Improved detection of depression in primary care through severity evaluation

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Original Research

Improved detection of depression in primary care through severity evaluation

J Fam Pract. 2002 December;51(12):1065-1070

By

Donald E. Nease Jr, MD

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References

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KEY POINTS FOR CLINICIANS

Existing instruments designed to improve primary care detection of depression carry significant associated burdens that may make their use difficult to sustain in routine practice.
A brief instrument designed to assess symptom severity can effectively target severely symptomatic patients for evaluation with Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for depression.
A strategy of initial assessment of symptom severity, followed by assessment for DSM depression criteria in the most symptomatic patients, can decrease the burden on primary care clinicians by accurately identifying depressed patients most in need of treatment.

ABSTRACT

OBJECTIVES: To determine whether the use of a symptom severity measure to augment an existing Diagnostic and Statistical Manual of Mental Disorders–Third Edition, Revised (DSM-III-R) criteria–based depression screener (PRIME-MD) would decrease the difficulties associated with depression screening in primary care by filtering out patients with minimal impairment.
STUDY DESIGN: The study design was secondary data analysis.
POPULATION: The study sample comprised 1317 patients, with intentional oversampling by ethnicity and sex, presenting for routine care at a university family practice center in Galveston, Texas.
OUTCOMES MEASURED: The primary outcomes were cross-sectional, health-related quality-of-life outcomes of subjects who met symptom severity criteria as well as criteria for a DSM-III-R mood disorder. Health care utilization outcomes were examined as secondary outcomes.
RESULTS: The combination of a 6-item depression severity instrument and the PRIME-MD resulted in 71% of depressed subjects being categorized as severely symptomatic and 29% as minimally symptomatic. Severely symptomatic subjects had significantly worse SF-36 Mental Health Component Summary scale (MCS) scores than did minimally symptomatic subjects (32.8 vs 43.5, P < .05). Minimally symptomatic subjects had MCS scores similar to those of a third group of subjects who did not meet DSM-III-R “threshold” criteria for mood disorder but who were severely symptomatic. Adjusted health care utilization was higher for the initial 3-month charge period in the severely symptomatic depressed subjects compared with minimally symptomatic depressed subjects ($679.20 vs $462.38, P < .05).
CONCLUSIONS: The 6-item depression severity measure effectively separated patients meeting DSM-III-R “threshold” depression criteria into 2 groups: one presenting with severe symptoms and impairment and the other presenting with mild symptoms and significantly less impairment. A strategy of initial screening using a brief depression severity instrument, followed with a DSM criteria–based instrument, could decrease the immediate clinician workload by one third and focus treatment on those most likely to benefit.

Numerous efforts have been directed toward improving primary care clinicians’ detection of depression since the report of early findings that depressive disorders are common yet often unrecognized in primary care.^1,2 Despite the recent release of a new United States Preventive Task Force recommendation,³ controversy exists about the benefits and cost-effectiveness of routine screening.^4–7

Despite the controversies around depression screening, it is clear that there is significant room for improvement in detection of and treatment outcomes for depression in primary care. Additionally, there is ample evidence from clinical trials that depressed patients with higher severity of illness receive the highest benefit from pharmacological treatment. Therefore, it makes sense to target these highly impaired, depressed patients for detection and treatment.

In previous studies exploring the relationships between symptom severity and diagnostic criteria in a large sample of primary care patients, we found that (1) the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for major depression were nonspecific at low levels of impairment but more accurate at high levels, and (2) mood symptom severity assessment performed better than DSM criteria as an independent predictor of impairment and utilization.^8,9 These findings lend support to the notion that case-finding methods incorporating severity in addition to criteria can improve the efficiency of screening in primary care. This study represents our initial exploration of the potential impact of severity-enhanced screening for depression.

We used a retrospective cohort design to answer the following study questions: (1) Can the administration of a symptom severity scale effectively “filter out” a group of patients who meet diagnostic criteria for “threshold” depression but who have less impairment (and may therefore not need treatment)? (2) Does this filtering strategy inappropriately “filter out” patients who are in need of treatment?

Methods

Population and setting

Our sample consisted of 1317 patients presenting for routine care in a university-based family medicine center at the University of Texas Medical Branch (UTMB) in Galveston. The sample, originally recruited for a National Institute for Alcohol Abuse and Alcoholism–funded study of primary care alcohol screening, has been previously described.¹⁰ The study methods and additional data collection methods were reviewed and approved by the UTMB Institutional Review Board.