Jane M. Murphy

Performance of a five-item mental health screening test

We compared the screening accuracy of a short, five-item version of the Mental Health Inventory (MHI-5) with that of the 18-item MHI, the 30-item version of the General Health Questionnaire (GHQ-30), and a 28-item Somatic Symptom Inventory (SSI-28). Subjects were newly enrolled members of a health maintenance organization (HMO), and the criterion diagnoses were those found through use of the Diagnostic Interview Schedule (DIS) in a stratified sample of respondents to an initial, mailed GHQ. To compare questionnaires, we used receiver operating characteristic analysis, comparing areas under curves through the method of Hanley and McNeil. The MHI-5 was as good as the MHI-18 and the GHQ-30, and better than the SSI-28, for detecting most significant DIS disorders, including major depression, affective disorders generally, and anxiety disorders. Areas under curve for the MHI-5 ranged from 0.739 (for anxiety disorders) to 0.892 (for major depression). Single items from the MHI also performed well. In this population, short screening questionnaires, and even single items, may detect the majority of people with DIS disorders while incurring acceptably low false-positive rates. Perhaps such extremely short questionnaires could more commonly reach use in actual practice than the longer versions have so far, permitting earlier assessment and more appropriate treatment of psychiatrically troubled patients in primary care settings.

A comparison of three psychiatric screening tests using receiver operating characteristic (ROC) analysis.

Self-administered screening questionnaires are available to assist primary care physicians in detecting undiagnosed depression and anxiety disorders. This study used receiver operating characteristic (ROC) analysis to evaluate three such tests: the General Health Questionnaire (GHQ), the Mental Health Inventory (MHI), and the Somatic Symptom Inventory (SSI). Stratified by the results of a preliminary GHQ, 364 health maintenance organization (HMO) members were given these tests and a Diagnostic Interview Schedule (DIS), the latter used as a “truth” standard for current psychiatric diagnosis. The MHI performed significantly better than the GHQ in detecting mental disorders generally and anxiety disorders in particular, and somewhat better in detecting affective disorders. The SSI performed best in detecting anxiety disorders and was significantly better than the GHQ. When subjects who had participated in a previous study involving repeated GHQ administration were excluded, sensitivity of all tests improved, especially the GHQ. We conclude that the MHI can be a useful tool for screening primary care patients, and that the SSI has additional predictive value with respect to anxiety disorders.

Incidence of depression in the Stirling County Study: historical and comparative perspectives.

BACKGROUND The Stirling County Study provides a 40-year perspective on the epidemiology of psychiatric disorders in an adult population in Atlantic Canada. Across samples selected in 1952, 1970 and 1992 current prevalence of depression was stable. This paper concerns time trends in annual incidence as assessed through cohorts selected from the first two samples. METHODS Consistent interview data were analysed by a computerized diagnostic algorithm. The cohorts consisted of subjects at risk for a first depression: Cohort-1 (N = 575) was followed 1952-1970; Cohort-2 (N = 639) was followed 1970-1992. Life-table methods were used to calculate incidence rates and proportional hazards procedures were used for statistical assessment. RESULTS Average annual incidence of depression was 4.5 per 1000 for Cohort-1 and 3.7 for Cohort-2. Differences by gender, age and time were not statistically significant. The stability of incidence and the similarity of distribution by gender and age in these two cohorts corresponds to findings about the two early samples. In contrast, current prevalence in the recent sample was distributed differently and showed an increase among women under 45 years. CONCLUSIONS The stability of the incidence of depression emphasizes the distinctive characteristics of current prevalence in the recent sample and suggests that the dominance of women in rates of depression may have occurred among those born after the Second World War. The results offer partial support for the interpretation of an increase in depression based on retrospective data in other recent studies but they indicate that the increase is specific to women.

Anxiety and depression: a 40-year perspective on relationships regarding prevalence, distribution, and comorbidity.

Objective:  Building on a report about the prevalence of depression over time, this paper examines historical trends regarding anxiety in terms of its prevalence, its distribution by age and gender, and its comorbidity with depression. Methods for conducting such time trend analysis are reviewed.

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.

A clinical practice guideline for treatment of septic arthritis in children: efficacy in improving process of care and effect on outcome of septic arthritis of the hip.

Background: The development of clinical practice guidelines is a central precept of the evidence-based-medicine movement. The purposes of this study were to develop a guideline for the treatment of septic arthritis in children and to evaluate its efficacy with regard to improving the process of care and its effect on the outcome of septic arthritis of the hip in children.Methods: A clinical practice guideline was developed by an interdisciplinary expert committee using evidence-based techniques. Efficacy was evaluated by comparing a historical control group of thirty consecutive children with septic arthritis of the hip managed before the utilization of the guideline with a prospective cohort group of thirty consecutive children treated with use of the guideline. Benchmark parameters of process and outcome were compared between groups.Results: The patients treated with use of the guideline, compared with those treated without use of the guideline, had a significantly higher rate of performance of initial and follow-up C-reactive protein tests (93% compared with 13% and 70% compared with 7%), lower rate of initial bone-scanning (13% compared with 40%), lower rate of presumptive drainage (13% compared with 47%), greater compliance with recommended antibiotic therapy (93% compared with 7%), faster change to oral antibiotics (3.9 compared with 6.9 days), and shorter hospital stay (4.8 compared with 8.3 days). There were no significant differences between the groups with regard to other process variables, and there were no significant differences with regard to outcome variables, including readmission to the hospital, recurrent infection, recurrent drainage, development of osteomyelitis, septic osteonecrosis, or limitation of motion.Conclusions: Patients treated according to the septic arthritis clinical practice guideline had less variation in the process of care and improved efficiency of care without a significant difference in outcome.Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

Incidence of depression and anxiety: the Stirling County Study.

Prevalence studies in psychiatric epidemiology out-number incidence investigations by a wide margin. This report gives descriptive information about the incidence of depression and anxiety disorders in a general population. Using data gathered in a 16-year follow-up of an adult sample selected as part of the Stirling County Study (Canada), the incidence of these types of disorders was found to be approximately nine cases per 1,000 persons per year. The data suggest that for every man who became ill for the first time with one of these disorders, three women became ill. Incidence tended to be higher among relatively young persons. These incidence rates are consistent with prevalence rates of approximately 10 per cent to 15 per cent for depression and anxiety disorders aggregated together, given an estimated average duration of illness of about 10 years. It is concluded that these incidence rates are fairly realistic in view of evidence that disorders of these types tend to be chronic.

Trends in depression and anxiety: men and women

Abstract— Recent reports from four longitudinal studies indicate that the epidemiology of depression and anxiety in general populations may have changed over the third quarter of this century. In each of two studies in the United States, one in Canada, and one in Sweden, more women than men at mid‐century were found to have experienced depression and/or anxiety. By the end of the quarter, women and men in a few to several age groups were more equal in this regard than they had been earlier. In each study, interpretation was offered to the effect that social and historical changes may have contributed to these epidemiologic trends. The four studies are reviewed, and it is suggested that the findings deserve attention as generating hypotheses for further research.

Differential item functioning between ethnic groups in the epidemiological assessment of depression.

A potential explanation for the finding that disadvantaged minority status is associated with a lower lifetime risk for depression is that individuals from minority ethnic groups may be less likely to endorse survey questions about depression even when they have the same level of depression. We examine this possibility using a nonparametric item response theory approach to assess differential item functioning (DIF) in a national survey of psychiatric disorders, the National Comorbidity Survey. Of 20 questions used to assess depression symptoms, we found evidence of DIF in 3 questions when comparing non-Hispanic blacks with non-Hispanic whites and in 3 questions when comparing Hispanics with non-Hispanic whites. However, removal of the questions with DIF did not alter the relative prevalence of depression between ethnic groups. Ethnic differences do exist in response to questions concerning depression, but these differences do not account for the finding of relatively low prevalence of depression among minority groups.

Obesity and weight gain in relation to depression: findings from the Stirling County Study.

Objective:This study concerns the question of whether obese subjects in a community sample experience depression in a different way from the nonobese, especially whether they overeat to the point of gaining weight during periods of depression.Design:A representative sample of adults was interviewed regarding depression and obesity.Subjects:The sample consisted of 1396 subjects whose interviews were studied regarding relationships between obesity and depression and among whom 114 had experienced a major depressive episode at some point in their lives and provided information about the symptoms experienced during the worst or only episode of major depression.Measurements:The Diagnostic Interview Schedule (DIS) was used to identify major depressive episodes. Information was also derived from the section on Depression and Anxiety (DPAX) of the Stirling Study Schedule. Obesity was calculated as a body mass index >30. Logistic regressions were employed to assess relationships, controlling for age and gender, by means of odds ratios and 95% confidence intervals.Results:In the sample as a whole, obesity was not related to depression although it was associated with the symptom of hopelessness. Among those who had ever experienced a major depressive episode, obese persons were 5 times more likely than the nonobese to overeat leading to weight gain during a period of depression (P<0.002). These obese subjects, compared to the nonobese, also experienced longer episodes of depression, a larger number of episodes, and were more preoccupied with death during such episodes.Conclusions:Depression among obese subjects in a community sample tends to be more severe than among the nonobese. Gaining weight while depressed is an important marker of that severity. Further research is needed to understand and possibly prevent the associations, sequences and outcomes among depression, obesity, weight gain and other adversities.