DONALD E. NEASE,, JR, MD MICHAEL S. KLINKMAN, MD, MS ROBERT J. VOLK, PHD Ann Arbor, Michigan, and Houston, Texas From the Department of Family Medicine, University of Michigan, Ann Arbor, MI, and the Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX. Portions of this work were presented at the National Institute of Mental Health’s Thirteenth International Conference on Mental Health Problems in the General Health Sector, Washington, DC, July 12–13, 1999 and the 27th Annual Meeting of the North American Primary Care Research Group, San Diego, CA, November 7–10, 1999. The authors report no competing interests. Address reprint requests to Donald E. Nease, Jr, MD, Department of Family Medicine,
Although we believe that the principle of severity targeting, rather than the specific instrument chosen, will improve screening performance, the instrument must nonetheless be chosen carefully. Kroenke et al22 examined the utility of using the quantitative score from the Patient Health Questionnaire, 9-item version, (PHQ-9) as a severity measure and found that higher scores correlated with lower functional status scores, greater numbers of sick days, and greater health care utilization. However, their methodology included as “positive” only those patients who met diagnostic criteria for MDD. Our use of an independent severity instrument identified an additional 17% of middle-ground patients who might benefit from close observation (“watchful waiting”) without the need for active management.
In summary, we believe that severity-targeted screening represents a promising “next step” in the evolution of office-based screening for depression in primary care. Much more work is needed to determine whether this “prompt to act” will be followed by improved treatment adherence and better treatment outcomes.
Acknowledgments
This project was supported in part by grants from the National Institute on Alcohol Abuse and Alcoholism (No. AA09496) and the Bureau of Health Professions, Health Resources and Services Administration (Nos. D32-PE16033 and D32-PE10158). The authors gratefully acknowledge the valuable feedback of James E. Aikens, PhD, during the preparation of this manuscript.
