Identifying depression in primary care: a literature synthesis of case-finding instruments☆
Introduction
Depressive disorders are prevalent, cause substantial suffering for patients and their families, and are associated with higher mortality due to suicide and interactions with other medical illness such as cardiovascular disease [1]. In the past decade, market forces, a better understanding of depression epidemiology and the development of additional treatment options have shifted much of the clinical and research focus to primary care settings. Despite this emphasis and the availability of effective therapies, efforts to improve the outcomes of depressed patients have produced mixed results. Some of the most effective strategies have incorporated case-finding for depression as a mechanism to boost recognition [2], [3], [4].
Case-finding is a strategy where patients making a routine health visit to their primary care provider are screened opportunistically for an illness, in this case, depression. It is reasoned that case-finding can overcome some of the barriers to recognition, including competing comorbid conditions and priorities among primary care patients, inadequate provider knowledge of the diagnostic criteria, and time limitations in busy office settings. To date, this strategy has not been recommended by the Canadian or U.S. Preventive Services Task Forces but is under active consideration because of pertinent new research, including evaluations of case-finding instruments. In this study, we update our previous review of case-finding instruments [5], [6] and address the feasibility and operating characteristics of case-finding instruments that have been evaluated in primary care settings. We discuss the implications for adopting case-finding in primary care and directions for future research.
Section snippets
Data acquisition
To update our previous study [5], [6], we searched MEDLINE and a specialized registry of depression trials for English-language medical literature published from 1994 through February 2000 [7]. Search terms included “depressive disorder or depression,” “diagnosis,” and the specific names of each of the 16 case-finding instruments cited in previous relevant reviews or bibliographies [5]. Other sources were references identified from pertinent articles.
Of 860 articles identified through our
Descriptions of case-finding instruments
Characteristics of the sixteen case-finding instruments evaluated in primary care are presented in Table 1. The questionnaires range from 1 to 30 items. Nine are depression specific, two address depression and anxiety, and five are multi-component or screen for general psychiatric illness. Except for the Hospital Anxiety and Depression Scale, all of the questionnaires are written at the easy (3rd to 5th grade) or average (6th to 9th grade) reading level. Almost all can be self-administered in
Discussion
Since our review five years ago, the number of studies and case-finding instruments has increased rapidly. Rather than simplify decision making, this instrument smorgasbord may present confusing choices for researchers studying depression. For clinicians and health care organizations, the decisions are more complex. They must decide whether to implement office-based, systematic screening for depression as part of the routine health evaluation, an approach known as case-finding. They also must
Acknowledgements
We thank Elizabeth O. Cain for assisting with manuscript preparation and Catherine Mills for assisting with data abstraction. We thank the authors of the original studies for promptly responding to our requests for additional information.
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Supported by the Veterans Evidence-based Research Dissemination and Implementation Center and developed by the RTI-UNC Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (Contract No. 290-97-0011), Rockville, M.D.
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Dr. Williams is now with the Center for Health Services Research in Primary Care, HSR&D, Department of Veterans Affairs Medical Center, and Duke University Medical Center, Durham, NC.
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The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality, the Department of Veterans Affairs, or the U.S. Department of Health and Human Services.
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Dr. Ramirez is now with the Center for Leadership Studies, Our Lady of the Lake University, San Antonio, TX.