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Recognition and identification of People with
  Depression - An update



       Alex Mitchell       ajm80@le.ac.uk
       Consultant in Liaison Psychiatry & Psycho-oncology


           Implementing the new NICE Guidance in IAPT services (London June 2010)
0. Introduction

    Background

    Quality of Care
Depression Care: Who Provides it?




                         2/3rds             1/3rd
                      Primary Care


                                  10%               25%
     cg42     cg90                Medical           Psychiatry
Percentage of U.S. retail psychotropic prescriptions written from August 2006 to jul07




              Mark et al. PSYCHIATRIC SERVICES September 2009 Vol. 60 No. 9
% Receiving Any treatment for Depression
  20

                                                                                                                   17.9
  18           n=84,850 face-to-face interviews
  16                                                                                                                                                      15.4

                                                                                                 13.8
  14


  12                          11.3
                       10.9                                                          10.9

  10
                                                      8.8
                                         8.1
      8                                                                                                                                                            7.2
                                                                                                           6.8

      6                                                                    5.6                                                                5.5

                                                                 4.3
      4                                                                                                                              3.4


      2


      0

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                                                                                                        Wang P et al (2007) Lancet 2007; 370: 841–50
94.2%




             37.4%




8 yrs   N= 9282 NCS‐R
N=23 studies; 50% some treatment 33% minimal treatment   N=19 studies; 30% 1 in 1/12;   10% 3 in 3 months
5 Steps to Improve QoC….and change clinical practice
  1. Look Again at Symptoms of Depression
   Too complex? Distress?


  2. Can We Afford to Detect Depression Routinely
   PC vs SC


  3. Does Enhanced Detection Work?
   Which tool?


  4. Depression in medical settings
   Special? Somatic symptoms?
1. Symptoms of Depression

   Back to Basics
Symptom Significance in Depression
Depression   ICD10        DSMIV          HADs D Score
Severity
Healthy      0 or 1       0 symptom      0-3
             symptom
Sub-syndromal 2 or 3      1 or No core   4-7
              symptoms    symptoms
Mild         4 symptoms   2-4 symptoms   8 -11
             (2+2)‫‏‬       (minor)‫‏‬
Moderate     (5 or )6     5 symptoms     12 - 15
             symptoms     (Mj)‫‏‬
Severe       (7 or) 8     Unspecified    16 - 21
             symptoms
             (3+4)‫‏‬
“Common” Symptoms of Depression

Item                           Depressed Frq   Non-Depressed Frq
Depressed mood                 0.93            0.18
Diminished drive               0.88            0.30
Loss of energy                 0.87            0.32
Concentration/indecision       0.87            0.27
Sleep disturbance              0.83            0.32
Diminished concentration       0.82            0.24


Diminished interest/pleasure   0.81            0.12
Insomnia                       0.70            0.27
Anxiety                        0.69            0.42
Worthlessness                  0.61            0.12
Psychic anxiety                0.59            0.33
Thoughts of death              0.56            0.12

                                                            Mitchell, Zimmerman et al n=2300
“Uncommon” Symptoms
                                                                  Non-Depressed
Item                             Depressed Proportion                Proportion


Somatic anxiety                            0.46                          0.25

Decreased appetite                         0.45                          0.11

Anger                                      0.44                          0.26

Psychomotor agitation                      0.34                          0.09

Psychomotor retardation                    0.28                          0.04

Decreased weight                           0.23                          0.06

Lack of reactive mood                      0.22                          0.06

Increased appetite                         0.19                          0.07

Hypersomnia                                0.19                          0.06

Increased weight                           0.16                          0.06



                          Mitchell, Zimmerman et al MIDAS Database. Psychol Med 2009
-0.10
                                                  0.00
                                                         0.10
                                                                0.20
                                                                       0.30
                                                                              0.40
                                                                                                                                                         0.50
                                     A nge
                                              r

                                   A nxie
                                             ty
             Decr
                 ea s e
                             d app
                                  eti te

                  Decr
                      ea s e
                                 d we
                                         ig ht

                    Depr
                        es sed
                                     m oo
                                              d
   Dimin
             is hed
                      c onc
                                 entr
                                        at ion
                                                                                                                       identifying non-depressed




                    Dimin
                             is hed
                                        dr ive
Dimin
        is hed
                  int er
                        est /p
                                   leasu
                                           re

                      Exc e
                               ss ive
                                         guilt


                           Help
                                le
                                                                                                                       Comment: Slide illustrates added value of each




                                     ss nes
                                           s
                                                                                                                       symptom when diagnosing depression and when




                           Hope
                                le   s snes
                                              s

                           Hy pe
                                 rsom
                                     n       ia
                 Inc re
                          ased
                                 appe
                                         t ite

                  Inc re
                           ased
                                   w eig
                                        ht

                      Indec
                                 isiv e
                                        ne   ss


                                 Ins om
                                           nia
         L ac k
                   of re
                           act iv
                                 e mo
                                      od

                      L os s
                               o f en
                                         erg y

                    Ps ych
                               i c an
                                        x iety
        Ps ych
                   omot
                           or a g
                                 i tatio
                                             n
           Ps ych
                     omot
                               or c h
                                        ang e
   Ps ych
          o      mot o
                       r   ret a
                                 rdatio
                                        n
                  Sl eep
                            dis tu
                                   rban
                                        ce

                    Soma
                             ti c a
                                    n   x iety
                                                                                                                        Rule-In Added Value (PPV-Prev)




                 Thou
                      g
                                                                                     Rule-Out Added Value (NPV-Prev)




                           hts o
                                 f dea
                                           th

                      Wor t
                           hle      s sne
                                             ss
1                  Depressed Mood
           S                   Diminished interest/pleasure
           e                            Diminished drive
 0.9       n
           s                                  Loss of energy
           i                                    Sleep disturbance
 0.8
           t                                      Diminished concentration
           i
 0.7       v
           i
           t
 0.6       y


 0.5


 0.4


 0.3                                                                 Comment: Slide illustrates summary ROC curve
                                                                     sensitivity/1-specficity plot for each mood
                                                                     symptom
 0.2


 0.1
                                                                                               1 - Specificity
  0
       0       0.1    0.2     0.3       0.4         0.5        0.6        0.7         0.8        0.9             1

n=1523
2. Recognition in Routine Care

   Is “diagnosis as usual” sufficient?
Sl e
                         ep
                             di s
                                 tur
                                       ban
                    Los                        ces
                          so                          ; in
                               fa                            som
                                  ppe                                   ni a
                    De                    ti te                               ; ea
                                                 ; ov                                 rly




                                                                                                                   0
                                                                                                                                10
                                                                                                                                                    20
                                                                                                                                                                         30
                                                                                                                                                                                             40
                                                                                                                                                                                                         50
                                                                                                                                                                                                                  60
                                                                                                                                                                                                                          70
                                                                                                                                                                                                                               80
                                                                                                                                                                                                                                                   90
                        pre
                              sse                       ere                                   wa                                                                                                                                                                  100
                                   dm                          a tin                                 ke n
                                           ood                          g; w                                  ing
                                                   ; ho                           e ig
                                                          pe                            ht c
         Los                    Ap                              les                               han                                                                                                                                               86.8
               so                    a th                               sne                                ges
                   f in                     y; l                               ss;
                        ter                       eth                                  sad
                            est                         arg
                                 ;w                             y; t                             ; gl
                                                                                                        oom
                                      ithd
                                              raw
                                                                        ired
                                                                                nes                               y
                                                     al ;                               s; l




                                                                                                                                                                                                              55.6 54.4
                              Los                           in d                               ass
                                   so                               iffe                                i tud
                                         fe                               ren                                   e
                                               ner                                ce;
                        Los                           gy;                                lo n




                                                                                                                                                                                                  43.3
                              so                             l os                                 eli n
                                  f lib                              so                                   ess
                                          ido                              f dr
                                                ; lo                               i ve




                                                                                                                                                                                             36
                                                      ss                                 ; bu
           An                                                of s                                  rnt
             xio                                                      ex                                   ou
                                                                                                                                                                                                                    Sleep



                  us;                                                       dri
                                                                                  ve;                            t
                        ag                                                                i mp




                                                                                                                                                                                      29.8
                            itat
                                ed;                          Te                                     ote
                                        irri t                     ars                                     nce
So                    Fe                      abl                          ;w
  ma                      eli n                      e; r                        eep
      tic;                                                  est                          ing
                                                                                                                                                                                                                     Appetite




           ve g                gw                                  l es                          ; cr
                eta                   ort                                 s, t                           yi n
                     tive                  hl e
                                                  ss;                            ens                            g
                           sym                           gui                            e; s
                                 pt o                          l ty;                              t re
                                                                                                                                                                                                                            Low




                                                                                                        sse
                                        ms
                                              ;m                         lac
                                                                               ko                               d
                                                     ala                             f se
                                                           i se
                                                                                                                                                                     26.2 25.6 25.2
                               Su                                 ;m                          lf e
                                   i ci d                                                             ste
            Los                                                           ulti
                                                                                 ple                        em
                  so                       e th
                                                  ou
                                                                                                                                                                                                                                                                        GP Asks about:




                       f co                                                             con
                                                                                                                                                                                                                              Energy



                                                                                                                                                               23.8


                             nce                        ght                                       sul
                                  ntr                         s; t                                      ta t
                                                                       hou                                     ion
                                        atio
                                                n; p                           ght                                  s
                                                                                      of
                                                                                                                                                                24




                           Dim                          oor                                  sel
                                 ini s                          me                                  f in
                                                                        mo                                 jur
                                        hed                                    ry,                               y
                                                  per                                 poo
                                                        f or                                   r th
                                                              ma                                       i nk
                                                                       nce                                    i ng
                                              Em                              ; in
                          Los                        otio                            abi
                                                                                                                                                         21.4 21.2




                                                            na                              li ty
                               so
                                    fa                             l la                              to
                                                                                                           cop
Be
   ha               Los                   ffec
                                                 t; f
                                                                          bil i
                                                                               ty;                                 e
     vi o                 so                           lat                            mo
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                                   njo                       a ff                             od
              l pr                       ym
                                                                    ect
                                                                          ; lo                        sw
                                                                                                            ing
                   obl
                        em                     ent                               ss                                s
                            s; a                       or                               of e
                                                                                                                                            13.9 12.8




                                  ggr                        pl e                                mo
                                         ess                         asu                                 tion
                                                ive                         re ;
                                                      nes                           lac
                                                                                                                                      9.5




                             Pe                                                           ko
                                                              s; b                                fh
                                 ssi                                   eh                                um
                                       mi s                                 avi                                 or
                                              m;                                   our
                                                    ne                                    al c
                                                                                                                                    7.2




                                                          gat                                      han
                                   Ps                            ive                                        ges
                                         ych                              atti
                                                                                 tud
                                                                                                                                7




    Ap                                          om                                     es,
       pe                                             oto                                        wo
           ara                                               r re                                      rry
                nce                                                   tar                                     ing
                     ; sp                                                   dat
                                                                                                                                7




                           eec                                                    i on
                                h; e                                                     ; sl
                                       xce                     He                                ow
                                                                                                        nes
                                              ssi
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                                                                       ada
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                                                          sm
                                                                                                                               5.9




                             He                                                        s; d
                                 avy                              i li n                        izz
                                                                          g; v                        i ne
                                          use                                    ag                           ss
                                                   of a                               uen
                                                                                                                              4.8




                                                          l co                                  ess
                                   De                             hol                                   , et
                                         l us                            , to                                   c.
                                               i on                             bac
                         Re                                                             co
                                                                                                                              4.1




                                                      s; h
                              act                            all u                             or
                                  ion                                  ci n                           dru
                                          to p                              atio                              gs
                                                  rob                                ns;
                                                                                                                         2.6




                                                        abl                                  con
                                   Fa                          ec                                     fus
                                        mil                            aus                                    ion
                                              yo                               es
                                                                                      or
                                                                                                                         1.8




                                                     r pa                                   life
                                                             st h
                                                                                                                                                                                                                               looking for depression




                                                                      i sto                          eve
                                                                             ry                              nts
                                                  Ob                               of d
                                                                                                                         1.8




                                                        ses                                 epr
                                                                si v                                ess
                                                                        e id                                i on
                                                                               eat
                                                                                                                        1.3




                                                                                      i on
                                                                                              ; ph
                                                                                                      ob
                                                                                                             ias
                                                                                                                                                                                                                               Comment: Slide illustrates which




                                                                                 Lac
                                                                                                                                                                                                                               symptoms are asked about by GPS




                                                                                                                        0.9




                                                      Pe                                ko
                                                            ri o                                f in
                                                                  do                                   sig
                                                                          f l if                               ht
                                                                                e(
                                                                                                                        0.4




                                                                                      me
                                                                                              no
                                                                                                    pau
                                                                                                             se )
                                                                                                                        0.4
GP Recognizes:
                            Proportion of Individual Symptoms Recognised by GPs


80.0      76.1

70.0

60.0

50.0

40.0                 36.4
                             34.6
                                        31.6
30.0
                                                  21.6
20.0                                                             16.7
                                                                              13.3
                                                                                           9.1           8.3          8.3
10.0

 0.0
                                       s




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                                                                  O’Conner et al (2001) Depression in primary care.
                                                                  Int Psychogeriatr 13(3) 367-374.
GP Detection of Depression – Meta-analysis

Methods
   – 140 studies of GP recognition
     rate =>

   –   90 depression
   –   40 interview
   –   19 se sp (+2)
   –   10 countries
Accuracy 2x2 Table
             Depression    Depression
             PRESENT       ABSENT


  Test +ve   True +ve      False +ve     PPV



  Test -ve   False -Ve     True -Ve      NPV



             Sensitivity   Specificity   Prevalence
N=35 studies
Accuracy of GP’s Diagnoses

         Depression    Depression
         PRESENT       ABSENT

GP +ve   2503          2515           5018
                                                          PPV 42.8%

GP -ve   4050          25,125         6678
                                                          NPV 85.1%

         6553          27,640         9559



         Sensitivity    Specificity
                                        Prevalence 19%
         48%            80.1%
N = 100
                        100 weekly referrals
GP Opinion                           n = 20                                n = 80
                        20 D                         80 ND

                                                                       Se 50%
                        GP Assessment                                  Sp 80%


                                        Screen #1    Screen #1
                                        +ve          -ve



              PPV 28%                                            NPV 88%



                           TP = 10                                                  TN =64
       10TP 10FN           FP = 16
                                                    64TN 16FP                       FN = 10




             50% TP and 25% FP Offered Treatment

                   50‐80% accept initial treatment
N = 100
                             100 weekly referrals
GP Notation                               n = 20                                n = 80
                             20 D                         80 ND

                                                                            Se 30%
                             GP Assessment                                  Sp 90%


                                             Screen #1    Screen #1
                                             +ve          -ve



                   PPV 50%                                            NPV 80%



                                TP = 10                                                  TN =64
       7TP 13FN                 FP = 16
                                                         72TN 8FP                        FN = 10




                  50% TP and 25% FP Offered Treatment

                        50‐80% accept initial treatment

      3/20TP Offered Rx => appropriate treatment rate of 5-20%

       2/80FP Offered Rx => inappropriate treatment rate of 1-2%

        1/3 of screen positive patients with no treatment well
                             at follow‐up
N = 100
                            Weekly Population
                                              n = 20                                       n = 80
                           Depression                          No Depression
77%
                                                                                         Se 50%
                            GP Assessment                                                Sp 80%


                                                 Screen #1     Screen #1
                                                 +ve           -ve



                PPV 28%                                                          NPV 88%



                                 TP = 10                                                              TN =64
      Possible case              FP = 16
                                                             Probable Non-Case                        FN = 10




                                            Se 50%
      2nd Assessment                        Sp 80%


             Screen #2    Screen #2
             +ve          +ve




                PPV 44%                                                        NPV 77%



                                           TP = 56                                                   TN =288

89%   Probable Depression                  FP = 72
                                                             Probable Non-Case                       FN = 84




                                                              TN = 728     FP = 72          Se 28%    PPV 44%
                  Cumulative Yield                            TP = 56      FN = 144         Sp 91%    NPV 83%
Predictors of Recognition
 Prevalence
  10% rural 15% mean 20% urban 20% (oncology 25%)
 Severity
  70% mild 20% moderate 10% severe
 International
  Low in developing but in Western:
  Italy > Netherlands >Australia > UK > US
 Contact
  Cummulative: 77% single 89% 3-6 months
  Appointment Duration
0.05
                                    0.15
                                                                                       0.25




                   0
                              0.1
                                                                   0.2
                                                                                                       0.3
         Ei
           gh
             t

         N
             in
               e

           Te
              n

       El
         ev
              en

      Tw
           el
              ve
     Th
        irt
           ee
                                                                                              HADS-D




              n
 Fo
    ur
       te
         en

       Fi
          fte
             en

      Si
        xt
          ee
            n
Se
   ve
      nt
                                                                   Proportion Missed




        ee
              n
                                           Proportion Recognized




 Ei
    gh
      te
         en
 N
   in
     et
       ee
          n
      Tw
           en
Tw            ty
     en
        ty
          -o
             ne
IAPT10 - Detecting depression - an update (June10)
80
           74
                         70    69.6
70

                                          61.5
                                                     59.6
60                                                                56.7        56.7          55.6
                                                                                                   54.2

50                                                                                                           45.7
                                                                                                                          43.9
                                                                                                                                   39.7
40


30                                                                                                                                            28.4

                                                                                                                                                      22.2
                                                                                                                                                                   21
                                                                                                                                                                            19.3
20


10


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                                                                                                   Recognition from WHO PPGHC Study (Ustun, Goldberg et al)
0.25
                         65%
                                          0.22
                               0.21
                                                     0.20
                    0.19
0.20



0.15



0.10


                                                                0.05
0.05
         0.03
                                                                           0.02       0.02
                                                                                                 0.01                  0.01
                                                                                                            0.01                  0.01       0.01       0.01

0.00
                    s


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  5m

             10


                        15


                                   20


                                              25


                                                         30


                                                                    35


                                                                               40


                                                                                          45


                                                                                                     50


                                                                                                                55


                                                                                                                           60


                                                                                                                                      65


                                                                                                                                                 70
IAPT10 - Detecting depression - an update (June10)
Detection in Hospital Settings
  CNS in oncology; n=402

  Chemotherapy and community nurses

  Bayesian analysis
100.0
                                                                                  5.9
                                                                                                11.1
                                                                                                              14.3
 90.0      Comment: Slide illustrates diagnostic                         21.4
           accuracy according to score on DT                                     11.8
                                                                  25.9


 80.0                                               38.7   38.1
                                43.5                                                            22.2          14.3
                                             46.7


 70.0               59.6
                                                                         21.4

        72.4
 60.0                                                                                   Judgement = Non-distressed
                                                                  33.3                  Judgement = Unclear
                                                    19.4   19.0                         Judgement = Distressed
 50.0

                                26.1
                                             24.4                                82.4
 40.0
                                                                                                              71.4
                                                                                                66.7
 30.0
                    25.0                                                 57.1


                                                    41.9   42.9   40.7
 20.0   15.8

                                30.4        28.9
 10.0
                   15.4
        11.8

  0.0
        Zero       One          Two         Three   Four   Five   Six    Seven   Eight          Nine          Ten
1.00



           Post-test Probability
                                         GP+
                                         GP-
0.90                                     Baseline Probability
                                         Nurse+
                                         Nurse-
0.80                                     Oncologist+
                                         Oncologists-

0.70



0.60



0.50



0.40



0.30                                                                                    Comment: Doctors appear to be more
                                                                                        successful at ruling-in or giving a
                                                                                        diagnosis, nurses more successful at
0.20                                                                                    ruling out


0.10

                                                                                                                  Pre-test Probability
0.00
       0                           0.1            0.2           0.3   0.4   0.5   0.6         0.7          0.8          0.9              1
3. Enhanced Detection Strategies

   Does Screening Work?
Methods to Evaluate Depression



                    Unassisted Clinician                                                                                                              Conventional Scales

            Untrained Trained                                                                                                                             Short (5-10)‫ ‏‬Long (10+)‫‏‬
                                Other/Uncertain
                                                                            Ultra-Short (<5)‫‏‬
                                      9%
   ICD10/DSMIV
       0%

Short QQ
  3%                                                                                                             Other/Uncertain                                                                   Other/Uncertain
                                                                                                                       9%                                                                                9%
                                                                                    ICD10/DSMIV                                                                       ICD10/DSMIV
                                                                                         0%                                                                                0%

                                                                                 Short QQ                                                                          Short QQ
             1,2 or 3 Sim ple
                                                                                   3%                                                                                3%
                    QQ
                   15%




                                             Clinical Skills                                  1,2 or 3 Sim ple                                                                  1,2 or 3 Sim ple
                                                 Alone                                               QQ                                                                                QQ
                                                  73%                                               15%                                                                               15%




                                                                                                                               Clinical Skills                                                                   Clinical Skills
                                                                                                                                   Alone                                                                             Alone
                                                                                                                                    73%                                                                               73%




                                                               Verbal Questions                                              Visual-Analogue Test

                                                                  PHQ2                                                                       Distress Thermometer

                                                                  WHO-5                                                                          Depression Thermometer

                                                                  Whooley/NICE
IAPT10 - Detecting depression - an update (June10)
1.00                                                                                                      HADS+



            Post-test Probability
                                                                                                           HADS-
                                                                                                           Baseline Probability
 0.90
                                                                                                           GDS30+
                                                                                                           GDS30-
 0.80                                                                                                      GDS15+
                                                                                                           GHQ28+
                                                                                                           HDRS+
 0.70
                                                                                                           ZUNG+

                                                                                                           GDS15-

 0.60                                                                                                      GHQ28-
                                                                                                           HDRS-

                                                                                                           ZUNG-
 0.50
                                                                                                           PHQ9+
                                                                                                           PHQ9-

 0.40                                                                                                      WHOOLEY2Q+
                                                                                                           WHOOLEY2Q-
                                                                                                           BDI+
 0.30                                                                                                      BDI-
                                                                                                           BDI-SF+

 0.20                                                                                                      BDI-SF-
                                                                                                           CESD+
                                                                                                           CESD-
 0.10                                                                                                      1Q+
                                                                                                           1Q-
                                                                                    Pre-test Probability
                                                                                                           GHQ12+
 0.00
        0                           0.1   0.2   0.3   0.4   0.5   0.6   0.7   0.8         0.9          1   GHQ12-




Rule-in
IAPT10 - Detecting depression - an update (June10)
IAPT10 - Detecting depression - an update (June10)
Comment: Slide illustrates actual gain in
meta-analysis of screening
implementation in primary care
1.00



           Post-test Probability
                                         Clinical+
                                         Clinical-
0.90                                     Baseline Probability
                                         Screen+
                                         Screen-
0.80



0.70



0.60



0.50



0.40


                                                                                        Comment: Slide illustrates Bayesian
0.30                                                                                    curve comparison from RCT studies of
                                                                                        clinician with and without screening

0.20                                                                                    This illustrates ACTUAL gain from
                                                                                        screening in Study from Christensen

0.10


                                                                                                                 Pre-test Probability
0.00
       0                           0.1               0.2        0.3   0.4   0.5   0.6        0.7          0.8          0.9              1
4. Summary

   Over and under-diagnosed

   Symptoms imperfect and hard to remember

   Screening works with enhancements

   Quality of care is key
=86.4%            =82.2%




Beals AGP 2004       =57.6%

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IAPT10 - Detecting depression - an update (June10)

  • 1. Recognition and identification of People with Depression - An update Alex Mitchell ajm80@le.ac.uk Consultant in Liaison Psychiatry & Psycho-oncology Implementing the new NICE Guidance in IAPT services (London June 2010)
  • 2. 0. Introduction Background Quality of Care
  • 3. Depression Care: Who Provides it? 2/3rds 1/3rd Primary Care 10% 25% cg42 cg90 Medical Psychiatry
  • 4. Percentage of U.S. retail psychotropic prescriptions written from August 2006 to jul07 Mark et al. PSYCHIATRIC SERVICES September 2009 Vol. 60 No. 9
  • 5. % Receiving Any treatment for Depression 20 17.9 18 n=84,850 face-to-face interviews 16 15.4 13.8 14 12 11.3 10.9 10.9 10 8.8 8.1 8 7.2 6.8 6 5.6 5.5 4.3 4 3.4 2 0 SA in n ly na ca m e l a y ne ce e nd e s m bi pa an m It a a nd ra u hi i an U ai la Sp fr co om gi co Ja m Is C kr rla A a Fr el In er In Ze ol U h B he G ut w h C ew et ig Lo So H N N Wang P et al (2007) Lancet 2007; 370: 841–50
  • 6. 94.2% 37.4% 8 yrs N= 9282 NCS‐R
  • 7. N=23 studies; 50% some treatment 33% minimal treatment N=19 studies; 30% 1 in 1/12; 10% 3 in 3 months
  • 8. 5 Steps to Improve QoC….and change clinical practice 1. Look Again at Symptoms of Depression Too complex? Distress? 2. Can We Afford to Detect Depression Routinely PC vs SC 3. Does Enhanced Detection Work? Which tool? 4. Depression in medical settings Special? Somatic symptoms?
  • 9. 1. Symptoms of Depression Back to Basics
  • 10. Symptom Significance in Depression Depression ICD10 DSMIV HADs D Score Severity Healthy 0 or 1 0 symptom 0-3 symptom Sub-syndromal 2 or 3 1 or No core 4-7 symptoms symptoms Mild 4 symptoms 2-4 symptoms 8 -11 (2+2)‫‏‬ (minor)‫‏‬ Moderate (5 or )6 5 symptoms 12 - 15 symptoms (Mj)‫‏‬ Severe (7 or) 8 Unspecified 16 - 21 symptoms (3+4)‫‏‬
  • 11. “Common” Symptoms of Depression Item Depressed Frq Non-Depressed Frq Depressed mood 0.93 0.18 Diminished drive 0.88 0.30 Loss of energy 0.87 0.32 Concentration/indecision 0.87 0.27 Sleep disturbance 0.83 0.32 Diminished concentration 0.82 0.24 Diminished interest/pleasure 0.81 0.12 Insomnia 0.70 0.27 Anxiety 0.69 0.42 Worthlessness 0.61 0.12 Psychic anxiety 0.59 0.33 Thoughts of death 0.56 0.12 Mitchell, Zimmerman et al n=2300
  • 12. “Uncommon” Symptoms Non-Depressed Item Depressed Proportion Proportion Somatic anxiety 0.46 0.25 Decreased appetite 0.45 0.11 Anger 0.44 0.26 Psychomotor agitation 0.34 0.09 Psychomotor retardation 0.28 0.04 Decreased weight 0.23 0.06 Lack of reactive mood 0.22 0.06 Increased appetite 0.19 0.07 Hypersomnia 0.19 0.06 Increased weight 0.16 0.06 Mitchell, Zimmerman et al MIDAS Database. Psychol Med 2009
  • 13. -0.10 0.00 0.10 0.20 0.30 0.40 0.50 A nge r A nxie ty Decr ea s e d app eti te Decr ea s e d we ig ht Depr es sed m oo d Dimin is hed c onc entr at ion identifying non-depressed Dimin is hed dr ive Dimin is hed int er est /p leasu re Exc e ss ive guilt Help le Comment: Slide illustrates added value of each ss nes s symptom when diagnosing depression and when Hope le s snes s Hy pe rsom n ia Inc re ased appe t ite Inc re ased w eig ht Indec isiv e ne ss Ins om nia L ac k of re act iv e mo od L os s o f en erg y Ps ych i c an x iety Ps ych omot or a g i tatio n Ps ych omot or c h ang e Ps ych o mot o r ret a rdatio n Sl eep dis tu rban ce Soma ti c a n x iety Rule-In Added Value (PPV-Prev) Thou g Rule-Out Added Value (NPV-Prev) hts o f dea th Wor t hle s sne ss
  • 14. 1 Depressed Mood S Diminished interest/pleasure e Diminished drive 0.9 n s Loss of energy i Sleep disturbance 0.8 t Diminished concentration i 0.7 v i t 0.6 y 0.5 0.4 0.3 Comment: Slide illustrates summary ROC curve sensitivity/1-specficity plot for each mood symptom 0.2 0.1 1 - Specificity 0 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 n=1523
  • 15. 2. Recognition in Routine Care Is “diagnosis as usual” sufficient?
  • 16. Sl e ep di s tur ban Los ces so ; in fa som ppe ni a De ti te ; ea ; ov rly 0 10 20 30 40 50 60 70 80 90 pre sse ere wa 100 dm a tin ke n ood g; w ing ; ho e ig pe ht c Los Ap les han 86.8 so a th sne ges f in y; l ss; ter eth sad est arg ;w y; t ; gl oom ithd raw ired nes y al ; s; l 55.6 54.4 Los in d ass so iffe i tud fe ren e ner ce; Los gy; lo n 43.3 so l os eli n f lib so ess ido f dr ; lo i ve 36 ss ; bu An of s rnt xio ex ou Sleep us; dri ve; t ag i mp 29.8 itat ed; Te ote irri t ars nce So Fe abl ;w ma eli n e; r eep tic; est ing Appetite ve g gw l es ; cr eta ort s, t yi n tive hl e ss; ens g sym gui e; s pt o l ty; t re Low sse ms ;m lac ko d ala f se i se 26.2 25.6 25.2 Su ;m lf e i ci d ste Los ulti ple em so e th ou GP Asks about: f co con Energy 23.8 nce ght sul ntr s; t ta t hou ion atio n; p ght s of 24 Dim oor sel ini s me f in mo jur hed ry, y per poo f or r th ma i nk nce i ng Em ; in Los otio abi 21.4 21.2 na li ty so fa l la to cop Be ha Los ffec t; f bil i ty; e vi o so lat mo ura fe njo a ff od l pr ym ect ; lo sw ing obl em ent ss s s; a or of e 13.9 12.8 ggr pl e mo ess asu tion ive re ; nes lac 9.5 Pe ko s; b fh ssi eh um mi s avi or m; our ne al c 7.2 gat han Ps ive ges ych atti tud 7 Ap om es, pe oto wo ara r re rry nce tar ing ; sp dat 7 eec i on h; e ; sl xce He ow nes ssi ve ada che s sm 5.9 He s; d avy i li n izz g; v i ne use ag ss of a uen 4.8 l co ess De hol , et l us , to c. i on bac Re co 4.1 s; h act all u or ion ci n dru to p atio gs rob ns; 2.6 abl con Fa ec fus mil aus ion yo es or 1.8 r pa life st h looking for depression i sto eve ry nts Ob of d 1.8 ses epr si v ess e id i on eat 1.3 i on ; ph ob ias Comment: Slide illustrates which Lac symptoms are asked about by GPS 0.9 Pe ko ri o f in do sig f l if ht e( 0.4 me no pau se ) 0.4
  • 17. GP Recognizes: Proportion of Individual Symptoms Recognised by GPs 80.0 76.1 70.0 60.0 50.0 40.0 36.4 34.6 31.6 30.0 21.6 20.0 16.7 13.3 9.1 8.3 8.3 10.0 0.0 s ng a d gy s ia st ty ism es oo si ni ex re xie pi er ia m ln m m te Co or en dr An so fu in i An w ss on ar In t of Lo No of Pe Te ch ss ss po Lo Lo Hy O’Conner et al (2001) Depression in primary care. Int Psychogeriatr 13(3) 367-374.
  • 18. GP Detection of Depression – Meta-analysis Methods – 140 studies of GP recognition rate => – 90 depression – 40 interview – 19 se sp (+2) – 10 countries
  • 19. Accuracy 2x2 Table Depression Depression PRESENT ABSENT Test +ve True +ve False +ve PPV Test -ve False -Ve True -Ve NPV Sensitivity Specificity Prevalence
  • 20. N=35 studies Accuracy of GP’s Diagnoses Depression Depression PRESENT ABSENT GP +ve 2503 2515 5018 PPV 42.8% GP -ve 4050 25,125 6678 NPV 85.1% 6553 27,640 9559 Sensitivity Specificity Prevalence 19% 48% 80.1%
  • 21. N = 100 100 weekly referrals GP Opinion n = 20 n = 80 20 D 80 ND Se 50% GP Assessment Sp 80% Screen #1 Screen #1 +ve -ve PPV 28% NPV 88% TP = 10 TN =64 10TP 10FN FP = 16 64TN 16FP FN = 10 50% TP and 25% FP Offered Treatment 50‐80% accept initial treatment
  • 22. N = 100 100 weekly referrals GP Notation n = 20 n = 80 20 D 80 ND Se 30% GP Assessment Sp 90% Screen #1 Screen #1 +ve -ve PPV 50% NPV 80% TP = 10 TN =64 7TP 13FN FP = 16 72TN 8FP FN = 10 50% TP and 25% FP Offered Treatment 50‐80% accept initial treatment 3/20TP Offered Rx => appropriate treatment rate of 5-20% 2/80FP Offered Rx => inappropriate treatment rate of 1-2% 1/3 of screen positive patients with no treatment well at follow‐up
  • 23. N = 100 Weekly Population n = 20 n = 80 Depression No Depression 77% Se 50% GP Assessment Sp 80% Screen #1 Screen #1 +ve -ve PPV 28% NPV 88% TP = 10 TN =64 Possible case FP = 16 Probable Non-Case FN = 10 Se 50% 2nd Assessment Sp 80% Screen #2 Screen #2 +ve +ve PPV 44% NPV 77% TP = 56 TN =288 89% Probable Depression FP = 72 Probable Non-Case FN = 84 TN = 728 FP = 72 Se 28% PPV 44% Cumulative Yield TP = 56 FN = 144 Sp 91% NPV 83%
  • 24. Predictors of Recognition Prevalence 10% rural 15% mean 20% urban 20% (oncology 25%) Severity 70% mild 20% moderate 10% severe International Low in developing but in Western: Italy > Netherlands >Australia > UK > US Contact Cummulative: 77% single 89% 3-6 months Appointment Duration
  • 25. 0.05 0.15 0.25 0 0.1 0.2 0.3 Ei gh t N in e Te n El ev en Tw el ve Th irt ee HADS-D n Fo ur te en Fi fte en Si xt ee n Se ve nt Proportion Missed ee n Proportion Recognized Ei gh te en N in et ee n Tw en Tw ty en ty -o ne
  • 27. 80 74 70 69.6 70 61.5 59.6 60 56.7 56.7 55.6 54.2 50 45.7 43.9 39.7 40 30 28.4 22.2 21 19.3 20 10 0 ns L ri s i n a n r go z an ai a tle re ro ak te TA ge ar n rli n gh he lo Pa ai i ad ia ro at es as ne k Be in TO ga M nt An an Se At Ve Ib ch g Ja n Sa n Na ro Sh an Ba de G M o Ri Recognition from WHO PPGHC Study (Ustun, Goldberg et al)
  • 28. 0.25 65% 0.22 0.21 0.20 0.19 0.20 0.15 0.10 0.05 0.05 0.03 0.02 0.02 0.01 0.01 0.01 0.01 0.01 0.01 0.00 s s s s s s s s s s s s s s in in in in in in in in in in in in in in m m m m m m m m m m m m m 5m 10 15 20 25 30 35 40 45 50 55 60 65 70
  • 30. Detection in Hospital Settings CNS in oncology; n=402 Chemotherapy and community nurses Bayesian analysis
  • 31. 100.0 5.9 11.1 14.3 90.0 Comment: Slide illustrates diagnostic 21.4 accuracy according to score on DT 11.8 25.9 80.0 38.7 38.1 43.5 22.2 14.3 46.7 70.0 59.6 21.4 72.4 60.0 Judgement = Non-distressed 33.3 Judgement = Unclear 19.4 19.0 Judgement = Distressed 50.0 26.1 24.4 82.4 40.0 71.4 66.7 30.0 25.0 57.1 41.9 42.9 40.7 20.0 15.8 30.4 28.9 10.0 15.4 11.8 0.0 Zero One Two Three Four Five Six Seven Eight Nine Ten
  • 32. 1.00 Post-test Probability GP+ GP- 0.90 Baseline Probability Nurse+ Nurse- 0.80 Oncologist+ Oncologists- 0.70 0.60 0.50 0.40 0.30 Comment: Doctors appear to be more successful at ruling-in or giving a diagnosis, nurses more successful at 0.20 ruling out 0.10 Pre-test Probability 0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  • 33. 3. Enhanced Detection Strategies Does Screening Work?
  • 34. Methods to Evaluate Depression Unassisted Clinician Conventional Scales Untrained Trained Short (5-10)‫ ‏‬Long (10+)‫‏‬ Other/Uncertain Ultra-Short (<5)‫‏‬ 9% ICD10/DSMIV 0% Short QQ 3% Other/Uncertain Other/Uncertain 9% 9% ICD10/DSMIV ICD10/DSMIV 0% 0% Short QQ Short QQ 1,2 or 3 Sim ple 3% 3% QQ 15% Clinical Skills 1,2 or 3 Sim ple 1,2 or 3 Sim ple Alone QQ QQ 73% 15% 15% Clinical Skills Clinical Skills Alone Alone 73% 73% Verbal Questions Visual-Analogue Test PHQ2 Distress Thermometer WHO-5 Depression Thermometer Whooley/NICE
  • 36. 1.00 HADS+ Post-test Probability HADS- Baseline Probability 0.90 GDS30+ GDS30- 0.80 GDS15+ GHQ28+ HDRS+ 0.70 ZUNG+ GDS15- 0.60 GHQ28- HDRS- ZUNG- 0.50 PHQ9+ PHQ9- 0.40 WHOOLEY2Q+ WHOOLEY2Q- BDI+ 0.30 BDI- BDI-SF+ 0.20 BDI-SF- CESD+ CESD- 0.10 1Q+ 1Q- Pre-test Probability GHQ12+ 0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 GHQ12- Rule-in
  • 39. Comment: Slide illustrates actual gain in meta-analysis of screening implementation in primary care
  • 40. 1.00 Post-test Probability Clinical+ Clinical- 0.90 Baseline Probability Screen+ Screen- 0.80 0.70 0.60 0.50 0.40 Comment: Slide illustrates Bayesian 0.30 curve comparison from RCT studies of clinician with and without screening 0.20 This illustrates ACTUAL gain from screening in Study from Christensen 0.10 Pre-test Probability 0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  • 41. 4. Summary Over and under-diagnosed Symptoms imperfect and hard to remember Screening works with enhancements Quality of care is key
  • 42. =86.4% =82.2% Beals AGP 2004 =57.6%