Meghan B. Gerety

Case-Finding Instruments for Depression in Primary Care Settings

Depressive disorders are common, persistent, and recurring afflictions among primary care patients. They cause substantial suffering for patients and their families and are associated with a loss of personal productivity and a markedly increased risk for suicide. Further, the presence of depression puts persons with comorbid conditions, such as recent myocardial infarction, at increased risk for illness and death. Persons with depression spend more time with their physicians during office visits and use more health care than persons without depression [1]. The annual health care cost associated with depression in the United States is estimated to be

Screening for frailty : criteria and predictors of outcomes

43.7 billion [2]. Underscoring the importance of identifying patients with depression is that the effectiveness of therapy, including antidepressants, psychotherapy, and counseling, has clearly been established [3]. Despite these issues, primary care providers fail to diagnose and treat as many as 35% to 50% of patients with depressive disorders [4, 5]. Obstacles to the appropriate recognition of depression include inadequate provider knowledge of diagnostic criteria; competing comorbid conditions and priorities among primary care patients; time limitations in busy office settings; concern about the implications of labeling; poor reimbursement mechanisms; and uncertainty about the value, accuracy, and efficiency of screening mechanisms for identifying patients with depression. We address the last of these obstacles and assess the feasibility and operating characteristics of several case-finding instruments that have been used to detect depressive disorders in primary care settings. Our ultimate goal is to familiarize providers with the advantages and disadvantages of these instruments so that they can make informed decisions about incorporating them into practice. Methods Data Acquisition We did a MEDLINE search of the English-language medical literature published from 1966 through February 1994. Search terms included depressive disorder or depression, diagnosis, and the specific names of each of 11 case-finding instruments cited in previous relevant reviews or bibliographies [6-9]. Other sources were references identified from pertinent articles and national experts in the field of depression. Experts included authors of papers that were selected for review and two members of the Agency for Health Care Policy and Research Guideline Panel on Depression. Of 906 articles identified through MEDLINE, 210 were deemed potentially relevant. These were reviewed to identify studies that met the following selection criteria. Study samples had to have been composed of primary care patients attending clinic. Patients were excluded if they had been selected because they had specific conditions (such as chronic pain or cancer) or because they had specific demographic characteristics (for example, they were immigrants in a particular ethnic group). Both a case-finding instrument and a diagnostic criterion standard had to have been administered. The criterion standard had to have had formal standardized diagnostic criteria for depression. Accepted criterion standards were the Diagnostic Schedule Manual-3 criteria (DSM-III or DSM-III-R) and the Research Diagnostic Criteria, or a close approximation of these. Standard interview procedures, such as the Diagnostic Interview Schedule or the Structured Clinical Interview for DSM-III, had to have been used to arrive at the diagnosis. Chart or physician diagnoses of depression that were made without specified formal interview procedures and diagnostic criteria were excluded. Nineteen studies involving nine case-finding instruments met the selection criteria: Fourteen were found during the MEDLINE search; 1 came from a relevant bibliography; and 4 were unpublished at the time of the search and came from experts [10-28]. Of the remaining articles screened, 92% were excluded because they did not involve primary care patients, 6% were excluded because they had used an inadequate criterion standard, and 2% were excluded because they involved selected populations [29, 30] or because they had tested modified and unvalidated versions of case-finding instruments [31]. Data Extraction Articles were abstracted by two independent reviewers. Determination of study quality was made on the basis of 1) whether the case-finding instrument was administered and interpreted independently of the criterion standard and 2) whether the proportion of persons receiving the criterion standard assessment was less than or more than 50% of those approached for criterion standard assessment. Quality assessment addressed methodologic issues relevant to the evaluation of diagnostic tests (such as independent assessment and selection bias) and did not necessarily reflect the ability of studies to address their original aims. There were no disagreements about quality assessments. Data Synthesis Established cut-points for case-finding instruments (Table 1) were used. Two-by-two tables were constructed that categorized numbers of screened-positive and screened-negative persons who did and did not meet criterion standard diagnosis for major depression and major depression or dysthymia. Kraemers method [32] was used to adjust for verification bias for studies that used two-stage assessment techniques; whereby the criterion standard was administered only to a random sample of persons who screened negative on case-finding instruments [33]. The authors of all but one study provided us with additional data and analyses when two-by-two tables could not be derived from abstraction of the published article. This one study [28] was dropped from further review because its authors could not be contacted and tables could not be derived from published information. Table 1. Characteristics of Case-Finding Instruments That Have Been Used to Detect Depression in Primary Care Settings* A scattergram (Figure 1) plotting true-positive against false-positive rates was constructed to visually evaluate variability among studies [34]. To provide a visual reference for the consistency of study results, we modeled a summary receiver-operating curve based on the logit transformations of the true-positive and false-positive rates. Figure 1. Plot of true-positive rate against false-positive rate for case-finding instruments to detect major depression. Average sensitivities and specificities, weighted by study size and corrected for two-stage assessment techniques when indicated, were computed both by case-finding instrument and by overall instruments [35]. The point estimates and 95% CIs were calculated using a linear random-effects model [36, 37]. Approximate 95% CIs were estimated using quadratic root formulae because most of the point estimates were near unity [37]. Differences in weighted average sensitivities and specificities between case-finding instruments were evaluated using the z statistic with the Scheffe multiple-comparison adjustment [37]. Stratified analyses were done to evaluate whether estimated sensitivities and specificities varied between high-quality studies and those with major selection bias or lack of independent assessment. Regression analysis was used to determine associations between reported study prevalences and sensitivity estimates [37]. Results Descriptions of Case-Finding Instruments Characteristics of the nine case-finding instruments that have been evaluated in primary care settings are presented in Table 1. All of the questionnaires are written either at the easy (3rd to 5th grade) or average (6th to 9th grade) reading level [38]. Almost all can be self-administered in less than 5 minutes. Except for the General Health Questionnaire, all include specific questions aimed at assessing depressed mood or whether a patient feels sad or blue. All include questions assessing anhedonia. Most are available in languages other than English, such as Spanish. The Beck Depression Inventory, the Center for Epidemiologic Studies Depression Screen, and the Zung Self-Assessment Depression Scale are three commonly used, traditional instruments that were developed specifically to identify depression. They include similar numbers of questions and use response formats that rely either on ranking symptom severity or on classifying frequency of symptoms. The time frames of questions are today for the Beck Depression Inventory, over the past week for the Center for Epidemiologic Studies Depression Screen, and recently for the Zung Self-Assessment Depression Scale. These three instruments have been used in numerous settings (including the community, the clinic, and the hospital) not only to identify depression but also to rate severity of depression and to monitor response to therapy. The General Health Questionnaire and the Hopkins Symptom Checklist are questionnaires that screen for general psychiatric illness; the Hopkins Checklist has a specific category for depression. Both of these instruments have several versions with different numbers of questions. The Medical Outcomes Study Depression Screen is a depression-specific screening instrument that was developed by combining two questions from the Diagnostic Interview Schedule [39] with six questions from the Center for Epidemiologic Studies Depression Screen. A logistic regression scoring method is used; this requires a calculator. The Primary Care Evaluation of Mental Disorders (PRIME-MD) and the Symptom Driven Diagnostic System-Primary Care instruments are recently developed, multidimensional questionnaires. Each has screening questions arranged in several categories (for example, mood or depression, anxiety, alcohol abuse, and somatization) that are used to trigger more extensive diagnostic interviewing sections for specific DSM-III-R diagnoses. The depression components of these two instruments include the fewest questions of all case-finding instruments that have been studied in primary care settings. Descriptions of Studies and Fi

A Randomized Trial of Physical Rehabilitation for Very Frail Nursing Home Residents

To determine the reliability of rapid screening by clinically derived geriatric criteria in predicting outcomes of elderly hospitalized patients.

Performance of Case‐Finding Tools for Depression in the Nursing Home: Influence of Clinical and Functional Characteristics and Selection of Optimal Threshold Scores

BACKGROUND Past studies suggest multidisciplinary interventions that include physical therapy (PT) can improve function of nursing home residents. This trial specifically evaluates effects of PT for frail long-stay nursing home residents. DESIGN Randomized, controlled trial. SETTING One academic nursing home and eight community nursing homes. PATIENTS A total of 194 elderly nursing home residents dependent in at least two activities of daily living residing in the nursing home for at least 3 months. INTERVENTIONS Patients were randomized to individually tailored one-on-one PT sessions or friendly visits (FVs) three times a week for 4 months. Physical therapy included range-of-motion, strength, balance, transfer, and mobility exercises. MAIN OUTCOME MEASURES Performance-based physical function assessed by the Physical Disability Index; self-perceived health status assessed with the Sickness Impact Profile; observer-reported activities of daily living; and falls. RESULTS Eighty-nine percent and 92% of PT and FV sessions, respectively, were attended; 5% and 9% of subjects dropped out in the PT group and FV group, respectively. Compared with the FV group, the PT group experienced no significant improvements in overall Physical Disability Index, Sickness Impact Profile, or activities of daily living scores. A 15.5% improvement in the mobility subscale of the Physical Disability Index was seen (95% confidence interval [CI], 6.4% to 24.7%); no benefits in range-of-motion, strength, or balance subscales were found. Compared with the FV group, the PT group used assistive devices for bed mobility tasks less often (P = .06) and were less likely to use assistive devices and wheelchairs for locomotion (P < .005). There were 79 falls in the PT group vs 60 falls in the FV group (P = .11). Charge for the 4-month PT program was

Medical Treatment Preferences of Nursing Home Residents: Relationship to Function and Concordance with Surrogate Decision-Makers

1220 per subject (95% CI,

The relationship between disease and function and perceived health in very frail elders.

412 to

Falls: an examination of three reporting methods in nursing homes.

1832). CONCLUSION This standardized physical therapy program provided modest mobility benefits for very frail long-stay nursing home residents with physical disability due to multiple comorbid conditions.

Targeting the Hospitalized Elderly for Geriatric Consultation

OBJECTIVE: To compare case‐finding tools for depression in the nursing home setting and to evaluate effects of subject function, cognition, and disease number on test performance.

Impact of prospective payment and discharge location on the outcome of hip fracture

Objective: To describe treatment preferences of nursing home residents, concordance with decisions by self‐selected proxies and to establish the relationship of sociodemographic and functional measures to decisions.

Effects of physical therapy on functional status of nursing home residents

Objective: To study associations between disease and observed function and self‐perceived health in very frail elders.