Screening for depression in primary care: what do we still need to know?

The United States Preventive Services Task Force (USPSTF) recently issued the recommendation that primary care physicians screen adult patients for depression. A policy to screen primary care patients for depression has appeal as a strategy to reduce the personal and societal costs of undiagnosed and untreated depression. Such appeal may be justified if the evidence supports the screening policy in three areas: effectiveness, cost-effectiveness, and feasibility. The USPSTF recommendation leaves many issues in each of these areas unresolved and physicians are left the choice of two important program characteristics: screening instrument and screening interval. We discuss how uncertainties in the screening protocol and treatment process affect whether screening is an effective and cost-effective use of resources with respect to other health interventions. We suggest that targeting screening to groups at a higher risk for depression may lead to a more effective use of health care resources. A screening program may not be feasible even if effectiveness and cost-effectiveness are optimized. We discuss uncertainties in the USPSTF recommendation that affect the feasibility of implementing such a program in physicians' practices.     

Prevention of late-life depression in primary care: do we know where to begin?

OBJECTIVE: This study attempted to compare two models for selective (people at elevated risk) and indicated (those with subsyndromal depressive symptoms) prevention and to determine the optimal strategy for prevention of late-life depression. METHOD: Onset was assessed at 3 years with the Geriatric Mental State AGECAT in a randomly selected cohort of 1,940 nondepressed and nondemented older people in Amsterdam. Risk factors that can easily be identified in primary care were used. RESULTS: The association of risk factors with depression incidence was expressed in absolute and relative risk estimates, number needed to treat, and population-attributable fractions. Prevention models were identified with classification and regression tree analyses. In the indicated prevention model, subsyndromal symptoms of depression were associated with a risk of almost 40% of developing depression and a number needed to treat of 5.8, accounting for 24.6% of new cases. Adding more risk factors raised the absolute risk to 49.3%, with a lower number needed to treat but also lower attributable fraction values. In the selective prevention model, spousal death showed the highest risk, becoming even higher if the subjects also had a chronic illness. Overall, the attributable fraction values in the indicated model were higher, identifying more people at risk. CONCLUSIONS: Consideration of the costs and benefits of both models in the context of the availability of evidence-based preventative interventions indicated that prevention aimed at elderly people with depressive symptoms is preferred. The focus on treatment should be readdressed; a new approach is needed, with a stronger emphasis on prevention.     

Quality improvement for depression in primary care: do patients with subthreshold depression benefit in the long run?

OBJECTIVE: Quality improvement programs for depression can improve outcomes, but the utility of including patients with subthreshold depression in quality improvement programs is unclear. The authors examined 57-month effects of quality improvement on clinical outcomes and mental health care utilization of primary care patients with depressive disorder and subthreshold depression. METHOD: In a group-level, randomized, controlled trial, 46 primary care clinics were randomly assigned to provide usual care or care with a quality improvement intervention that included provider training and other resources for either medication management (medications quality improvement) or evidence-based psychotherapy (therapy quality improvement). Among 1,356 enrolled depressed patients, 991 completed the 57-month follow-up interview (604 patients with depressive disorder and 387 with subthreshold depression). Outcomes measured at 57 months were presence of probable depressive disorder, unmet need for appropriate care (untreated probable disorder), and mental health care utilization in the prior 6 months. RESULTS: Among patients with subthreshold depression at baseline, those seen in clinics with quality improvement programs with special resources for therapy were less likely to have probable depressive disorder and unmet need for care at follow-up, compared with those seen in clinics that provided usual care. Among patients with depressive disorder at baseline, those seen in clinics with quality improvement programs with special resources for medication management were less likely to have unmet need for care at follow-up, compared with those seen in clinics that provided usual care. Patients with subthreshold depression at baseline seen in clinics with a quality improvement intervention were less likely at follow-up to have had a mental health visit (in primary care or specialty care, depending on the intervention) in the prior 6 months. CONCLUSIONS: Relative to usual care, quality improvement interventions improved 57-month outcomes (probable depression, unmet need, or both) for primary care patients with depressive disorder and subthreshold depression and lowered use of mental health visits for those with subthreshold depression. The results highlight the feasibility and utility of including patients with subthreshold depression in such programs.     

Postpartum depression: do we still need this diagnostic term?

OBJECTIVE: The diagnostic term 'postpartum depression' is still widely used. This paper attempts to discuss if this is still justified in the light of recent research. METHOD: Comprehensive review of literature. RESULTS: Postpartum depression is not a specific entity in terms of having a specific aetiology. Rather, giving birth to a child with all its biological and psychosocial consequences seems to act as a major stressor, which - within a general vulnerability-stress model - can trigger the outbreak of the disease in predisposed women. Nevertheless, it might still be justified to continue the use of this diagnostic term, as depression in early motherhood confronts us with specific needs. Thus, help-seeking is often delayed due to shame and stigma, and diagnosis is often missed due to misinterpretation of symptoms. Services often do not meet these women's needs adequately, as they do not take into account their specific situation, problems and fears. Untreated, postpartum depression can have especially severe long-term consequences, not only for the mother but also for the child and the whole family. Therefore, special attention and special treatment is necessary. This necessitates modifications of our pharmacological, non-pharmacological and psychotherapeutic treatment and also provision of new low-threshold mother-infant services. CONCLUSION: Although postpartum depression is not a specific entity from an aetiological point of view, the diagnostic term [as 'specifier', as in the Diagnostic and Statistical Manual (DSM)-IV)] should not be abandoned, as depression in the postpartum period confronts us with specific needs for care.     

How well are DSM-5 diagnostic criteria for ASD represented in standardized diagnostic instruments?

Five years after the publication of DSM-5 in 2013, three widely used diagnostic instruments have published algorithms designed to represent its (sub-)criteria for Autism Spectrum Disorder (ASD) in children and adolescents. This study aimed to: (1) establish the content validity of these three DSM-5-adapted algorithms, and (2) identify problems with the operationalization of DSM-5 diagnostic criteria in measurable and observable behaviors. Algorithm items of the Autism Diagnostic Observation Schedule—Second Edition (ADOS-2), Developmental, Dimensional and Diagnostic Interview (3di) and Diagnostic Interview for Social and Communication Disorders—11th edition (DISCO-11) were mapped onto DSM-5 sub-criteria. The development and decision-making rules integrated in their algorithms were then compared with DSM-5. Results demonstrated significant variability in the number and nature of sub-criteria covered by the ADOS-2, 3di and DISCO-11. In addition to differences in the development of algorithms and cut-off scores, instruments also differed in the extent to which they follow DSM-5 decision-making rules for diagnostic classification. We conclude that such differences in interpretation of DSM-5 criteria provide a challenge for symptom operationalization which will be most effectively overcome by consensus, testing and reformulation.

     

Who refuses the diagnostic assessment for dementia in primary care?

OBJECTIVE: Early screening and detection of dementia in primary care remains controversial. At least half of the patients identified as cognitively impaired by screening instruments do not meet criteria for dementia and some patients refuse further evaluation following a positive screen. The aim of this study was to identify the characteristics of patients who refuse a clinical diagnostic assessment for dementia after screening. DESIGN: Cross sectional study. SETTING: Seven primary care practice centers in Indianapolis. PARTICIPANTS: Four hundred and thirty-four individuals aged 65 and older who screened positive for dementia with a mean age of 74.6, 67% women, and 68% African-American. MAIN OUTCOME MEASURE: Patients' acceptance of undergoing a dementia diagnostic assessment that included neuropsychological testing, caregiver interview, and medical chart review. RESULTS: Among patients with positive screening results for dementia, approximately half (47.7%) refused further assessment to confirm their screening results. In a bivariate analysis, possible factors associated with a higher probability of refusing dementia assessment were older age and better screening score. In a multiple logistic regression model, performing well on the temporal orientation of the screening instrument was associated with a higher probability of refusing diagnostic assessment for dementia (OR = 1.37; p = 0.001). Also, African-American patients aged 80 and older were more likely to refuse the diagnostic assessment than African-Americans less than 80 years of age (OR = 3.1, p < 0.001), while there was no significant age association for white patients (OR = 0.9, p = 0.728). CONCLUSIONS: Older primary care patients who perceived themselves as having no cognitive symptoms refused dementia diagnostic assessment despite their positive screening results. We must improve our understanding of the decision-making process driving patients' beliefs and behaviors about the benefits and risks of dementia screening and diagnosis before implementing any broad-based screening initiatives for dementia.     

Different diagnostic criteria for Parkinson disease: what are the pitfalls?

As there are no definite diagnostic tests or reliable biomarkers for Parkinson disease (PD), its diagnosis still relies on the presence of a combination of cardinal motor features, along with the exclusion of other causes of Parkinsonism and the presence of some of supportive features. To date, several diagnostic criteria have been developed for different purposes through expert opinions or comprehensive review of the literature. However, none of them are without limitations. In this article, we review different diagnostic criteria for PD which have been published in the English medical literature, highlighting specific limitations and pitfalls. With considerable progress in the understanding of PD, particularly in a view of diverse clinical symptomatology and its evolution, it will be difficult to establish a single criterion that is capable of capturing all cases at different disease stages. Rather, we should aim to develop a set of criteria which include a consensus on clinical gold standard or reliable biomarkers at different levels of diagnostic certainty for different purposes. Despite a more refined set of criteria that may aid in the recognition of PD, the accuracy of its diagnosis still largely depends on the observational skills and clinical sensitivity of the treating physician.     

Why do neuroprotective drugs work in animals but not humans?

Many neuroprotective agents that seemed promising in animal studies of ischemic brain injury prove to have no effect when tested in clinical trials, suggesting that fundamental elements of translational research require better definition. A number of modifications have led to improvements in preclinical and human studies since the earliest controlled trials failed to confirm hypotheses suggested by animal data. Continued re-evaluation and sharing of information derived from the laboratory bench or the patient's bedside should eventually lead to effective neuroprotection in acute stroke. Experimental data should be carefully studied to improve the quality of agents coming to clinical trials and to design trial phasing that effectively determines drug safety and efficacy. This article will examine preclinical modeling and its translation to prospective studies of acute stroke therapy and will focus on some potential solutions directed at clinical trial design.     

Screening for depression in primary care: Will one or two items suffice?

Abstract. Small differences in implementation of screening and the associated burden on clinicians and patients could have substantial effects on the sustainability of screening in routine primary care. Therefore, we investigated the psychometric properties of single items and two–item combinations of the WHO-5 Well Being Index (WHO-5) and compared the obtained characteristics to those of the original version as well as to another proposed two–item screener (developed from PRIME–MD and BPHQ, respectively).Screening and diagnostic interview data from 431 primary care patients were analysed. Main outcome measures were sensitivity, specificity and AUC values. All test characteristics were assessed using the diagnoses derived from the Composite International Diagnostic Interview (CIDI) as the criterion standard.Single–item screening questions proved rather inadequate. However, only marginal differences in performance were found between two questions and the longer screening instrument with respect to major depression, dysthymia and any depressive disorder. There were no statistically significant differences between these AUC values and most other test characteristics assessed.The results suggest that screening could be reduced to two questions with a potential advantage in terms of ease of administration and scoring and decreased staff and patient burden and perhaps a reduced stigma associated with a positive screening score.     

Why do you need to move beyond first-line therapy for major depression?

Primary care clinicians need to move beyond first-line therapy for major depression. While initial treatment is ineffective in about two-thirds of patients, patients who have not responded to such initial treatments can be managed effectively. The severity of depression is as high in primary care as in specialty care settings. The risk of depression is currently elevated because economic hardship, job insecurity, and low socioeconomic status increase the likelihood of depression and treatment resistance. Depression worsens outcomes for medical comorbidities, such as cardiac disease, chronic obstructive pulmonary disease, and diabetes mellitus, and it increases the risk of rehospitalization. When depression is treatment-resistant (generally defined as not responding to 2 courses of treatment of adequate dose and duration), morbidity and mortality are increased, quality of life and function are reduced, and long-term brain changes may occur. Opportunities for change in care are available. Screening for depression in primary care settings with staff-assisted support, adopting the concepts of the patient-centered medical home and stepped care, and using new treatment options such as atypical antipsychotics and other treatment modalities can improve outcomes for these patients. Now is the time to make these moves because new tools, systems, and treatments offer ways to help these patients.     

What leads to frequent re-hospitalisation when community care is not well developed?

BACKGROUND: Treatment programmes are largely hospital based in developing countries and yet research on factors predicting frequent re-hospitalisation remains scarce from them. This cross-sectional study of factors predictive of frequent re-hospitalisation explored whether factors reported from developed countries could apply to India. METHODS: Information was collected on four dimensions (socio-demographic, socio-cultural, treatment and illness variables) from 90 patients readmitted to a teaching psychiatric institute in India over a 3 month period. Patients were grouped into Frequently Re-hospitalised (FR) with three or more admissions to hospital in the last 18 months and Less Frequently Re-hospitalised (LFR) with two or fewer admissions in the last 18 months. RESULTS: Support available for treatment, days spent in hospital and cost of treatment had a significant effect on whether the patient was more frequently hospitalised. The place of domicile tended to have an effect on the frequency of hospitalisation. CONCLUSIONS: Factors predictive of frequent re-hospitalisation reported in this study differed from those in developed countries. The above variables identify high users of inpatient beds who may be targeted for specific interventions to reduce re-hospitalisation rates.     

Does depression precede or follow executive dysfunction? Outcomes in older primary care patients

OBJECTIVE: The authors sought to test the potentially reciprocal relationships between depression and executive dysfunction in older patients over time. METHOD: In this prospective 2-year cohort study, the authors enrolled 709 patients age 65 years and older who presented for primary care on selected days and gave informed consent. Of these, 431 and 284 patients completed follow-up interviews at 1 year and 2 years, respectively. The main outcome measures included depression diagnosis, and measures assessing selected components of executive functions: the initiation-perseveration subscale of the Mattis Dementia Rating Scale, Trail Making tests A and B, and D Trails (Trails B time minus Trails A time). RESULTS: No cognitive measure was significantly independently associated with depression diagnosis concurrently or in 1-year lagged outcomes. A diagnosis of depression was independently associated with concurrent poorer Trails B time and with both Trails B and D Trails times in 1-year lagged models. In path analyses testing 2-year competing dynamic models, no baseline executive function measure predicted the score on the Hamilton Depression Rating Scale (HAM-D), but HAM-D score independently predicted poorer Trails B and D Trails times. Overall medical burden also independently predicted both depressive and cognitive outcomes, but cerebrovascular risk factors only predicted Trails B time. CONCLUSIONS: Older persons with depression are at risk of subsequent decline in at least some aspects of executive functioning. The study's findings leave open the possibility that either neurobiological or psychosocial factors play prominent roles in the mechanisms underlying the course of geriatric depression.