BOSTON — The use of simple screening instruments in the emergency department setting could aid in the recognition of mental health disorders, a study has shown.
And subsequent referral to mental health services of patients who screen positive would likely have a significant public health impact, as many of them might otherwise go undiagnosed and untreated, Edwin Boudreaux, Ph.D., said in a presentation at the annual meeting of the Society for Behavioral Medicine.
In a prospective, multicenter trial, 28% of consecutive adult patients presenting to an urban emergency department during a 3-week period screened positive for depression, and 7% screened positive for bipolar disorder using brief mood disorder screening instruments, reported Dr. Boudreaux of Cooper Hospital and the Robert Wood Johnson Medical School in Camden (N.J.). The results of the brief screens were then measured against those of validated screening tools to assess the utility of the screens.
The cross-sectional study of patients 18 years or older excluded those who were severely ill or who had altered mental status upon presentation to the emergency department. The initial interview of patients meeting study criteria included the Mood Disorder Questionnaire (MDQ) to screen for bipolar disorder and a depression screener comprising the two questions recommended by the U.S. Preventive Health Services Task Force: Over the past few weeks, have you felt down, depressed, or hopeless? Over the past 2 weeks, have you felt little interest or pleasure in doing things?
To test the validity of the results of the initial screen, investigators contacted all of the patients 3–5 days postvisit and rescreened them using the self-report Center for Epidemiologic Studies Depression (CES-D) scale and the Bipolar Spectrum Diagnostic Scale (BSDS).
Of the 243 patients enrolled, 69 screened positive for depression and 18 screened positive for bipolar disorder based on emergency department interviews.
“The depression screener possessed very strong test characteristics,” said Dr. Boudreaux, noting that the sensitivity and specificity were 91% and 67%, respectively, and the positive and negative predictive values were 91% and 67%, respectively, when measured against the results from the validated tools.
The MDQ standard scoring yielded many false negatives, with a sensitivity of only 21%. Specificity and positive predictive value were both 100%, and negative predictive value was 78%. However, Dr. Boudreaux noted, “alternate scoring helped address this problem” by increasing the sensitivity of the MDQ results to 50%, while reducing the specificity only slightly to 97%.
The results justify the expansion of research efforts on screening, assessment, and emergency department-based brief interventions for affective disorders, said Dr. Boudreaux.
“The MDQ is unlikely to be adopted into routine clinical care in the ED because of its length [three multi-item questions], but the rapid depression screener only consists of two questions,” he said. “I could see such a [tool] being promoted for routine screening, similar to the CAGE alcohol screen.”
The four-question CAGE screening instrument “is already routinely used in practice and has gained widespread acceptance across most fields of medicine,” Dr. Boudreaux said. “It seems as though a similar trend could occur with the depression screening, especially when one considers that depression is more common than alcoholism.”
Dr. Boudreaux and colleagues plan to extend their research by validating the screening instruments against structured clinical interviews.