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Case-Finding Instruments for Depression in Primary Care Settings

Cynthia D. Mulrow, MD, MSc; John W. Williams, MD, MHS; Meghan B. Gerety, MD; Gilbert Ramirez, DrPH; Oscar M. Montiel, MD; and Caroline Kerber, MD
[+] Article and Author Information

From the Audie L. Murphy Memorial Veterans Affairs Hospital, San Antonio, Texas. Requests for Reprints: Cynthia D. Mulrow, MD, MSc, Audie L. Murphy Memorial Veterans Hospital (11C6), 7400 Merton Minter Boulevard, San Antonio, TX 78284. Acknowledgments: The authors thank the many investigators who provided either raw data or reanalysis of data or who made unpublished information available. Grant Support: In part by a Robert Wood Johnson Generalist Physician Faculty Award and the Mexican American Medical Treatment Effectiveness Research Center funded by the Agency for Health Care Policy and Research.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1995;122(12):913-921. doi:10.7326/0003-4819-122-12-199506150-00004
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Objective: To evaluate the usefulness of case-finding instruments for identifying patients with major depression in primary care settings.

Data Sources: A MEDLINE search of the English-language medical literature; bibliographies of selected papers; and experts.

Study Selection: Studies that were done in primary care settings with unselected patients and that compared case-finding instruments with accepted diagnostic criterion standards for major depression were selected.

Data Synthesis: 9 case-finding instruments were assessed in 18 studies. More than 15 000 patients received screening with a case-finding instrument; approximately 5300 of these received criterion standard assessment. Case-finding instruments ranged in length from 2 to 28 questions. Average administration times ranged from less than 2 minutes to 6 minutes. Sensitivities and specificities for detecting major depression ranged from 67% to 99% and from 40% to 95%, respectively. No significant differences between instruments were found. Overall sensitivity was 84% (95% CI, 79% to 89%); overall specificity was 72% (CI, 67% to 77%). If a case-finding instrument were administered to 100 primary care patients with a 5% prevalence of major depression, the clinician could expect that 31 patients would screen positive, that 4 of the 31 would have major depression, and that 1 patient with major depression would not be identified.

Conclusions: Several instruments with reasonable operating characteristics are available to help primary care clinicians identify patients with major depression. Because the operating characteristics of these instruments are similar, 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.

Figures

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Figure 1.
Plot of true-positive rate against false-positive rate for case-finding instruments to detect major depression.[27]

The numbered data point represents the outlier study . The dashed curve represents the summary receiver-operating curve through all data points with the outlier study included; the solid curve represents the summary receiver-operating curve through all data points with the outlier study excluded.

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Figure 2.
Sensitivities of case-finding instruments (CFI) for identifying major depression.

Point estimates with 95% CIs are presented for single studies (•), for summary data on case-finding instruments (■), and overall (*symbol*). BDI = Beck Depression Inventory; CES-D = Center for Epidemiologic Studies Depression Screen; GHQ = General Health Questionnaire; HSCL = Hopkins Symptoms Checklist; MOS-D = Medical Outcomes Study Depression Screen; ID = Popoff Index of Depression; PRIME-MD = Primary Care Evaluation of Mental Disorders; SDDS-PC = Symptom Driven Diagnostic System-Primary Care; and SDS = Zung Self-Assessment Depression Scale.

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Figure 3.
Specificities of case-finding instruments (CFI) for identifying major depression.

Point estimates with 95% CIs are presented for single studies (•), for summary data on case-finding instruments (■), and overall (*symbol*). BDI = Beck Depression Inventory; CES-D = Center for Epidemiologic Studies Depression Screen; GHQ = General Health Questionnaire; HSCL = Hopkins Symptoms Checklist; MOS-D = Medical Outcomes Study Depression Screen; ID = Popoff Index of Depression; PRIME-MD = Primary Care Evaluation of Mental Disorders; SDDS-PC = Symptom Driven Diagnostic System-Primary Care; and SDS = Zung Self-Assessment Depression Scale.

Grahic Jump Location
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Figure 4.
Yield of case-finding instrument strategy.

Hypothetical group of 100 undiagnosed primary care clinic patients with 5% prevalence of major depression. Sensitivity of instrument is set at 80% and specificity at 72%.

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