Case-finding for depression in primary care: a randomized trial∗

doi:10.1016/S0002-9343(98)00371-4

The American Journal of Medicine

Volume 106, Issue 1, January 1999, Pages 36-43

https://doi.org/10.1016/S0002-9343(98)00371-4 Get rights and content

Abstract

PURPOSE: Depression is a highly prevalent, morbid, and costly illness that is often unrecognized and inadequately treated. Because depression questionnaires have the potential to improve recognition, we evaluated the accuracy and effects on primary care of two case-finding instruments compared to usual care.

SUBJECTS AND METHODS: The study was conducted at three university-affiliated and one community-based medical clinics. Consecutive patients were randomly assigned to be asked a single question about mood, to fill out the 20-item Center for Epidemiologic Studies Depression Screen, or to usual care. Within 72 hours, patients were assessed for Diagnostic and Statistical Manual of Mental Disorders Third Revised Edition (DSM-III-R) disorders by an assessor blinded to the screening results. Process of care was assessed using chart audit and administrative databases; patient and physician satisfaction was assessed using Likert scales. At 3 months, depressed patients and a random sample of nondepressed patients were re-assessed for DSM-III-R disorders and symptom counts.

RESULTS: We approached 1,083 patients, of whom 969 consented to screening and were assigned to the single question (n = 330), 20-item questionnaire (n = 323), or usual care (n = 316). The interview for DSM-III-R diagnosis was completed in 863 (89%) patients; major depression, dysthymia, or minor depression was present in 13%. Both instruments were sensitive, but the 20-item questionnaire was more specific than the single question (75% vs 66%, P = 0.03). The 20-item questionnaire was less likely to be self-administered (54% vs 90%) and took significantly more time to complete (15 vs 248 seconds). Case-finding with the 20-item questionnaire or single question modestly increased depression recognition, 30/77 (39%) compared with 11/38 (29%) in usual care (P = 0.31) but did not affect treatment (45% vs 43%, P = 0.88). Effects on DSM-III-R symptoms were mixed. Recovery from depression was more likely in the case-finding than usual care groups, 32/67 (48%) versus 8/30 (27%, P = 0.03), but the mean improvement in depression symptoms did not differ significantly (1.6 vs 1.5 symptoms, P = 0.21).

CONCLUSIONS: A simple question about depression has similar performance characteristics as a longer 20-item questionnaire and is more feasible because of its brevity. Case-finding leads to a modest increase in recognition rates, but does not have consistently positive effects on patient outcomes.

Section snippets

Subjects

The study was conducted at a community-based family medicine clinic, a Veterans-Affairs general internal medicine clinic, a university-affiliated general internal medicine clinic located in San Antonio, Texas, and a university-affiliated general internal medicine clinic in Washington, DC. Participating physicians were given a copy of the “Quick Reference Guide for Clinicians” (13) on managing depression in primary care and a continuing medical education session on interpreting case-finding

Case finding instruments

The single question is “Have you felt depressed or sad much of the time in the past year?” and is answered yes or no (14). The Center for Epidemiological Studies Depression Questionnaire is a 20-item validated instrument that focuses on depressive symptoms within the last week; scores ≥16 identify patients with probable depression (15). Case-finding instruments were self-administered unless the patient could not read or requested that the questionnaire be read to them.

Psychiatric and medical assessments

Psychiatric diagnoses were

Results

From November 1993 through August 1995, 1,083 patients were approached for study entry (Figure 1). Of these, 969 patients (89%) were eligible and randomly assigned to usual care (n = 316), the single question (n = 330), or the 20-item instrument (n = 323). The 114 patients who were ineligible or refused participation were more likely to be men but did not differ from participants by age or ethnic background. Of the participants, 863 (89%) completed the criterion standard interview; patients

Discussion

Our study confirms that the recognition of depression in the primary-care setting is low in usual care. Encouragingly, patients with more severe depression and more functional impairment were more likely to be diagnosed or treated. These data confirm that primary-care physicians incorporate the level of disability into diagnostic and treatment decisions and are appropriately focusing their efforts on those with greater impairment 31, 32, 33, 34. Nevertheless, many patients with major depression

References (54)

K.B Wells et al.
Agreement between face-to-face and telephone-administered versions of the depression section of the NIMH diagnostic interview schedule
J Psychiatr Res
(1988)
F Guillemin et al.
Cross-cultural adaptation of health-related quality of life measuresliterature review and proposed guidelines
J Clin Epidemiol
(1993)
G.R.J Parkerson et al.
Associations among family support, family stress, and personal functional health status
J Clin Epidemiol
(1989)
E.H Rand et al.
Toward a resolution of contradictions. Utility of feedback from the GHQ
Gen Hosp Psychiatr
(1988)
L.S Linn et al.
Recognition of depression and anxiety by primary physicians
Psychosomatics
(1984)
E.W Hoeper et al.
The usefulness of screening for mental illness
Lancet
(1984)
Depression Guideline Panel. Depression in Primary Care: Volume 1. Detection and Diagnosis. Clinical Practice Guideline,...
K.B Wells et al.
The functioning and well-being of depressed patientsresults from the Medical Outcomes study
JAMA
(1989)
R.L Spitzer et al.
Health-related quality of life in primary care patients with mental disorders. Results from the PRIME-MD 1000 Study
JAMA
(1995)
P.E Greenberg et al.
The economic burden of depression in 1990
J Clin Psychiatr
(1993)

G.S Norquist et al.

The epidemiology of psychiatric disorders and the de factor mental health care system

Ann Rev Med

(1996)

G.E Simon et al.

Recognition, management, and outcomes of depression in primary care

Arch Fam Med

(1995)

P.D Gerber et al.

Recognition of depression by internists in primary carea comparison of internist and “gold standard” psychiatric assessments

J Gen Intern Med

(1989)

W.W Zung

The role of rating scales in the identification and management of the depressed patient in the primary care setting

J Clin Psychiatr

(1990)

J.M Zich et al.

Depression in Primary CareScreening and Detection

(1990)

D.A Banazak

Late-life depression in primary care. How well are we doing?

J Gen Intern Med

(1996)

R.L Spitzer et al.

Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study

JAMA

(1994)

W.E Broadhead et al.

Development and validation of the SDDS-PC screen for multiple mental disorders in primary care

Arch Fam Med

(1995)

Depression Guideline Panel. Depression in Primary Care: Quick Reference Guide for Clinicians. Clinical Practice...

K Rost et al.

Development of screeners for depressive disorders and substance disorder history

Med Care

(1993)

L.S Radloff

The CES-D scalea self-report depression scale for research in the general population

Appl Psychol Meas

(1977)

L.N Robins et al.

National Institute of Mental Health and Diagnostic Interview Scheduleits history, characteristics, and validity

Arch Gen Psychiatr

(1981)

J.E Helzer et al.

The predictive validity of lay Diagnostic Interview Schedule diagnoses in the general population. A comparison with physician examiners

Arch General Psychiatr

(1987)

M Karno et al.

Development of the Spanish-language version of the National Institute of Mental Health Diagnostic Interview Schedule

Arch Gen Psychiatr

(1983)

M.A Burnam et al.

The Spanish Diagnostic Interview Schedule. Reliability and comparison with clinical diagnoses

Arch Gen Psychiatr

(1983)

W.E Broadhead et al.

Depression, disability days, and days lost from work in a prospective epidemiologic survey

JAMA

(1990)

D.G Mayfield et al.

The CAGE questionnairevalidation of a new alcoholism screening instrument

Am J Psychiatr

(1974)

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^☆: Supported by a Robert Wood Johnson Generalist Physician Faculty Award (No. 22324) and the Hispanic Healthy Aging Center, NIA Grant No. IT20AG12044-04.

^∗: Access the “Journal Club” discussion of this paper at http://www.elsevier.com/locate/ajmselect/

View full text

Clinical StudiesCase-finding for depression in primary care: a randomized trial∗ ∗☆,

Abstract

Section snippets

Subjects

Case finding instruments

Psychiatric and medical assessments

Results

Discussion

J Psychiatr Res

J Clin Epidemiol

J Clin Epidemiol

Gen Hosp Psychiatr

Psychosomatics

Lancet

The functioning and well-being of depressed patientsresults from the Medical Outcomes study

JAMA

Health-related quality of life in primary care patients with mental disorders. Results from the PRIME-MD 1000 Study

JAMA

The economic burden of depression in 1990

J Clin Psychiatr

The epidemiology of psychiatric disorders and the de factor mental health care system

Ann Rev Med

Recognition, management, and outcomes of depression in primary care

Arch Fam Med

Recognition of depression by internists in primary carea comparison of internist and “gold standard” psychiatric assessments

J Gen Intern Med

The role of rating scales in the identification and management of the depressed patient in the primary care setting

J Clin Psychiatr

Depression in Primary CareScreening and Detection

Late-life depression in primary care. How well are we doing?

J Gen Intern Med

Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study

JAMA

Development and validation of the SDDS-PC screen for multiple mental disorders in primary care

Arch Fam Med

Development of screeners for depressive disorders and substance disorder history

Med Care

The CES-D scalea self-report depression scale for research in the general population

Appl Psychol Meas

National Institute of Mental Health and Diagnostic Interview Scheduleits history, characteristics, and validity

Arch Gen Psychiatr

The predictive validity of lay Diagnostic Interview Schedule diagnoses in the general population. A comparison with physician examiners

Arch General Psychiatr

Development of the Spanish-language version of the National Institute of Mental Health Diagnostic Interview Schedule

Arch Gen Psychiatr

The Spanish Diagnostic Interview Schedule. Reliability and comparison with clinical diagnoses

Arch Gen Psychiatr

Depression, disability days, and days lost from work in a prospective epidemiologic survey

JAMA

The CAGE questionnairevalidation of a new alcoholism screening instrument

Am J Psychiatr

Clinical Studies
Case-finding for depression in primary care: a randomized trial∗ ∗☆,