Can case-finding instruments be used to improve physician detection of depression in primary care?
M. S. Klinkman, J. C. Coyne, S. Gallo and T. L. Schwenk
Department of Family Practice, University of Michigan, Ann Arbor, USA. mklinkma@umich.edu
OBJECTIVE: To explore the issue of diagnostic specificity for major
depression in the primary care setting by examining the relative accuracy
of 3 methods to detect major depression in primary care. DESIGN: Comparison
of performance characteristics of 3 case-finding methods for depression
(ie, the Center for Epidemiologic Studies-Depression scale [CES-D], unaided
physician detection, and "augmented" physician detection by use of a
case-finding instrument), with the standard criterion being the Structured
Clinical Interview for Diagnostic and Statistical Manual of Mental
Disorders, Third Edition, Revised (DSM-III-R). SETTING: The offices of 50
family physicians from private and academic practice in southeastern
Michigan. PATIENTS: Adult patients (N = 1580) who presented for routine
care, from which a weighted random sample of 425 patients completed the
Structured Clinical Interview for DSM-III-R. MAIN OUTCOME MEASURES:
Sensitivity, specificity, positive predictive value, and positive
likelihood ratio for each case-finding method. RESULTS: Major depression
was present in 13.4% of the sample. Both the CES-D and unaided physician
detection methods performed poorly in identifying patients who met
DSM-III-R criteria for major depressive disorder. The CES-D had high
sensitivity but low specificity at standard and high cut points, resulting,
respectively, in low positive predictive values (0.307 and 0.385) and low
positive likelihood ratios (2.9 and 4.0). Unaided physician detection
showed lower sensitivity, higher specificity, and a slightly higher
positive predictive value (0.45) and positive likelihood ratio (4.9).
Raising of the CES-D threshold for a positive test did not enhance the
detection of depression. Augmented physician detection with CES-D scores
resulted in minimal improvement. Although the positive predictive value and
positive likelihood ratio increased to 0.50 and 6.1, respectively, using
the most stringent case-finding definition (ie, physician identification
plus the CES-D score [score > or = 22]), the proportion of depressed
patients who were correctly identified decreased to 26.9%. CONCLUSIONS:
Neither high scores on the CES-D nor unaided physician detection accurately
identified patients with major depression who were seen in primary care
settings, while the supplementation of physician detection with CES-D
scores had a minimal net effect on the accuracy of detection. The data do
not support the routine use of the CES-D as a primary care screening
instrument for depression, either as a stand-alone measure or as a
supplement to physician detection.
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