This is an academic (evidence-based) talk from 2007 re diagnosis and screening for depression. It is from the 17TH ANNUAL PSYCHIATRIC PHARMACY PROGRAMME

1. Alex Mitchell alex.mitchell@leicspart.nhs.uk
Consultant in Liaison Psychiatry
Monitoring to Improve Long Term Outcomes
in Schizophrenia and Depression (September 2006)
17TH ANNUAL PSYCHIATRIC PHARMACY PROGRAMME

2. Addition: Comparison of Scale Scores
47–4939–4133–35262665–6763-654
45–4637–3832252562–2460-624
42–4435–3630–31242459–6157-594
40–4133–3429232356–5854-564
393228222254–5552-534
35–3829–3126–27212149–5347-514 (v Severe)
342825202048463
332724191946–4744-453
31–322623181844–4542-433
29–3024–2521–22171741–4340-413
303527–282320161639–4037-393 (severe)
2934262218–19151537–38362
24–2520–2118–19141434–3633-352
22–2318–1917131331–3330-322
20–211716121229–3028-292
1920191614–15111126–2824-272 (Moderate)
181917–1814–1513101024–25231
15–1613129922–2321-221
13–1411–12118819–2118-201
12109–107717–1816-171
10710–11986614–1612-151 (Mild)
968–97–875512–13110
6–75–65–6449–119-100
544337–87-80
3–43322660
221–2114–54-50
000–10–10000–30-30 (None)
BDIMADRSHRSD24HRSD21HRSD17QIDS-SR16QIDS-C16IDS-SR30IDS-C30Severity1

3. Audience
What % Receive Any Treatment for Depression (12mo)?
What % Receive Adequate Treatment?
What % Receive Specialist Treatment?

4. GP Recognition of Individual symptom
Proportion of Individual Symptoms Recognised by GPs
76.1
36.4
34.6
31.6
21.6
16.7
13.3
9.1 8.3 8.3
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
Low
m
ood
Insom
niaHypochondriasisLoss
ofinterest
Tearfulness
Anxiety
Loss
ofenergy
Pessim
ism
Anorexia
NotCoping
O’Conner et al (2001) Depression in primary care.
Int Psychogeriatr 13(3) 367-374.

5. % Receiving Any treatment for Depression
10.9
11.3
8.1
8.8
4.3
5.6
10.9
13.8
6.8
17.9
3.4
5.5
15.4
7.2
0
2
4
6
8
10
12
14
16
18
20
High
Incom
e
B
elgium
France
G
erm
any
Israel
Italy
JapanN
etherlandsN
ew
Zealand
Spain
U
SALow
Incom
e
China
C
olom
biaSouth
Africa
U
kraine
Wang P et al (2007) Lancet 2007; 370: 841
n=84,850 face-to-face interviews

6. Contents
What Do We Mean by Depression?
Mild Moderate Severe Major etc
What Are the Symptoms of Depression?
Cf the non-depressed
Who is Looking for Depression?
GPs, PCPs
How to Detect Depression
Accuracy, assisted vs unassisted methods
Developments in Screening
Ultra-screening – primary / secondary

7. What Do We Mean by Depression?
Mild Moderate Severe Major etc
Audience:
How many symptoms until someone becomes a case?
How many symptoms are common after a life-event?
=> Cancer

9. Distribution of DT Scores
Ransom (2006) PO (n=491)
13.8
14.7
15.7
13.2
10.4
8.4
7.7
7.3
3.7
3.3
1.8
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
Score 0 Score 1 Score 2 Score 3 Score 4 Score 5 Score 6 Score 7 Score 8 Score 9 Score 10
Gessler, Lowe Psycho-oncology (in press 2008)

10. Symptom Significance in Depression
16 - 217 symptoms (3+4)Severe
12 - 155 or 6 symptomsModerate
8 -114 symptoms (2+2)Mild
4 - 72 or 3 symptomsSub-syndromal
0 - 30 or 1 symptomHealthy
HADs ScoreICD10Depression Severity
=> HADS

11. => Symptoms

12. What Are the Symptoms of Depression?
=> Audience

13. Lost Symptoms of Depression
Loss of confidence
Low motivation / drive
Withdrawal
Avoidance
Social isolation
Worry
Feelings of dread
Helplessness
Hopelessness
Psychic anxiety
Somatic anxiety
Anger
Lack of reactive mood
Cognitive Change (=> memory complaints)
Perceptual distortion
Which Are Recognized Symptoms of MDD?
=> ICD10

14. YesYesGuilt or self-blame
DSMIVICD10Core Symptoms
YesNoSignificant change in weight
YesYesAgitation or slowing of
movements
YesYesSuicidal thoughts or acts
NoYesPoor or increased appetite
NoYesLow self-confidence
YesYesPoor concentration or
indecisiveness
YesYesDisturbed sleep
YesYes (core)Fatigue or low energy
Yes (core)Yes (core)Loss of interests or pleasure
Yes (core)Yes (core)Persistent sadness or low mood

15. “Common” Symptoms of Depression
Audience – How common are the following?
Low mood
Insomnia
Worthlessness
Anxiety
Suicidal thoughts
Anger
Psychomotor retardation
Weight gain
=> MIDAS

16. “Common” Symptoms of Depression
0.120.56Thoughts of death
0.330.59Psychic anxiety
0.120.61Worthlessness
0.420.69Anxiety
0.270.70Insomnia
0.120.81Diminished interest/pleasure
0.240.82Diminished concentration
0.320.83Sleep disturbance
0.270.87Concentration/indecision
0.320.87Loss of energy
0.300.88Diminished drive
0.180.93Depressed mood
Non-Depressed FrqDepressed FrqItem
Mitchell, Zimmerman et al MIDAS Database. Psychol Med 2007 Submitted

17. “Uncommon” Symptoms
0.060.16Increased weight
0.060.19Hypersomnia
0.070.19Increased appetite
0.060.22Lack of reactive mood
0.060.23Decreased weight
0.040.28Psychomotor retardation
0.090.34Psychomotor agitation
0.260.44Anger
0.110.45Decreased appetite
0.250.46Somatic anxiety
0.080.51Indecisiveness
0.130.54Excessive guilt
0.120.55Psychomotor change
0.150.55Hopelessness
0.150.55Helplessness
Non-Depressed
ProportionDepressed ProportionItem
Mitchell, Zimmerman et al MIDAS Database. Psychol Med 2007 Submitted

18. 0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
Lossofenergy
Diminisheddrive
Sleepdisturbance
Concentration/indecision
Depressedmood
Anxiety
Diminishedconcentration
Insomnia
Diminishedinterest/pleasure
Psychicanxiety
Helplessness
Worthlessness
Hopelessness
Somaticanxiety
Thoughtsofdeath
Anger
Excessiveguilt
Psychomotorchange
Indecisiveness
Decreasedappetite
Psychomotoragitation
Psychomotorretardation
Decreasedweight
Lackofreactivemood
Increasedappetite
Hypersomnia
Increasedweight
All Case Proportion
Depressed Proportion
Non-Depressed Proportion
Mitchell, Zimmerman et al MIDAS Database. Psychol Med 2007 Submitted

19. Who is Looking for Depression?
Frequency
Reliability
Success
=> QQ

20. => Audience

21. Do Clinicians Look for Depression?
Mitchell, Kaar, Coggan, Herdman (N=226) Psychooncology 2007

22. 1,2 or 3 Simple
QQ
15%
Clinical Skills
Alone
73%
ICD10/DSMIV
0%
Short QQ
3%
Other/Uncertain
9% Other/Uncertain
2%
Use a QQ
15%
ICD10/DSMIV
13%
Clinical Skills
Alone
55%
1,2 or 3 Simple
QQ
15%
Cancer Staff Psychiatrists
Mitchell, Kaar, Poster APA 2007Current Method

23. 1,2 or 3 Simple
QQ
24%
Clinical Skills
Alone
20%
ICD10/DSMIV
24%
Short QQ
24%
Long QQ
8%
Algorithm
26%
Short QQ
23%
ICD10/DSMIV
0%
Clinical Skills
Alone
17%
1,2 or 3 Simple
QQ
34%
Cancer Staff Psychiatrists
Mitchell, Kaar, Poster APA 2007Ideal Method
=> GP Rate
Effective?

24. Audience?
What is the recognition rate of depression by GPs?

25. Detection rates 10-90%
Whooley’s (1997) found that General Practitioners
recognised only 8.8% of depression!
New Zealand MaGPIe survey (2005) rate was
56.4%(n=775 ).
In those definitely depressed (on three independent
instruments) GP recognition rate was 85.1%
= XLS
GP Detection of Depression

26. GP Detection of Depression
=> Go to Spreadsheet
Methods
100 studies of GP recognition rate => 35 with Se Sp
9x DSM
7x ICD10
9x HADS
4x CES-D; 4x PHQ
2x BDI
Mitchell, Vaze, Rao (2007) Unpublished data

27. Accuracy 2x2 Table
PrevalenceSpecificitySensitivity
NPVTrue -VeFalse -VeTest -ve
PPVFalse +veTrue +veTest +ve
Depression
ABSENT
Depression
PRESENT

28. Accuracy of GP’s Diagnoses
955927,6406553
667825,1254050GP -ve
501825152503GP +ve
Depression
ABSENT
Depression
PRESENT
Sensitivity
38%
PPV 49.8%
Specificity
90.1%
NPV 86.1%
Prevalence 19%
N=35 studies
Mitchell, Vaze, Rao Unpublished data

29. Unassisted Accuracy
Non-Depressed
Depressed
#
of
Individuals
Test
Result
Cut-off value
False +veFalse -ve
5%
90%
True -ve
38%
True +ve
50%

30. Professional Variables
Length of consultation
Therapeutic Relationship
Having a high index of suspicion
Asking questions about well-being
Asking open questions
Using a non-medical or holistic model
Using MDTs (see later)
Patient Variables
Level of distress
Absence of denial
High social class
Married patients
Progressive disease
Sollner (2001) BJC; n=298 => How To

31. How to Detect Depression
1. Unassisted
2. Assisted

32. 0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
Lossofenergy
Diminisheddrive
Sleepdisturbance
Concentration/indecision
Depressedmood
Anxiety
Diminishedconcentration
Insomnia
Diminishedinterest/pleasure
Psychicanxiety
Helplessness
Worthlessness
Hopelessness
Somaticanxiety
Thoughtsofdeath
Anger
Excessiveguilt
Psychomotorchange
Indecisiveness
Decreasedappetite
Psychomotoragitation
Psychomotorretardation
Decreasedweight
Lackofreactivemood
Increasedappetite
Hypersomnia
Increasedweight
All Case Proportion
Depressed Proportion
Non-Depressed Proportion
Mitchell, Zimmerman et al MIDAS Database. Psychol Med 2007 Submitted

33. Value of Symptoms of Depression
53%90%Psychomotor Retardation
50% (decreased)81% (decreased)Significant change in weight
83%78%Diminished drive
61%83%Guilt or self-blame
NPVPPVCore Symptoms
95%72%Low energy or Low drive
62%84%Agitation or slowing of movements
63%83%Suicidal thoughts or acts
57% (decreased)83% (decreased)Poor or increased appetite
66% (worthlessness)86% (worthlessness)Low self-confidence
83%80%Poor concentration or
indecisiveness
77%76%Disturbed sleep
82%77%Fatigue or low energy
79%89%Loss of interests or pleasure
91%86%Persistent sadness or low mood

34. Added Value when Ruling-in Depression (PPV-Prev)
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
0.5
Psychomotorretardation
Diminishedinterest/pleasure
Indecisiveness
Depressedmood
Worthlessness
Thoughtsofdeath
Psychomotorchange
Decreasedappetite
Excessiveguilt
HelplessnessPsychomotoragitation
Hopelessness
DecreasedweightLackofreactivemoodDiminishedconcentration
Hypersomnia
Diminisheddrive
Lossofenergy
Sleepdisturbance
Insomnia
Increasedappetite
Increasedweight
Somaticanxiety
Psychicanxiety
Anger
Anxiety

35. Added Value when Ruling-Out Depression (PPV-Prev)
-0.1
0
0.1
0.2
0.3
0.4
0.5
Depressedmood
Diminisheddrive
Lossofenergy
Diminishedinterest/pleasureDiminishedconcentration
Sleepdisturbance
Insomnia
Worthlessness
Helplessness
ThoughtsofdeathPsychomotorchange
Hopelessness
Excessiveguilt
Indecisiveness
Anxiety
Psychicanxiety
DecreasedappetitePsychomotoragitation
SomaticanxietyPsychomotorretardation
Anger
DecreasedweightLackofreactivemood
Hypersomnia
Increasedappetite
Increasedweight

36. -0.10
0.00
0.10
0.20
0.30
0.40
0.50
Anger
Anxiety
Decreasedappetite
Decreasedweight
Depressedmood
Diminishedconcentration
DiminisheddriveDiminishedinterest/pleasure
Excessiveguilt
Helplessness
Hopelessness
Hypersomnia
Increasedappetite
Increasedweight
Indecisiveness
Insomnia
Lackofreactivemood
Lossofenergy
Psychicanxiety
Psychomotoragitation
Psychomotorchange
Psychomotorretardation
Sleepdisturbance
Somaticanxiety
Thoughtsofdeath
Worthlessness
Rule-In Added Value (PPV-Prev)
Rule-Out Added Value (NPV-Prev)

37. 0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Depressed Mood
Diminished drive
Diminished interest/pleasure
Loss of energy
Sleep disturbance
Diminished concentration
S
e
n
s
i
t
i
v
i
t
y
1 - Specificity

38. How to Detect Depression. 2. Screening

39. Definition
Screening:
Short; Easy; some false +ve (low SpS PPV), few false –ve
(High Sens, NPV)
Diagnosis (case-finding)
Accurate, Few false +ve or –ve
Rating
Simple, patient rated, correl. With QoL and other outcomes

40. Screening Evidence - Yes
USPSTF
good evidence that screening improves the
accurate identification of depressed patients in
primary care settings and that treatment of
depressed adults identified in primary care
settings decreases clinical morbidity.
Small benefits have been observed in studies
that simply feed back screening
results to clinicians.
Larger benefits have been observed in studies
in which the communication of screening
results is coordinated with effective follow-up
and treatment.
Pignone, M. P., Gaynes, B. N., Rushton, J. L., et al (2002) Screening for depression in adults: a summary of the evidence for the U.S.
Preventive Services Task Force. Annals of Internal Medicine, 136, 765-776. => Gilbody

41. Screening Evidence - No
Feedback results => 23%
Gilbody, S. M., House, A. O. & Sheldon, T. A. (2001) Routinely administered questionnaires for depression and anxiety: systematic
review. BMJ, 322 (7283), 406-409. => NICE

42. Guidance
=> Detail

43. NICE Screening: How?
Step 1: Recognition
• Use two screening questions, such as:
– “During the last month, have you often been bothered by
feeling down, depressed or hopeless?”
– “During the last month, have you often been bothered by
having little interest or pleasure in doing things?”

44. Instruments
=> Defns

45. 20 Instruments for Depression
SDS (20)EPDS (10)
GDS (30,15)MADRAS (10)
DEPS (10)DADS (7)
Zung (20)DSMIV (9)
CES-D (20,10)PHQ9 (9)Distress Therm (1)
BSI (53)MOS-D (8)WHO-5 (5)
BDI (21,13)BDI (7)PHQ2 (2)
HAM-D (21)HADS (7)PHQ1
Long > 10Short > 5 < 11Ultra-short <6

49. Developments in Detection
Ultra-Screening – Primary Care

50. Test Duration
Ultra-short screening tools were
defined as those with 1-4 items
taking less than 2 minutes to
complete.
Short screening tools were
defined as those with 5-14 items,
taking between 2 and five
minutes to complete.
Standard screening tools were
defined as those with 15 or more
items, taking more than five
minutes to complete.
=> Tools table

51. 93.0%38.3%74.7%73.7%9653Pooled effect for two and three question TestsSub-Total
99.732.489.495.7936Arroll B et al (2005) BMJ 331:884-8862005
99.718.978.495.7936Arroll B et al (2005) BMJ 331:884-8862005
97.4938.5177.9587.32520Lowe et al (2005) Journal of Psychosomatic Research 58: 163– 1712005
98.2125.1770.8888.37431Henckel et al (2004) Eur Arch Psychiatry Clin Neurosci (2004) 254 : 215–2232004
98.3620.8661.8690.70431Henckel et al (2004) Eur Arch Psychiatry Clin Neurosci (2004) 254 : 215–2232004
93.8379.9295.0076.101211Corson et al (2004) Am J Manag Care. 2004;10(part 2):839-8452004
98.6169.2888.9695.221211Corson et al (2004) Am J Manag Care. 2004;10(part 2):839-8452004
97.938.7426.3592.68580Kroenke et al (2003) Medical Care 41(11): 1284–12922003
88.526.5510.0282.93580Kroenke et al (2003) Medical Care 41(11): 1284–12922003
97.2563.6067.0596.82421Arroll B et al (2003) BMJ 327:1144–62003
67.0996.5599.6217.83421Arroll B et al (2003) BMJ 327:1144–6 *2003
80.36100.00100.0049.231000Brody et al (1998) Arch Intern Med. 158:2469-24751998
98.4332.9856.9595.88536Whooley MA et al (1997) J Gen Intern Med 12:439–4451997
86.3961.3881.9468.99439Spitzer RL et al JAMA. (1994) 272(22)1994
NPV.PPV.SpecificitySensitivityTotal Sample SizeAuthorYear of Pub
Two or Three Question Tests
92.3%55.6%97%32%17,624Pooled effect for single Question TestsSub-Total
9063.673%85.4115Means-Christensen et al (2006). Gen Hosp Psych 28 108– 118.2006
98.640.794.374936Arroll B et al (2005) BMJ 331:884-8862005
77.0889.5096.7748.851211Corson et al (2004) Am J Manag Care;10(part 2):839-8452004
92.856.699.57.7913670Osborn et al (2003) Family Practice 20 (6): 682-6842003
94.1272.7394.1272.73310Lowe et al (2003) Psychosomatic Medicine 65:764–7702003
90.2365.9194.1252.73310Lowe et al (2003) Psychosomatic Medicine 65:764–7702003
94.0538.5071.9879.38536Whooley MA et al (1997) J Gen Intern Med 12:439–4451997
97.4935.0261.9692.78536Whooley MA et al (1997) J Gen Intern Med 12:439–4451997
NPV.PPV.SpecificitySensitivityTotal Sample SizeAuthorYear of Pub
Single Question Tests

52. Relative risk meta-analysis plot (fixed effects)
0.1 0.2 0.5 1 2 5 10 100
[3] Arroll B et al (2005) 8.75 (7.25, 10.60)
[2] Arroll B et al (2005) 3.82 (3.37, 4.36)
[2] Lowe et al (2005) 3.81 (3.22, 4.55)
[2] Henckel et al (2004) 2.65 (2.26, 3.14)
[2] Henckel et al (2004) 1.84 (1.59, 2.13)
[2] Corson et al (2004) 10.21 (8.54, 12.25)
[2] Corson et al (2004) 9.26 (7.81, 11.02)
[2] Kroenke et al (2003) 0.45 (0.39, 0.51)
[2] Kroenke et al (2003) 0.18 (0.15, 0.22)
[2] Arroll B et al (2003) 3.58 (2.98, 4.33)
[2] Arroll B et al (2003)* 2.24 (1.92, 2.63)
[2] Brody et al (1998) 5.06 (4.40, 5.84)
[2] Whooley MA et al (1997) 1.78 (1.56, 2.03)
[2] Spitzer RL et al (1994) 3.57 (2.99, 4.31)
[1] Means-Christensen et al (2006) 3.42 (2.45, 4.92)
[1] Arroll B et al (2005) 13.86 (10.94, 17.62)
[1] Corson et al (2004) 3.88 (3.47, 4.36)
[1] Osborn et al (2003) 12.22 (11.52, 12.96)
[1] Lowe et al (2003) 9.33 (6.69, 13.18)
[1] Lowe et al (2003) 6.56 (4.95, 8.79)
[1] Whooley MA et al (1997) 2.75 (2.37, 3.20)
[1] Whooley MA et al (1997) 2.08 (1.82, 2.39)
combined [fixed] 5.46 (5.31, 5.62)
relative risk (95% confidence interval)

53. Accuracy of Ultra-short Tests
955973892170
66785955723Test -ve
228114341447Test +ve
Depression
ABSENT
Depression
PRESENT
Sensitivity
66%
PPV 50%
Specificity
80%
NPV 90%
Prevalence 22%
N=17 studies
in 7 reports

54. Developments in Detection
Ultra-Screening – Cancer Care

55. Ultra-short Tests & Depression
36033816787
27952643152Test -ve
18081173635Test +ve
Depression
ABSENT
Depression
PRESENT
Sensitivity
81%
PPV 32%
Specificity
69%
NPV 93%
Prevalence 18%
N=17 studies
3603

56. Ultra-short Tests & Distress
368222071475
18911514337Test -ve
18316931138Test +ve
Distress
ABSENT
Distress
PRESENT
Sensitivity
77%
PPV 65%
Specificity
68%
NPV 80%
Prevalence 39%
N=17studies
3682

57. Ultra-short Tests & Anxiety
22151372843
969776193Test -ve
1248596652Test +ve
Anxiety
ABSENT
Anxiety
PRESENT
Sensitivity
77%
PPV 55%
Specificity
56%
NPV 80%
Prevalence 38%
N= 4 studies
2215

58. PPV DT Distress = 55%; PPV Other Methods 65%

59. SCAN, SCID, PSE, CIDI, MINI
BDI, MADRAS, Hamilton
HADS, EPDS, PHQ9, CES-D
LONG
PHQ2, NICE, DT
SHORT
High NPV
Low PPV
High NPV
Med PPV
High NPV
High PPV
MEDIUM

60. Extras

61. 86.8
55.6 54.4
43.3
36
29.8
26.2 25.6 25.2
23.8 24
21.4 21.2
13.9 12.8
9.5
7.2 7 7 5.9 4.8 4.1
2.6 1.8 1.8 1.3 0.9 0.4 0.4
0
10
20
30
40
50
60
70
80
90
100
Sleepdisturbances;insomnia;earlywakening
Lossofappetite;overeating;weightchanges
Depressedmood;hopelessness;sad;gloomy
Apathy;lethargy;tiredness;lassitude
Lossofinterest;withdrawal;indifference;loneliness
Lossofenergy;lossofdrive;burntout
Lossoflibido;lossofsexdrive;impotence
Tears;weeping;crying
Anxious;agitated;irritable;restless,tense;stressed
Feelingworthless;guilty;lackofselfesteem
Somatic;vegetativesymptoms;malaise;multipleconsultations
Suicidethoughts;thoughtofselfinjury
Lossofconcentration;poormemory,poorthinking
Diminishedperformance;inabilitytocope
Emotionallability;moodswings
Lossofaffect;flataffect;lossofemotion
Lossofenjoymentorpleasure;lackofhumor
Behaviouralproblems;aggressiveness;behaviouralchanges
Pessimism;negativeattitudes,worrying
Psychomotorretardation;slowness
Headaches;dizziness
Appearance;speech;excessivesmiling;vagueness,etc.
Heavyuseofalcohol,tobaccoordrugs
Delusions;hallucinations;confusion
Reactiontoprobablecausesorlifeevents
Familyorpasthistoryofdepression
Obsessiveideation;phobiasLackofinsight
Periodoflife(menopause)

62. Myths re depression
Depression is a clearly delineated disorder cf the
non-depressed
Depression cannot be detected by a severity scale
Clinicians spot depress in most cases
Clinicians look for depression robustly
Clinicians can rely on 1 or 2 QQ for depression
Antidepressants take 2 weeks to act
Somatic symptoms are unhelpful in diagnosing
depression in physical disease