Studies evaluating the use of depression questionnaires in non-specialist settings
| Reference | Study design | Population, setting and sample size | Intervention and control conditions | Length of follow up and outcomes studied | Results |
|---|---|---|---|---|---|
| I=intervention; C=control; RR=relative risk. | |||||
| Callahan et al (1994)39 | RCT, individual patients randomised | Elderly US primary care patients with a score above 15 on the Hamilton Depression Rating Scale (HDRS) (n=175) | I: Three additional appointments made over a 3 month period with the primary care physician. Clinicians provided with written patient specific materials including HDRS scores; an interpretation of their meaning; a list of all medications and a specific instruction that drugs causing depression should be reviewed; and a written instruction that the presence of depression should be examined and managed appropriately; clinical algorithm provided (n=100) C: No written feedback and no extra visits scheduled (n=75) | Diagnoses of depression Discontinuation of drugs causing depression Initiation of antidepressants Psychiatric referrals Depression scores Functional status scores (Symptom Impact Profile, SIP) Follow up at 6 months | Increased diagnosis of depression in I group (I 32/100 v C 9/75) More frequent discontinuation of depressant drugs (I 23/100 v C 17/75) Increased rate of antidepressants in I group (I 26/100 v C 6/75; RR 3.25, 95% CI 1.47 to 7.42) No difference in rate of psychiatric referrals (I 12/100 v C 10/75; RR 0.9, 95% CI 0.42 to 1.94) No difference in HDRS scores at 6 months between groups No difference in SIP scores between groups |
| Dorwick et al (1995)10 40 | RCT; individual patients randomised | Consecutive GP attenders (n=116) in Liverpool, UK with depression score above 14 on the BDI. | I: Beck depression Inventory (BDI) administered pre consultation and depression scores disclosed to GP (n=52) C1: BDI administered but not fed back to GP (n=64) | BDI scores at 6 and 12 months | Disclosure had no discernible effect on BDI scores at 12 months (p=0.92) |
| German et al (1987)36 101 | RCT; individual patients randomised | US adult & elderly general medical outpatient attenders with high GHQ scores (n=488). | I: GHQ administered pre consultation and results fed back to clinician, together with an indication that score was high and suggested “psychiatric diagnosis” (n=165) C: GHQ administered but not fed back (n=323) | Detection of depression by clinicians. Presence of depression according to diagnostic interview (DIS) Treatment initiated for depression Six month follow up | No effect on detection rate of depression (RR 0.93; 95% CI 0.78 to 1.11) No difference in management of depression (RR 1.02; 95% CI 0.93 to 1.13) |
| Gold (1989)37 | CCT; individual patients allocated | US emergency department attenders. Patients with existing or recognised psychiatric disorders excluded (n=599) | I: 28 item GHQ administered to 357 patients and results fed back to emergency physicians C: GHQ administered to 242 patients but not fed back | Psychiatric diagnosis made by clinician Psychosocial referrals made Immediate follow up post consultation | No overall improved recognition of psychiatric illness (40% v 40%) Increased rate of psychosocial referrals following feedback (I 23% v C 5%; RR 4.45; 95% CI 2.52 to 7.96) |
| Hoeper et al (1984)35 | RCT; individual patients randomised | Adult US primary care patients (n=1452) | I: GHQ administered by researcher and scores fed back to clinician, with information that a score >5 indicated mental illness (n=730) C: GHQ administered but not fed back to clinicians (n=722) | Physician diagnoses of mental illness at reference visit (info elicited as part of the study) Immediate follow up post consultation | No difference in rate of detection of mental disorders (I 16.0% v C 16.8%; RR 0.98 95% CI 0.78 to 1.23) |
| Johnstone & Goldberg (1976)31 | CCT; individual patients randomised; odd/even allocation | Sequential attenders at a single UK general practitioner (n=1093). Those with psychiatric morbidity (n=119 with GHQ >5) which had not been hitherto recognised by the GP (hidden psychiatric morbidity) followed up. | I: GHQ administered and clinician asked about likelihood of psychiatric morbidity. GHQ then fed back to clinician. Those with unrecognised depression and high scores at initial interview (hidden psychiatric morbidity) followed up (n=60) C: GHQ administered and clinician asked about the likelihood of psychiatric morbidity. GHQ folded and placed in the patient note envelope. Those with unrecognised depression and high scores at initial interview (hidden psychiatric morbidity) followed up (n=59) | For those with hidden psychiatric morbidity, the following were studied: Diagnosis and severity of depression during 12 months follow up (incl GHQ scores) Length of depressive episodes Pattern of consultation over 12 months | No differences in consultation rates, but more identified as ‘psychological’ for GHQ group (p=0.09) No differences in the rate of psychotropic prescriptions (p=0.7) No differences in the rate of referral to outside agencies between C and GHQ feedback (RR 1.62; 95% CI 0.72 to 3.71) Moderate improvement (5%, 95% CI –3 to 14%) in GHQ scores at 6 weeks for computerised feedback. No between group differences over longer term |
| Linn et al (1980)33 102 | RCT; individual patients randomised | New referrals to US medical outpatients (n=150); mean age 56 | I1: SDS administered before consultation and results placed at front of notes, together with normative values. Physician also asked about depression after consultation (n=24) I2: SDS fed back to clinician following consultation (n=26) I3: SDS provided before consultation but clinician’s impression of depression not elicited (n=25) I4: SDS given to clinician following consultation, no impression of depression sought (n=25) I5: no screening by SDS but impression of depression sought (n=25) C: no screening by SDS, no physician opinion sought (n=25) | Depression noted in charts Initiation of treatment for depression Two week follow up | Screening and feedback of SDS increased the frequency of notation of depression (C 8% v I 25%; RR 3.13, 95% CI 1.24 to 8.33) Increased notation of depression occurs irrespective of the time of feedback (pre or post consultation Screening has a much smaller effect on the initiation of treatment for ‘depression’ (RR 1.75; 95% CI 0.65 to 4.90) |
| Lewis et al (1996)41 | RCT; individual patients randomised | UK general practice attenders at a single practice with GHQ-12 score >2 (n=681) | I1: GHQ administered and placed in notes with no interpretation or instruction on the presence of mental disorder (n=227) I2: Patient asked to complete a computerised assessment of symptomatology and the results of this assessment fed back to the clinician (n=227) C: No feedback given (n=227 ) NB. A random sample of 200 patients with GHQ <2 had their GHQ results also placed in the notes so that GPs would be blind to the presence of likely psychiatric disorder in I1 and I2 | Consultation rates and clinician attribution of encounters as due to psychological or physical problems Prescription of a psychotropic drug Rates of outside mental health referrals to outside agencies GHQ scores at 6 weeks, 3 and 6 months | No differences in consultation rates, but more identified as ‘psychological’ for GHQ group (p=0.09) No differences in the rate of psychotropic prescriptions No differences in the rate of referral to outside agencies Moderate improvement (5%, 95% CI –3 to 14%) in GHQ scores at 6 weeks for computerised feedback. No between group differences over longer term |
| Magruder Habib et al (1990)38 | RCT; individual patients randomised | Male adult US veterans (mean age 60) attending a US general internal medicine OP clinic with Zung SDS score >50 (n=100) | I: Zung SDS administered and fed back to physicians at first clinic assessment visit - placed at front of clinic notes (n=48) C: SDS administered but not fed back to clinicians (n=52) | Recognition of depression Initiation of management of depression 12 month follow up | Greater recognition of depression in intervention group (56% v 35% at 12 months, RR 2.78; 95% CI 1.19 to 6.50) Non-significant increase in intervention in feedback group (56% v 42% at 12 months, RR 1.32, 95% CI 0.89 to 2.01) |
| Moore et al (1978)32 | RCT; individual patients randomised | General practice attenders with SDS scores >50 (n=96) | I: Zung SDS administered and score fed back (‘mildly’ or ‘severely depressed’) (n=50) C: SDS administered but no feedback to clinician (n=46) | Notation of depression following index visit Immediate follow up post consultation | Feedback increased recognition of depression for high risk patients (22% v 56%, RR 2.58, 95% CI 1.41 to 4.70) |
| Reilfer et al (1996)42 | RCT; internal medicine firms randomised; potential unit of analysis error | Randomly selected patients attending a US urban internal medicine clinic (n=357) | I: Patients (n=185) given screening questionnaire (16 item Symptom Driven Diagnostic Interview Schedule). Results of diagnostic codes elicited (depression; generalised anxiety disorder; panic disorder; alcohol or drug abuse; obsessive-compulsive disorder; suicidal ideation) and fed back to the clinician before the clinical encounter C: Questionnaire administered to patients (n=172) but results not fed back | Functional status at 3 months using Short Form 36 Zung self rated depression and Sheehan anxiety scores at 3 months for those screened positive for depression Health care utilisation over 3 months Satisfaction with care | 65% of all patients screened positive for at least one disorder No statistical difference between I and C in SF36 scores No statistical difference between I and C in Zung depression scores No statistical difference between I and C in anxiety scores Reduction on health utilisation in I group (referrals to non-mental health specialists reduced 0.9 v 2.1 visits, p<0.005) No change in patient satisfaction with care |
| Schriger et al46 | RCT; individual patients randomised | Unselected attenders in US emergency departments (n=190) | I: Computerised PRIME-MD administered and results and recommendations pinned to front of clinical chart (n=92) C: PRIME-MD administered but not fed back (n=98) | Notation of depression and outside referral Immediate follow up post consultation | No difference in rate of recognition of depression (RR 1.60, 95% CI 0.50 to 5.14) |
| Weatherall et al (2000)44 | CCT (odd even allocation) of individual patients | Elderly inpatients, in New Zealand (n=100) | I: GDS administered, together with the Mini Mental State Examination. Scores written in the notes (by hand) and an interpretation of the significance of scores given (n=50) C: An activity of daily living questionnaire administered in place of the GDS (n=50) | Rate of prescription of antidepressants Follow up at discharge and 3 months | No difference in rate of antidepressant prescription (I 13.0% v C 6.3%, RR 1.4; 95% CI 0.72 to 2.09) |
| Williams et al (1999)43 | RCT; individual patients randomised | Sequential attenders at a US family medicine clinic (n=969) | I1: CES-D self administered, scored by researcher and results fed back to clinicians as either ‘positive’ or negative’ (n=323) I2: Single item question (‘Have you felt depressed or sad much of the time in the past year?’) asked and answer yes or no fed back to clinician (n=330) C: Usual care (n=316) NB. All clinicians were given a copy of the ‘Quick reference guide for clinicians on the management of depression’103 | Sensitivity and specificity of the instruments Recognition of depression from case note review, corroborated by DSM-III-R interview schedule Severity of depression from DSM-III-R symptom counts Treatment for depression (referral, antidepressants) Patient and physician satisfaction with care and use of questionnaires Functional status from the SF36 Immediate follow up post consultation and at 3 months. | CES-D sensitivity 88%, specificity 75% Single item questionnaire sensitivity 85%, specificity 66% Interventions 1 and 2 were combined in the reported analysis making the effects difficult to interpret further Authors report: Increased rate of recognition of depression (I. 30/77 v C 11/38; RR 1.34, 95% CI 0.79 to 2.43) No difference in rate of intervention: outside referral or antidepressant prescription (exact figures not given) No difference in prevalence of depression at 3 months |
| Whooley et al (2000)45 | RCT; primary care clinics randomised; potential unit of analysis error | Sequential US family practice attenders over 65 years (n=331) | I: GDS administered and scored by research assistant. Scores fed back to physicians with an indication that the score suggested moderate (score 6–10) or severe (11+) depression. In addition, clinic attenders screened positive were offered a series of organised educational sessions (n=162) C: GDS administered but scores not fed back. Educational sessions not offered (n=169) | Physician diagnosis of depression (case note review, by blinded researcher) Prescription of antidepressants Healthcare ustilisation (number of clincia visits and hospitalisations) Depression scores of the GDS Outcomes all measured at 2 years NB. Only those with screen positive depression followed up (n=331) | No difference in detection of depression (I 56/162 v C 58/169 RR 1.00) No difference in the rate of prescription of antidepressants (I 59/162 v C 72/169; RR 0.87) No difference in mean number of clinic visits (p=0.5) or hospitalisation (p=0.8) No significant between group difference in GDS scores at 2 years (based upon 69% follow up) Proportion of participants with GDS >5: I 41/97 v C 54/109 (RR 0.85) |
| Zung et al (1983)34 | RCT; individual patients randomised | US patients with undetected depression attending a family medicine centre (n=143) | I: Patients’ (n=102) SDS results attached to the front of the medical record and the clinician verbally informed of the positive result and asked to evaluate the patient carefully for the presence of depressive disorder C: Patients’ (n=41) SDS results not fed back to the clinician | Notation of depression in the medical notes SDS scores and clinical improvement (operationally defined as a decrease of at least 12 points from baseline) Follow up 4 weeks | Increased notation of depression in charts for identified group (I 68% v C 15%) Direct comparisons of SDS scores between I and C groups not possible due to incomplete reporting of the data |