsolicited treatment offer. Our objective was to explore limiting and motivating factors in accepting an offer to join a "coping with depression" course, and perceived needs among persons aged ≥75 years who screened positive for depressive symptoms in general practice. METHODS In a randomized controlled trial, in which 101 persons who had screened positive for depressive symptoms were offered a "coping with depression" course, a sample of 23 persons were interviewed, of whom five (22%) accepted the treatment offer. Interview transcripts were coded independently by two researchers. RESULTS All five individuals who accepted a place on the course felt depressed and/or lonely and had positive expectations about the course. The main reasons for declining to join the course were: not feeling depressed, or having negative thoughts about the course effect, concerns about group participation, or about being too old to change and learn new things. Although perceived needs to relieve depressive symptoms largely matched the elements of the course, most of those who had been screened were not (yet) prepared to accept an intervention offer. Many expressed the need to discuss this treatment decision with their general practitioner. CONCLUSIONS Although the unsolicited treatment offer closely matched the perceived needs of people screening positive for depressive symptoms, only those who combined feelings of being depressed or lonely with positive expectations about the offered course accepted it. Treatment should perhaps be more individually tailored to the patient's motivational stage towards change, a process in which general practitioners can play an important role.
Collapse
|
22
|
Palmer SC, Taggi A, Demichele A, Coyne JC. Is screening effective in detecting untreated psychiatric disorders among newly diagnosed breast cancer patients? Cancer 2011; 118:2735-43. [PMID: 21989608 DOI: 10.1002/cncr.26603] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 07/25/2011] [Accepted: 07/27/2011] [Indexed: 11/08/2022]
Abstract
BACKGROUND A key purpose of routine distress screening is to ensure that cancer patients receive appropriate mental health care. Most studies validating screening instruments overestimate the effectiveness of screening by not differentiating between patients with untreated disorders and patients who are already being treated. This study adopts the novel strategy of evaluating the effectiveness of screening after correcting for disorder for which treatment is already being provided. METHODS A total of 437 recently diagnosed breast cancer patients received in-clinic distress screening and telephone-based psychiatric interviews. Analyses were conducted using receipt of psychotropic medication for mental health difficulties in the context of a psychiatric disorder as a proxy for identification and treatment. RESULTS Rates of elevated distress (33%), major depressive disorder (8%), minor depression (6%), dysthymia (2%), or generalized anxiety disorder (3%) were similar to those in other samples. Thirty-six percent of patients received psychotropic medication around the time of cancer diagnosis, including 64% of those with a current psychiatric diagnosis. Although 39% of patients with elevated distress had a psychiatric disorder, the positive predictive value of screening fell to 15% for an untreated psychiatric disorder and 6% had untreated depression. CONCLUSION Given the high rates of existing treatment, screening may not be efficient for identifying untreated disorder. Almost two-thirds of patients with treated disorders remain symptomatic. Use of symptom scales might reasonably be expanded to surveillance of treatment response or ruling out disorder. Substantial resources would likely be required to coordinate or manage psychiatric care among patients, as would a willingness to intervene in existing relationships with other providers.
Collapse
Affiliation(s)
- Steven C Palmer
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
| | | | | | | |
Collapse
|
23
|
Thombs BD, Coyne JC, Cuijpers P, de Jonge P, Gilbody S, Ioannidis JPA, Johnson BT, Patten SB, Turner EH, Ziegelstein RC. Rethinking recommendations for screening for depression in primary care. CMAJ 2011; 184:413-8. [PMID: 21930744 DOI: 10.1503/cmaj.111035] [Citation(s) in RCA: 146] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Brett D Thombs
- Department of Psychiatry, McGill University and Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Que.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Thombs BD, Arthurs E, El-Baalbaki G, Meijer A, Ziegelstein RC, Steele RJ. Risk of bias from inclusion of patients who already have diagnosis of or are undergoing treatment for depression in diagnostic accuracy studies of screening tools for depression: systematic review. BMJ 2011; 343:d4825. [PMID: 21852353 PMCID: PMC3191850 DOI: 10.1136/bmj.d4825] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2011] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To investigate the proportion of original studies included in systematic reviews and meta-analyses on the diagnostic accuracy of screening tools for depression that appropriately exclude patients who already have a diagnosis of or are receiving treatment for depression and to determine whether these systematic reviews and meta-analyses evaluate possible bias from the inclusion of such patients. DESIGN Systematic review. DATA SOURCES Medline, PsycINFO, CINAHL, Embase, ISI, SCOPUS, and Cochrane databases were searched from 1 January 2005 to 29 October 2009. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Systematic reviews and meta-analyses in any language that reported on the diagnostic accuracy of screening tools for depression. RESULTS Only eight of 197 (4%) unique publications from 17 systematic reviews and meta-analyses specifically excluded patients who already had a diagnosis of or were receiving treatment for depression. No systematic reviews or meta-analyses commented on possible bias from the inclusion of such patients, even though 10 reviews used quality assessment tools with items to rate risk of bias from composition of the sample of patients. CONCLUSIONS Studies of the accuracy of screening tools for depression rarely exclude patients who already have a diagnosis of or are receiving treatment for depression, a potential bias that is not evaluated in systematic reviews and meta-analyses. This could result in inflated estimates of accuracy on which clinical practice and preventive care guidelines are often based, a problem that takes on greater importance as the rate of diagnosed and treated depression in the population increases.
Collapse
Affiliation(s)
- Brett D Thombs
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
| | | | | | | | | | | |
Collapse
|
25
|
Depressionsscreening bei Patienten mit somatischen Erkrankungen. DER NERVENARZT 2011; 82:1469-72, 1474. [DOI: 10.1007/s00115-011-3281-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
26
|
A practical approach to assess depression risk and to guide risk reduction strategies in later life. Int Psychogeriatr 2011; 23:280-91. [PMID: 20880427 DOI: 10.1017/s1041610210001870] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Many factors have been associated with the onset and maintenance of depressive symptoms in later life, although this knowledge is yet to be translated into significant health gains for the population. This study gathered information about common modifiable and non-modifiable risk factors for depression with the aim of developing a practical probabilistic model of depression that can be used to guide risk reduction strategies. METHODS A cross-sectional study was undertaken of 20,677 community-dwelling Australians aged 60 years or over in contact with their general practitioner during the preceding 12 months. Prevalent depression (minor or major) according to the Patient Health Questionnaire (PHQ-9) assessment was the main outcome of interest. Other measured exposures included self-reported age, gender, education, loss of mother or father before age 15 years, physical or sexual abuse before age 15 years, marital status, financial stress, social support, smoking and alcohol use, physical activity, obesity, diabetes, hypertension, and prevalent cardiovascular diseases, chronic respiratory diseases and cancer. RESULTS The mean age of participants was 71.7 ± 7.6 years and 57.9% were women. Depression was present in 1665 (8.0%) of our subjects. Multivariate logistic regression showed depression was independently associated with age older than 75 years, childhood adverse experiences, adverse lifestyle practices (smoking, risk alcohol use, physical inactivity), intermediate health hazards (obesity, diabetes and hypertension), comorbid medical conditions (clinical history of coronary heart disease, stroke, asthma, chronic obstructive pulmonary disease, emphysema or cancers), and social or financial strain. We stratified the exposures to build a matrix that showed that the probability of depression increased progressively with the accumulation of risk factors, from less than 3% for those with no adverse factors to more than 80% for people reporting the maximum number of risk factors. CONCLUSIONS Our probabilistic matrix can be used to estimate depression risk and to guide the introduction of risk reduction strategies. Future studies should now aim to clarify whether interventions designed to mitigate the impact of risk factors can change the prevalence and incidence of depression in later life.
Collapse
|
27
|
Baas KD, Cramer AOJ, Koeter MWJ, van de Lisdonk EH, van Weert HC, Schene AH. Measurement invariance with respect to ethnicity of the Patient Health Questionnaire-9 (PHQ-9). J Affect Disord 2011; 129:229-35. [PMID: 20888647 DOI: 10.1016/j.jad.2010.08.026] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Revised: 08/25/2010] [Accepted: 08/26/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Patient Health Questionnaire-9 (PHQ-9) has been widely used in research and clinical settings. To be able to attribute differences in PHQ-9 scores between groups with different cultural backgrounds to differences in the level of depression, the instrument has to possess measurement invariance. METHODS Data from the Apollo-D study were used. We used two strongly contrasting cultural groups (n=1772). Measurement invariance was assessed by comparing four categorical single factor models with an increasing number of restrictions, representing an increasingly stronger measurement invariance assumption. RESULTS The PHQ-9 was measurement invariant for ethnicity in women and partially measurement invariant for ethnicity in men. The item 'psychomotor problems' seemed to be culturally biased in the Surinam Dutch males. It had a higher loading and threshold compared to Dutch males. LIMITATIONS The sample is restricted to high risk primary care patients, we did not include a gold standard measure of depression and the analyses pertain to a single cross cultural comparison. CONCLUSIONS The observed higher total depression score for females in the Surinam Dutch group can be attributed to a true difference in the latent trait depression. For Surinam Dutch and Dutch men some caution is warranted when comparing results obtained with the PHQ-9. In the former group the scores may be biased slightly downward. Future research is needed to examine how the item 'psychomotor problems' performs in different populations. These findings highlight the necessity of establishing measurement invariance before drawing conclusions based on observed scores.
Collapse
Affiliation(s)
- Kim D Baas
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | | | | | | | | | | |
Collapse
|
28
|
Abstract
PURPOSE OF REVIEW Screening young people for emotional disorder in primary care has seemed sensible given most attend annually and most mental disorder is undetected. Yet evidence supporting screening has been scant. This review considers recent progress around conceptual frameworks, epidemiological findings, accuracy of available instruments and evidence for effectiveness of screening in reducing the burden of emotional disorders. RECENT FINDINGS Despite better evidence about the accuracy of screens in identifying adolescent depression and possible benefits of early intervention with current treatments, demonstration of improved health outcomes and cost-effectiveness is still lacking. Even when screening detects mental disorder other factors such as readiness for care and availability of effective treatments may affect responses. Best results are obtained when screening is linked to collaborative models of care. Evidence around harms from screening is scant but debate exists over potential harms of false-positives such as stigma and increased strain on healthcare resources. SUMMARY There is growing consensus that, if screening for emotional disorder is to be effective in primary care, facilitated access of identified young people to effective treatment options is necessary. Further research is required to demonstrate that routine screening will improve mental health outcomes and be cost-effective.
Collapse
|
29
|
Mitchell AJ. Interpretation of screening implementation studies. Br J Psychiatry 2009; 195:462-3; author reply 463. [PMID: 19880941 DOI: 10.1192/bjp.195.5.462a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
30
|
Wittkampf K, van Ravesteijn H, Baas K, van de Hoogen H, Schene A, Bindels P, Lucassen P, van de Lisdonk E, van Weert H. The accuracy of Patient Health Questionnaire-9 in detecting depression and measuring depression severity in high-risk groups in primary care. Gen Hosp Psychiatry 2009; 31:451-9. [PMID: 19703639 DOI: 10.1016/j.genhosppsych.2009.06.001] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Revised: 06/08/2009] [Accepted: 06/08/2009] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Only half of patients with depressive disorder are diagnosed by their family physicians. Screening in high-risk groups might reduce this hidden morbidity. This study aims to determine the accuracy of the Patient Health Questionnaire-9 (PHQ-9) in (a) screening for depressive disorder, (b) diagnosing depressive disorder and (c) measuring the severity of depressive disorder in groups that are at high risk for depressive disorder. METHOD We compared the performance of the PHQ-9 as a screening instrument and as a diagnostic instrument to that of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) interview, which we used as reference standard. Three high-risk groups of patients were selected: (a) frequent attenders, (b) patients with mental health problems and (c) patients with unexplained complaints. Patients completed the PHQ-9. Next, patients who were at risk for depression (based on PHQ scores) and a random sample of 20% of patients who were not at risk were selected for a second PHQ-9 and the reference standard (SCID-I). We assessed the adequacy of the PHQ-9 as a tool for severity measurement by comparing PHQ-9 scores with scores on the 17-item Hamilton Depression Rating Scale (HDRS-17) in patients diagnosed with a depressive disorder. RESULTS Among 440 patients, both PHQ-9 and SCID-I were analyzed. The test characteristics for screening were sensitivity=0.93 and specificity=0.85; those for diagnosing were sensitivity=0.68 and specificity=0.95. The positive likelihood ratio for diagnosing was 14.2. The HDRS-17 was administered in 49 patients with depressive disorder. The Pearson correlation coefficient of the PHQ-9 to the HDRS-17 was r=.52 (P<.01). CONCLUSION The PHQ-9 performs well as a screening instrument, but in diagnosing depressive disorder, a formal diagnostic process following the PHQ-9 remains imperative. The PHQ-9 does not seem adequate for measuring severity.
Collapse
Affiliation(s)
- Karin Wittkampf
- Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | | | | | | | | | | | | | | | | |
Collapse
|