APPP07 - Specific Symptom Screening for Depression (Sept 2007)

Alex Mitchell [email protected]

Consultant in Liaison Psychiatry

Monitoring to Improve Long Term Outcomesin Schizophrenia and Depression (September 2006)

17TH ANNUAL PSYCHIATRIC PHARMACY PROGRAMME

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

Audience

What % Receive Any Treatment for Depression (12mo)?

What % Receive Adequate Treatment?

What % Receive Specialist Treatment?

GP Recognition of Individual symptomProportion of Individual Symptoms Recognised by GPs

76.1

36.4 34.631.6

21.616.7

13.39.1 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

Insomnia

Hypoc

hondri

asis

Loss

of in

terest

Tearfu

lness

Anxiety

Loss

of en

ergy

Pessim

ism

Anorex

ia

Not Copin

g

O’Conner et al (2001) Depression in primary care.Int Psychogeriatr 13(3) 367-374.

% Receiving Any treatment for Depression

10.9 11.3

8.18.8

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 Inc

omeBelg

ium

France

German

y

Israe

l

Italy

Japa

nNeth

erlan

dsNew

Zeala

nd

Spain USALow

Inco

me

ChinaColom

biaSouth

Afri

caUkra

ine

Wang P et al (2007) Lancet 2007; 370: 841

n=84,850 face-to-face interviews

ContentsWhat 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 DepressionAccuracy, assisted vs unassisted methods

Developments in ScreeningUltra-screening – primary / secondary

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

Distribution of DT ScoresRansom (2006) PO (n=491)

13.814.7

15.7

13.2

10.4

8.47.7 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)

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

=> Symptoms

What Are the Symptoms of Depression?

=> Audience

Lost Symptoms of Depression

Loss of confidenceLow motivation / driveWithdrawalAvoidanceSocial isolationWorryFeelings of dreadHelplessnessHopelessnessPsychic anxietySomatic anxietyAngerLack of reactive moodCognitive Change (=> memory complaints)Perceptual distortion

Which Are Recognized Symptoms of MDD?

=> ICD10

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

“Common” Symptoms of Depression

Audience – How common are the following?

Low moodInsomniaWorthlessnessAnxietySuicidal thoughtsAngerPsychomotor retardationWeight gain

=> MIDAS

“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

“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


0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

Loss

of

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driv

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Con

cent

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ress

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ood

Anx

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inis

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conc

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/ple

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Psyc

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reas

ed w

eigh

t

Lack

of

reac

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moo

d

Incr

ease

d ap

peti

te

Hyp

erso

mni

a

Incr

ease

d w

eigh

t

All Case ProportionDepressed ProportionNon-Depressed Proportion


Who is Looking for Depression?

Frequency

Reliability

Success

=> QQ

=> Audience

Do Clinicians Look for Depression?

Mitchell, Kaar, Coggan, Herdman (N=226) Psychooncology 2007

1,2 or 3 Simple QQ15%

Clinical Skills Alone73%

ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9% Other/Uncertain

2%

Use a QQ15%

ICD10/DSMIV13%



Cancer Staff Psychiatrists

Mitchell, Kaar, Poster APA 2007Current Method



ICD10/DSMIV24%

Short QQ24%

Long QQ8%

Algorithm26%

Short QQ23%

ICD10/DSMIV0%



Cancer Staff Psychiatrists

Mitchell, Kaar, Poster APA 2007Ideal Method=> GP Rate

Effective?

Audience?

What is the recognition rate of depression by GPs?

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

GP Detection of Depression

=> Go to Spreadsheet

Methods100 studies of GP recognition rate => 35 with Se Sp9x DSM7x ICD109x HADS4x CES-D; 4x PHQ2x BDI

Mitchell, Vaze, Rao (2007) Unpublished data

Accuracy 2x2 Table

PrevalenceSpecificitySensitivity

NPVTrue -VeFalse -VeTest -ve

PPVFalse +veTrue +veTest +ve

DepressionABSENT

DepressionPRESENT

Accuracy of GP’s Diagnoses

955927,6406553

667825,1254050GP -ve

501825152503GP +ve

DepressionABSENT

DepressionPRESENT

Sensitivity38%

PPV 49.8%

Specificity90.1%

NPV 86.1%

Prevalence 19%

N=35 studies

Mitchell, Vaze, Rao Unpublished data

Unassisted Accuracy

Non-Depressed

Depressed# ofIndividuals

TestResult

Cut-off value

False +veFalse -ve

5%

90%

True -ve

38%

True +ve

50%

Professional VariablesLength of consultationTherapeutic Relationship Having a high index of suspicionAsking questions about well-beingAsking open questionsUsing a non-medical or holistic modelUsing MDTs (see later)

Patient VariablesLevel of distressAbsence of denialHigh social classMarried patientsProgressive disease

Sollner (2001) BJC; n=298 => How To

How to Detect Depression

1. Unassisted

2. Assisted

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

Loss

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Dim

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Con

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Lack

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Hyp

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All Case ProportionDepressed ProportionNon-Depressed Proportion


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

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

Psyc

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Added Value when Ruling-Out Depression (PPV-Prev)

-0.1

0

0.1

0.2

0.3

0.4

0.5

Depr

esse

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ood

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0.00

0.10

0.20

0.30

0.40

0.50A

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Rule-In Added Value (PPV-Prev)Rule-Out Added Value (NPV-Prev)

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 driveDiminished interest/pleasure

Loss of energySleep disturbance

Diminished concentration

Sensitivity

1 - Specificity

How to Detect Depression. 2. Screening

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

RatingSimple, patient rated, correl. With QoL and other outcomes

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 screeningresults 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

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

Guidance

=> Detail

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?”

Instruments

=> Defns

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

Developments in DetectionUltra-Screening – Primary Care

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

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 SizeAuthor Year 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



NPV.PPV.SpecificitySensitivityTotal Sample SizeAuthor Year of Pub

Single Question Tests

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)

Accuracy of Ultra-short Tests

955973892170

66785955723Test -ve

228114341447Test +ve

DepressionABSENT

DepressionPRESENT

Sensitivity66%

PPV 50%

Specificity80%

NPV 90%

Prevalence 22%

N=17 studies in 7 reports

Developments in DetectionUltra-Screening – Cancer Care

Ultra-short Tests & Depression

36033816787

27952643152Test -ve

18081173635Test +ve

DepressionABSENT

DepressionPRESENT

Sensitivity81%

PPV 32%

Specificity69%

NPV 93%

Prevalence 18%

N=17 studies 3603

Ultra-short Tests & Distress

368222071475

18911514337Test -ve

18316931138Test +ve

DistressABSENT

DistressPRESENT

Sensitivity77%

PPV 65%

Specificity68%

NPV 80%

Prevalence 39%

N=17studies 3682

Ultra-short Tests & Anxiety

22151372843

969776193Test -ve

1248596652Test +ve

AnxietyABSENT

AnxietyPRESENT

Sensitivity77%

PPV 55%

Specificity56%

NPV 80%

Prevalence 38%

N= 4 studies 2215

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

SCAN, SCID, PSE, CIDI, MINI

BDI, MADRAS, Hamilton

HADS, EPDS, PHQ9, CES-D

LONG

PHQ2, NICE, DT

SHORT

High NPVLow PPV

High NPVMed PPV

High NPVHigh PPV

MEDIUM

Extras

86.8

55.6 54.4

43.3

36

29.826.2 25.6 25.2 23.8 24

21.4 21.2

13.9 12.89.5

7.2 7 7 5.9 4.8 4.1 2.6 1.8 1.8 1.3 0.9 0.4 0.40

10

20

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100Sl

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d m

ood;

hop

eles

snes

s; sa

d; g

loom

y

Apat

hy; l

etha

rgy;

tired

ness

; las

situd

e

Loss

of i

nter

est;

with

draw

al; in

diffe

renc

e; lo

nelin

ess

Loss

of e

nerg

y; lo

ss o

f driv

e; b

urnt

out

Loss

of l

ibido

; los

s of

sex

driv

e; im

pote

nce

Tear

s; we

eping

; cry

ing

Anxio

us; a

gita

ted;

irrit

able

; res

tless

, ten

se; s

tress

ed

Feeli

ng w

orth

less

; guil

ty; la

ck o

f sel

f este

em

Som

atic;

vege

tativ

e sy

mpt

oms;

mala

ise; m

ultip

le co

nsult

ation

s

Suici

de th

ough

ts; th

ough

t of s

elf in

jury

Loss

of c

once

ntra

tion;

poo

r mem

ory,

poo

r thi

nkin

g

Dim

inish

ed p

erfo

rman

ce; i

nabi

lity to

cop

e

Emot

ional

labil

ity; m

ood

swing

s

Loss

of a

ffect

; flat

affe

ct; lo

ss o

f em

otion

Loss

of e

njoym

ent o

r ple

asur

e; la

ck o

f hum

or

Beha

viour

al pr

oble

ms;

agg

ress

ivene

ss; b

ehav

iour

al ch

ange

s

Pess

imism

; neg

ative

atti

tude

s, w

orry

ing

Psyc

hom

otor

reta

rdat

ion;

slow

ness

Head

ache

s; d

izzin

ess

Appe

aran

ce; s

peec

h; e

xces

sive

smilin

g; va

guen

ess,

etc.

Heav

y use

of a

lcoho

l, tob

acco

or d

rugs

Delu

sions

; hall

ucin

atio

ns; c

onfu

sion

Reac

tion

to p

roba

ble

caus

es o

r life

eve

nts

Fam

ily o

r pas

t hist

ory

of d

epre

ssio

n

Obs

essiv

e id

eatio

n; p

hobia

sLa

ck o

f ins

ight

Perio

d of

life

(men

opau

se)

Myths re depression

Depression is a clearly delineated disorder cf the non-depressedDepression cannot be detected by a severity scaleClinicians spot depress in most casesClinicians look for depression robustlyClinicians can rely on 1 or 2 QQ for depressionAntidepressants take 2 weeks to actSomatic symptoms are unhelpful in diagnosing depression in physical disease

APPP07 - Specific Symptom Screening for Depression (Sept 2007)

Health & Medicine