Practical Mental Health Assessment in Primary Care

,

Original Research

Practical Mental Health Assessment in Primary Care

J Fam Pract. 2000 July;49(7):614-621

By

Jonathan Shedler, PhD

Validity and Utility of the Quick PsychoDiagnostics Panel

References

1. Regier DA, Goldberg ID, Taube CA. The de facto US mental health services system. Arch General Psych 1978;35:685-93.

2. Barret JE, Barrett JA, Oxman TE, Gerber PD. The prevalence of psychiatric disorders in a primary care practice. Arch Gen Psych 1988;45:1100-06.

3. Andersen SM, Harthorn BH. The recognition, diagnosis, and treatment of mental disorders by primary care physicians. Med Care 1989;27:869-86.

4. Borus JF, Howes MJ, Devins NP, Rosenberg R, Livingston WW. Primary health care providers’ recognition and diagnosis of mental disorders in their patients. Gen Hosp Psychiatry 1988;10:317-21.

5. Katon W. The epidemiology of depression in medical care. Int J Psychiatry Med 1987;17:93-112.

6. Nielson AC, Williams T. Depression in ambulatory medical patients. Arch Gen Psychiatry 1980;37:999-1004.

7. Ormel J, Koeter MWJ, van den Brink W, van de Willige G. Recognition, management, and course of anxiety and depression in general practice. Arch Gen Psychiatry 1991;48:700-06.

8. Rydon P, Redmon S, Sanson-Fisher RW, Reid ALA. Detection of alcohol-related problems in general practice. J Stud Alcohol 1992;53:197-202.

9. Schulberg HC, Burns BJ. Mental disorders in primary care: epidemiologic, diagnostic, and treatment research directions. Gen Hosp Psychiatry 1988;10:79-87.

10. Schulberg HC, Saul M, McClelland M. Assessing depression in primary medical and psychiatric practices. Arch Gen Psychiatry 1985;12:1164-70.

11. Kessler LG, Cleary PD, Burke JD, Jr. Psychiatric disorders in primary care: results of a follow-up study. Arch Gen Psychiatry 1985;42:583-87.

12. Mulrow CD, Williams JW, Gerety MB, Ramirez G, Montel OM, Kerber C. Case-finding instruments for depression in primary care settings. Ann Intern Med 1995;122:913-21.

13. Weissman MM, Olfson M, Leon AC, et al. Brief diagnostic interviews (SDDS-PC) for multiple mental disorders in primary care: a pilot study. Arch Fam Med 1995;4:220-27

14. Shedler J. The Shedler QPD Panel (Quick PsychoDiagnostics Panel): a psychiatric ‘lab test’ for primary care. In: Maruish M, ed. Handbook of psychological assessment in primary care settings. Mahwah, NJ: Lawrence Erlbaum Associates; 2000.

15. Spitzer RL, Williams JBW, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. JAMA 1994;272:1749-56.

16. Spitzer RL, Kroenke K, Williams JBW, et al. Validation and utility of a self-report version of the PRIME-MD. JAMA 1999;282:1737-44.

17. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association; 1994.

18. Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrica 1951;16:297-334.

19. First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IV Axis I Disorders (SCID). Washington, DC: American Psychiatric Press; 1995.

20. Reynolds WM, Kobak KA. Hamilton Depression Inventory: a self-report version of the Hamilton Depression Rating Scale. Odessa, Fla: Psychological Assessment Resources; 1995.

21. Cohen J. A coefficient of agreement for nominal scales. Educ Psychol Meas 1960;20:37-46.

22. Beck AT, Ward CH, Mendelson M, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561-71.

23. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1977;1:385-401.

24. Zung WWK. A self-rating depression scale. Arch Gen Psychiatry 1965;12:63-70.

25. Spielberger CD, Gorsuch RC, Lushene RE. Manual for the State-Trait Anxiety Inventory. Palo Alto, Calif: Consulting Psychologists, 1970.

26. Derogatis LR. The SCL-90-R. Baltimore, Md: Clinical Psychometric Research; 1975.

27. Beck A, Nimmer C. A case study: the Kaiser Permanente integrated care project. In: Maruish M, ed. Handbook of psychological assessment in primary care settings. Mahwah, NJ: Lawrence Erlbaum Associates; 2000.

28. Whooley MA, Avins AL, Miranda J, Browner W. Case-finding instruments for depression: two questions are as good as many. J Gen Intern Med 1997;12:439-45

BACKGROUND: Many case-finding instruments are available to help primary care physicians (PCPs) diagnose depression, but they are not widely used. Physicians often consider these instruments too time consuming or feel they do not provide sufficient diagnostic information. Our study examined the validity and utility of the Quick PsychoDiagnostics (QPD) Panel, an automated mental health test designed to meet the special needs of PCPs. The test screens for 9 common psychiatric disorders and requires no physician time to administer or score.

METHODS: We evaluated criterion validity relative to the Structured Clinical Interview for DSM-IV (SCID), and evaluated convergent validity by correlating QPD Panel scores with established mental health measures. Sensitivity to change was examined by readministering the test to patients pretreatment and posttreatment. Utility was evaluated through physician and patient satisfaction surveys.

RESULTS: For major depression, sensitivity and specificity were 81% and 96%, respectively. For other disorders, sensitivities ranged from 69% to 98%, and specificities ranged from 90% to 97%. The depression severity score correlated highly with the Beck, Hamilton, Zung, and CES-D depression scales, and the anxiety score correlated highly with the Spielberger State-Trait Anxiety Inventory and the anxiety subscale of the Symptom Checklist 90 (Ps <.001). The test was sensitive to change. All PCPs agreed or strongly agreed that the QPD Panel “is convenient and easy to use,” “can be used immediately by any physician,” and “helps provide better patient care.” Patients also rated the test favorably.

CONCLUSIONS: The QPD Panel is a valid mental health assessment tool that can diagnose a range of common psychiatric disorders and is practical for routine use in primary care.

Approximately 60% of patients with diagnosable psychiatric disorders seek care from primary care physicians (PCPs) rather than mental health professionals; primary care has been called the de facto mental health services system in the United States.¹ Unfortunately, PCPs often underdiagnose and undertreat mental disorders. Research indicates that mental disorders are present in at least 20% of medical outpatients,² and 50% to 65% of these cases go undetected.^3-11 Numerous case-finding tools are available to help PCPs diagnose depression, the most common mental disorder. A recent and comprehensive review of depression case-finding instruments¹² showed that all are comparable in their ability to detect depression, with an average sensitivity of 84% and average specificity of 72%. However, many PCPs find these instruments too cumbersome and time consuming for routine use,^3,13 and none has gained widespread adoption in primary care. The authors of that comprehensive review concluded that “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.”

Interviews and focus groups with PCPs echoed these conclusions,¹⁴ indicating that factors other than validity are often overlooked by investigators and pose obstacles to physician acceptance and implementation. Physicians emphasized the time constraints of primary care practice and noted that mental health case-finding instruments took time to administer and score, had the potential to disrupt office routines and patient flow, and created paperwork. Another reason for dissatisfaction was that many instruments provided only numeric scores, not specific psychiatric diagnoses that could better inform treatment decisions. Finally, physicians questioned the utility of instruments that screened for depression only and did not assess other psychiatric disorders that often coexist with depression and have implications for treatment (eg, anxiety disorders, addictive disorders). One instrument that is designed to diagnose multiple disorders, the Primary Care Evaluation of Mental Disorders (PRIME-MD),¹⁵ requires physicians to conduct patient interviews that last an average of 8.4 minutes and can run to 15 minutes or more, and is therefore impractical in many primary care settings.*

This article describes a new mental health assessment tool, the Quick PsychoDiagnostics (QPD) Panel, designed to meet the need for a practical and time-efficient psychiatric assessment tool for primary care. Our 3 study goals were to establish the validity of the test, evaluate the utility of the test for assessing treatment outcomes, and assess both patient and physician acceptance of the test in busy primary care settings.

Methods

Description of the QPD Panel

The QPD Panel is a fully automated test that requires no time from physicians to administer or score. Patients self-administer the test in 6.2 minutes on average, using specially designed hand-held computer units. The hand-held units are approximately the size of a textbook and have large liquid crystal display (LCD) screens and “True” and “False” response buttons. Patients read diagnostic questions on the screen and answer by pressing the response buttons (all questions use a True/False response format). When a patient completes the test, the hand-held unit is placed on a docking station connected to a printer, and a diagnostic report is printed immediately. The computer-generated report resembles a familiar laboratory blood chemistry report ([Figure 1]). Patient data are also stored electronically, and the database can be accessed for subsequent analysis (eg, to create aggregate reports for the patient population).