Karen Falloon

Validation of PHQ-2 and PHQ-9 to Screen for Major Depression in the Primary Care Population

PURPOSE Although screening for unipolar depression is controversial, it is potentially an efficient way to find undetected cases and improve diagnostic acumen. Using a reference standard, we aimed to validate the 2- and 9-question Patient Health Questionnaires (PHQ-2 and PHQ-9) in primary care settings. The PHQ-2 comprises the first 2 questions of the PHQ-9. METHODS Consecutive adult patients attending Auckland family practices completed the PHQ-9, after which they completed the Composite International Diagnostic Interview (CIDI) depression reference standard. Sensitivities and specificities for PHQ-2 and PHQ-9 were analyzed. RESULTS There were 2,642 patients who completed both the PHQ-9 and the CIDI. Sensitivity and specificity of the PHQ-2 for diagnosing major depression were 86% and 78%, respectively, with a score of 2 or higher and 61% and 92% with a score 3 or higher; for the PHQ-9, they were 74% and 91%, respectively, with a score of 10 or higher. For the PHQ-2 a score of 2 or higher detected more cases of depression than a score of 3 or higher. For the PHQ-9 a score of 10 or higher detected more cases of major depression than the PHQ determination of major depression originally described by Spitzer et al in 1999. CONCLUSIONS We report the largest validation study of the PHQ-2 and PHQ-9, compared with a reference standard interview, undertaken in an exclusively primary care population. The PHQ-2 score or 2 or higher had good sensitivity but poor specificity in detecting major depression. Using a PHQ-2 threshold score of 2 or higher rather than 3 or higher resulted in more depressed patients being correctly identified. A PHQ-9 score of 10 or higher appears to detect more depressed patients than the originally described PHQ-9 scoring for major depression.

Prevalence of causes of insomnia in primary care: a cross-sectional study.

BACKGROUND As a result of a research interest in primary insomnia, the prevalence of other causes of insomnia in primary care must be ascertained. No source was found in the literature. It is also essential to know the epidemiology of the common causes of a condition to make an accurate diagnosis in primary care. AIM To determine the prevalence of causes of insomnia in primary care, as part of a method of identifying patients with primary insomnia. DESIGN AND SETTING Cross-sectional study in three general practices in Auckland, New Zealand. METHOD Consecutive patients from the waiting room were asked to complete a nine-page questionnaire on possible causes of insomnia. RESULTS In total, 1517 patients were approached and 955 completed the nine-page questionnaire (63%). Of the 41% (388) who reported difficulty with sleeping, primary insomnia occurred in 12% (45) of the population (95% confidence interval = 9% to 15%); 50% (195) had depression, 48% (185) had anxiety and 43% (165) had general (physical) health problems. Obstructive sleep apnoea occurred in 9% (34) and delayed sleep phase disorder in 2% (7). Only primary insomnia and delayed sleep phase disorder are mutually exclusive; the others can co-exist. CONCLUSION This is the first description of the prevalence of causes of insomnia in primary care. It is hoped that the focus on primary insomnia will result in more behavioural treatments and lower the use of hypnotics in primary care; it should also assist in the appropriate detection and treatment of other causes of insomnia in primary care.

DeLLITE Depression in late life: an intervention trial of exercise. Design and recruitment of a randomised controlled trial

BackgroundPhysical activity shows potential in combating the poor outcomes associated with depression in older people. Meta-analyses show gaps in the research with poor trial design compromising certainty in conclusions and few programmes showing sustained effects.Methods/designThe Depression in Late Life: an Intervention Trial of Exercise (DeLLITE) is a 12 month randomised controlled trial of a physical activity intervention to increase functional status in people aged 75 years and older with depressive symptoms. The intervention involves an individualised activity programme based on goal setting and progression of difficulty of activities delivered by a trained nurse during 8 home visits over 6 months. The control group received time matched home visits to discuss social contacts and networks. Baseline, 6 and 12 months measures were assessed in face to face visits with the primary outcome being functional status (SPPB, NEADL). Secondary outcomes include depressive symptoms (Geriatric Depression Scale), quality of life (SF-36), physical activity (AHS Physical Activity Questionnaire) and falls (self report).DiscussionDue to report in 2008 the DeLLITE study has recruited 70% of those eligible and tests the efficacy of a home based, goal setting physical activity programme in improving function, mood and quality of life in older people with depressive symptomatology. If successful in improving function and mood this trial could prove for the first time that there are long term health benefit of physical activity, independent of social activity, in this high risk group who consume excess health related costs.Trial registrationAustralian and New Zealand Clinical Trials Register ACTRN12605000475640

The assessment and management of insomnia in primary care

#### Summary points Insomnia affects about a third of the general population according to a recent longitudinal study in the UK1 and cross sectional studies estimate the prevalence in patients attending primary care to be between 10% and 50%.2 3 According to the American Sleep Disorders Association International Classification of Sleep Disorders coding manual, insomnia refers to “a repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate time and opportunity for sleep and results in some form of daytime impairment and lasting for at least one month.”4 Although some patients who have this problem may not report it as such, inadequate sleep has been associated with reduced physical health3 4 5 6 and mental health.7 8 9 The continued widespread use of sedative medication to treat insomnia raises concern about the potential for long term tolerance and addiction, particularly where insomnia is the presenting complaint of missed diagnoses such as depression, or when adverse effects might be a problem—for example, falls in older adults.10 11 12 The normal range of sleep is seven to nine hours per night,13 although some individuals claim they can function on as little as four hours, whereas others need up to …

Sleep disorder (insomnia)

A 53 year old man comes to you complaining of not having slept well for many years. He always feels tired the next day. He has tried sleeping pills, which sometimes help, but he is not keen on taking them continually and has found that the benefits they give him don’t last. He spends about 9-10 hours in bed each night (going to bed about 9 30 pm or 10 pm and getting up at 7 am) and has trouble getting to sleep. His actual hours of sleep are 5.5 to 6 each night. He wakes about three times a night and describes the quality of his sleep as poor. ### Assessment Rule out secondary causes. To assess whether he has depression or anxiety, for example, ask screening questions, take a full history of depression and anxiety, or use a scale such as the Hospital Anxiety and Depression Scale, which gives a score for both conditions. Consider sleep apnoea if he snores a lot at night, has periods of apnoea, falls asleep easily during the day (for instance, …