Elsevier

General Hospital Psychiatry

Volume 24, Issue 4, July–August 2002, Pages 225-237
General Hospital Psychiatry

Identifying depression in primary care: a literature synthesis of case-finding instruments

https://doi.org/10.1016/S0163-8343(02)00195-0Get rights and content

Abstract

We evaluated the usefulness of case-finding instruments for identifying patients with major depression or dysthymia in primary care settings using English language literature from Medline, a specialized trials registry and bibliographies of selected papers. Studies were done in primary care settings with unselected patients and compared case-finding instruments with accepted diagnostic criterion standards for major depression were selected. A total of 16 case-finding instruments were assessed in 38 studies. More than 32,000 patients received screening with a case-finding instrument; approximately 12,900 of these received criterion standard assessment. Case-finding instruments ranged in length from 1 to 30 questions. Average administration times ranged from less than 2 min to 6 min. Median sensitivity for major depression was 85% (range 50% to 97%); median specificity was 74% (range 51% to 98%). No significant differences between instruments were found. However for individual instruments, estimates of sensitivity and specificity varied significantly between studies. For the combined diagnoses of major depression or dysthymia, overall sensitivity was 79% (CI, 74% to 83%) and overall specificity 75% (CI, 70% to 81%). Stratified analyses showed no significant effects on overall instrument performance for study methodology, criterion standard choice, or patient characteristics. We found that multiple instruments with reasonable operating characteristics are available to help primary care clinicians identify patients with major depression. Because operating characteristics of these instruments are similar, selection of a particular instrument should depend on issues such as feasibility, administration and scoring times, and the instruments’ ability to serve additional purposes, such as monitoring severity or response to therapy.

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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  • Cited by (0)

    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.

    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.

    ∗∗

    Dr. Ramirez is now with the Center for Leadership Studies, Our Lady of the Lake University, San Antonio, TX.

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