Article

Do ultra-short screening instruments accurately detect depression in primary care? A pooled analysis and meta-analysis of 22 studies

Department of Liaison Psychology, Leicester General Hospital, Leicester.
British Journal of General Practice (Impact Factor: 2.29). 02/2007; 57(535):144-51.
Source: PubMed

ABSTRACT

Guidance from the National Institute for Health and Clinical Excellence recommends one or two questions as a possible screening method for depression. Ultra-short (one-, two-, three- or four-item) tests have appeal due to their simple administration but their accuracy has not been established.
To determine whether ultra-short screening instruments accurately detect depression in primary care.
Pooled analysis and meta analysis.
A literature search revealed 75 possible studies and from these, 22 STARD-compliant studies (Standards for Reporting of Diagnostic Accuracy) involving ultra-short tests were entered in the analysis.
Meta-analysis revealed a performance accuracy better than chance (P<0.001). More usefully for clinicians, pooled analysis of single-question tests revealed an overall sensitivity of 32.0% and specificity of 97.0% (positive predictive value [PPV] was 55.6% and negative predictive value [NPV] was 92.3%). For two- and three-item tests, overall sensitivity on pooled analysis was 73.7% and specificity was 74.7% with a PPV of only 38.3% but a pooled NPV of 93.0%. The Youden index for single-item and multiple item tests was 0.289 and 0.47 respectively, suggesting superiority of multiple item tests. Re-analysis examining only 'either or' strategies improved the 'rule in' ability of two- and three-question tests (sensitivity 79.4% and NPV 94.7%) but at the expense of being able to rule out a possible diagnosis if the result was negative.
A one-question test identifies only three out of every 10 patients with depression in primary care, thus unacceptable if relied on alone. Ultra-short two- or three-question tests perform better, identifying eight out of 10 cases. This is at the expense of a high false-positive rate (only four out of 10 cases with a positive score are actually depressed). Ultra-short tests appear to be, at best, a method for ruling out a diagnosis and should only be used when there are sufficient resources for second-stage assessment of those who screen positive.

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    • "However, given that the prevalence of depression in mental health care centres is high, this might be an optimal setting to use the VAMS. In a meta-analysis on screeners in primary care, it was found that single-item screeners have low sensitivity (i.e., pooled SE¼ 0.32) that increased when additional items were added (Mitchell and Coyne, 2007). Since we exclusively focused on sad mood, adding an additional VAMS for anhedonia, the other core symptom of depression (APA, 2000), might also reduce false positives. "
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    • "We screened for anxiety symptoms in the same manner, asking: have you felt anxious much of the time in the past year? Single-item questions have been used for depressive disorders screening in both general and clinical populations [35] [36] "
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