Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2005 Oct 19;2005(4):CD002792.
doi: 10.1002/14651858.CD002792.pub2.

Screening and case finding instruments for depression

S Gilbody  1 , A O House, T A Sheldon
Affiliations

Screening and case finding instruments for depression

S Gilbody et al. Cochrane Database Syst Rev. .

Abstract

Background: Screening or case finding instruments have been advocated as a simple, quick and inexpensive method to improve detection and management of depression in non-specialist settings, such as primary care and the general hospital. However, screening/case finding is just one of a number of strategies that have been advocated to improve the quality of care for depression. The adoption of this seemingly simple and effective strategy should be underpinned by evidence of clinical and cost effectiveness.

Objectives: To determine the clinical and cost effectiveness of screening and case finding instruments in: (1) improving the recognition of depression; (2) improving the management of depression, and (3) improving the outcome of depression.

Search strategy: The researchers undertook electronic searches of The Cochrane Library (Issue 4, 2004); The Cochrane Depression, Anxiety and Neurosis Group's Register [2004); EMBASE (1980-2004); MEDLINE (1966-2004); CINAHL (to 2004) and PsycLIT (1974-2004). References of all identified studies were searched for further trials, and the researchers contacted authors of trials.

Selection criteria: Randomised controlled trials of the administration of case finding/screening instruments for depression and the feedback of the results of these instruments to clinicians, compared with no clinician feedback. Trials had to be conducted in non-mental health settings, such as primary care or the general hospital. Studies that used screening strategies in addition to enhanced care, such as case management and structured follow up, were specifically excluded.

Data collection and analysis: Citations and, where possible, abstracts were independently inspected by researchers, papers ordered, re-inspected and quality assessed. Data were also independently extracted. Data relating to: (1) the recognition of depression; (2) the management of depression and (3) the outcome of depression over time were sought. For dichotomous data the Relative Risk (RR), 95% confidence interval (CI) were calculated on an intention-to-treat basis. For continuous data, weighted and standardised mean difference were calculated. A series of a priori sensitivity analyses relating to the method of administration of questionnaires and population under study were used to examine plausible causes of heterogeneity.

Main results: Twelve studies (including 5693 patients) met our inclusion criteria. Synthesis of these data gave the following results:(1) the recognition of depression: according to case note entries of depression, screening/case finding instruments had borderline impact on the overall recognition of depression by clinicians (relative risk 1.38; 95% confidence interval 1.04 to 1.83). However, substantial heterogeneity was found for this outcome. Screening and feedback, irrespective of baseline score of depression has no impact on the detection of depression (relative risk 1.00; 95% confidence interval 0.89 to 1.13). In contrast, three small positive studies using a two stage selective procedure, whereby patients were screened and only patients scoring above a certain threshold were entered into the trial, did suggest that this approach might be effective (relative risk 2.66; 95% confidence interval 1.78 to 3.96). Separate pooling according to this variable reduced the overall level of heterogeneity. Publication bias was also found for this outcome.(2) the management of depression: according to case note entries for active interventions and prescription data, a selected subsample of all studies reported this outcome and found that there was there was an overall trend to showing a borderline higher intervention rate amongst those who received feedback of screening/case finding instruments (relative risk 1.35; 95% confidence interval 0.98 to 1.85), although substantial heterogeneity between studies existed for this outcome. This result was dependant upon the presence of one highly positive study.(3) the outcome of depression: few studies reported the impact of case finding/screening instruments on the actual outcome of depression, and no statistical pooling was possible. However, three out of four studies reported no clinical effect (p<0.05) at either six months or twelve months. No studies examined the cost effectiveness of screening/case finding as a strategy.

Authors' conclusions: There is substantial evidence that routinely administered case finding/screening questionnaires for depression have minimal impact on the detection, management or outcome of depression by clinicians. Practice guidelines and recommendations to adopt this strategy, in isolation, in order to improve the quality of healthcare should be resisted. The longer term benefits and costs of routine screening/case finding for depression have not been evaluated. A two stage procedure for screening/case finding may be effective, but this needs to be evaluated in a large scale cluster randomised trial, with a prospective economic evaluation.

PubMed Disclaimer

Conflict of interest statement

None.

Figures

1.1
1.1. Analysis
Comparison 1 Recognition of depression following feedback, Outcome 1 Recognition of depression following feedback [all studies].
1.2
1.2. Analysis
Comparison 1 Recognition of depression following feedback, Outcome 2 Recognition of depression following feedback [unselected patients].
1.3
1.3. Analysis
Comparison 1 Recognition of depression following feedback, Outcome 3 Recognition of depression following feedback [high risk patients].
2.1
2.1. Analysis
Comparison 2 Management of depression following feedback, Outcome 1 Any intervention for depression.
2.2
2.2. Analysis
Comparison 2 Management of depression following feedback, Outcome 2 Prescription of anti‐depressants.
3.1
3.1. Analysis
Comparison 3 Outcome of depression following feedback, Outcome 1 Short term outcome of depression (0‐6 months) ‐ Dichotomous outcomes from depression rating scales.
3.2
3.2. Analysis
Comparison 3 Outcome of depression following feedback, Outcome 2 Short term outcome of depression (0‐6 months) following feedback [depression rating scale endpoint scores].
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Callahan 1994 {published data only}
    1. Callahan CM, Dittus RS. Primary care physicians' medical decision making for late life depression. Journal of General Internal Medicine 1996;11:218‐9. - PubMed
    1. Callahan CM, Hendrie HC, Dittus RS, Brater DC. Improving treatment of late life depression in primary care: a randomized clinical trial. Journal of the American Geriatrics Society 1994;42:839‐46. - PubMed
Dowrick 1995 {published data only}
    1. Dorwick C. Does testing for depression influence diagnosis or management by general practioners?. Family Practice 1995;12:461‐5. - PubMed
    1. Dowrick C, Buchan I. Twelve month outcome of depression in general practice: does detection or disclosure make a difference?. BMJ 1995;311:1274‐6. - PMC - PubMed
German 1987 {published data only}
    1. German PS, Shapiro S, Skinner EA. Detection and management of mental health problems of older patients by primary care providers. JAMA 1987;257:489‐96. - PubMed
    1. Shapiro S, German PS, Skinner EA, VonKorf M, Turner RW, Klein LE, et al. An experiment to change the detection and management of mental morbidity in primary care. Medical Care 1987;25:327‐39. - PubMed
Hoeper 1984 {published data only}
    1. Hoeper EW, Nycz GR, Kessler JD, Pierce WE. The usefulness of screening for mental illness. Lancet 1984;1:33‐5. - PubMed
Lewis 1996 {published data only}
    1. Lewis G, Sharp D, Bartholomew J, Pelosi AJ. Computerized assessment of common mental disorders in primary care: effect on clinical outcome. Family Practice 1996;13:120‐6. - PubMed
Linn 1980 {published data only}
    1. Linn LS, Yager J. Screening for depression in relationship to subsequent patient and physician behaviour. Medical Care 1980;20:1233‐45. - PubMed
    1. Linn LS, Yager J. The effect of screening, sensitisation and feedback on notation of depression. Journal of Medical Education 1980;20:942‐53. - PubMed
Magruder‐Habib 1990 {published data only}
    1. Magruder Habib K, Zung WW, Feussner JR. Improving physicians' recognition and treatment of depression in general medical care. Results from a randomized clinical trial. Medical Care 1990;28:239‐50. - PubMed
Moore 1978 {published data only}
    1. Moore JT, Silimperi DR, Bobula JA. Recognition of depression by family medicine residents: the impact of screening. Journal of Family Practice 1978;7:509‐13. - PubMed
Weatherall 2000 {published data only}
    1. Weatherall M. A randomized controlled trial of the Geriatric Depression Scale in an inpatient ward for older adults. Clinical Rehabilitation 2000;14:186‐91. - PubMed
Whooley 2000 {published data only}
    1. Whooley MA, Stone B, Soghikian K. Randomized trial of case‐ finding for depression in elderly primary care patients. Journal of General Internal Medicine 2000;15:293‐300. - PMC - PubMed
Williams 1999 {published data only}
    1. Williams JW, Mulrow CD, Kroenke K. Case‐finding for depression in primary care: a randomized trial. American Journal of Medicine 1999;106:36‐43. - PubMed
Zung 1983 {published data only}
    1. Zung WW, Magill M, Moore JT, George DT. Recognition and treatment of depression in a family medicine practice. Journal of Clinical Psychiatry 1983;44:3‐6. - PubMed

References to studies excluded from this review

Calkins 1994 {published data only}
    1. Calkins DR, Rubenstein LV, Cleary PD. Functional disability screening of ambulatory patients: a randomised controlled trial in a hopital based group practice. Journal of General Internal Medicine 1994;9:590‐2. - PubMed
Gold 1989 {published data only}
    1. Gold I, Baraff LJ. Psychiatric screening in the emergency department: its effect on physician behaviour. Annals of Emergency Medicine 1989;18:875‐80. - PubMed
Goldsmith 1989 {published data only}
    1. Goldsmith G, Brodwick M. Assessing the functional status of older patients with chronic illness. Family Medicine 1989;21:38‐41. - PubMed
Johnstone 1976 {published data only}
    1. Johnstone A, Goldberg D. Psychiatric screening in General Practice. Lancet 1976;1:605‐12. - PubMed
Katzelnick 2000 {published data only}
    1. Katzelnick DJ, Simon GE, Pearson SD, Manning WG, Helstad CP, Henk HJ. Randomized trial of a depression management program in high utilizers of medical care. Archives of Family Medicine 2000;9:345‐51. - PubMed
Kazis 1990 {published data only}
    1. Kazis LE, Callahan LF, Meenan RF, Pincus TS. Health status reports in the care of patients with rheumatoid arthritis. Journal of Clinical Epidemiology 1990;43:1243‐53. - PubMed
Reilfer 1996 {published data only}
    1. Reilfer DR, Kessler HS, Bernhard EJ, Leon AC, Martin G. Imapct of screening for mental health concerns on health service ustilisation and functional status in primary care patients. Archives of Internal Medicine 1996;156:2593‐9. - PubMed
Rost 2001 {published data only}
    1. Rost K, Nutting PA, Smith J, Werner J, Duan N. Improving depression outcomes in community primary care practice: a randomised trial of the QuEST intervention. Journal of General Internal Medicine 2001;16:143‐9. - PMC - PubMed
Rubenstein 1989 {published data only}
    1. Rubenstein LV, Calkins DR, Young RT. Improving patient functioning: a randomised trial of functional disability screening. Annals of Internal Medicine 1989;111:836‐42. - PubMed
Rubenstein 1995 {published data only}
    1. Rubenstein LV, McCoy JM, Cope DW, Barrett PA, Hirsch SH, Messer KS. Improving patient quality of life with feedback to physicians about functional status. Journal of General Internal Medicine 1995;10:607‐14. - PubMed
Street 1994 {published data only}
    1. Street RL Jr, Gold WR, McDowell T. Using health status surveys in medical consultations. Medical Care 1994;32:732‐44. - PubMed
Wagner 1997 {published data only}
    1. Wagner AK, Ehrenberg BL, Tran TA, Bungay KM, Cynn DJ, Rodgers WH. Patient based health status measurement in clinical practice: a study of its impact in epilepsy patients. Quality of Life Research 1997;6:329‐41. - PubMed
Wasson 1992 {published data only}
    1. Wasson J, Hays R, Rubenstein L, Nelson E, Leaning J, Johnson D, et al. The short‐term effect of patient health status assessment in a health maintenance organization. Quality of Life Research 1992;1:99‐106. - PubMed
Wells 2000 {published data only}
    1. Wells KA, Sherbourne C, Schoenbaum M, Duan N, Meridith L, Unutzer, J. Impact of disseminating quality improvement programmes for depression in managed primary care: a randomized controlled trial. JAMA 2000;283:212‐20. - PubMed

Additional references

Beck 1961
    1. Beck AT, Ward CH. An inventory for measuring depression. Archives of General Psychiatry 1961;4:561‐71. - PubMed
Bland 1997
    1. Bland JM, Kerry SM. Statistics notes. Trials randomised in clusters. BMJ 1997;710:600. - PMC - PubMed
Bowling 1997
    1. Bowling, A. Measuring Health: A review of quality of life measurement scales. 2nd Edition. Milton Keynes: Open University Press, 1997.
Cochrane 1971
    1. Cochrane AL, Holland WW. Validation of screening procedures. British Medical Bulletin 1971;27:3‐8. - PubMed
Divine 1992
    1. Divine GW, Brown JT, Frazer LM. The unit of analysis error in studies about physicians' patient care behavior. Journal of General Internal Medicine 1992;7:623‐29. - PubMed
Donner 2002
    1. Donner A, Klar N. Issues in the meta‐analysis of cluster randomized trials. Statistics in Medicine 2002;21:2971‐80. - PubMed
Egger 1997
    1. Egger M, Davey‐Smith G, Schneider M, Minder C. Bias in meta‐analysis detected by a simple graphical test. BMJ 1997;315:629‐35. - PMC - PubMed
Elbourne 1997
    1. Elbourne D. Guidelines are needed for evaluations that use a cluster approach. BMJ 1997;315:1620‐1.
Feldman 1987
    1. Feldman E, Mayou R, Hawton K, Ardern M, Smith EB. Psyhciatric disorders in medical in‐patients. Quarterly Journal of Medicine 1987;63:405‐12. - PubMed
Gail 1996
    1. Gail MH, Mark SD, Carroll RJ, Green SB, Pee D. On design considerations and randomization‐based inference for community intervention trials. Statistics In Medicine 1996;15:1069‐92. - PubMed
Gilbody 1999
    1. Gilbody SM, Petticrew M. Rational descison making in mental health: the role of systmetic reviews in clinical and economic evaluation. Journal of Mental Health Policy and Economics 1999;2:99‐107. - PubMed
Gilbody 2001
    1. Gilbody SM, House AO, Sheldon TA. Routinely administered questionnaires for depression and anxiety: a systematic review. BMJ 2001;322:406‐9. - PMC - PubMed
Gilbody 2002
    1. Gilbody SM, House AO, Sheldon TA. Routine administration of health related quality of life (HRQoL) and needs assessment tools ‐ a systematic review. Psychological Medicine 2002;32:1345‐56. - PubMed
Gilbody 2003a
    1. Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organizational interventions to improve the management of depression in primary care: a systematic review. JAMA 2003;289:3145‐51. - PubMed
Gilbody 2003b
    1. Gilbody SM, House AO, Sheldon TA. Routine outcome and needs assessment for those with schizophrenia. Cochrane Library 2003, Issue 1. - PMC - PubMed
Goldberg 1972
    1. Goldberg D. The Detection of Psychiatric Illness by Questionnaire. Oxford: Oxford University Press, 1972.
Goldberg 1986
    1. Goldberg, D. The use of the general health questionnaire in clinical work. British Medical Journal 1986;293:1188‐9. - PMC - PubMed
Goldberg 1988
    1. Goldberg DP, Williams P. The user's guide to the General Health Questionnaire. Windsor: NFER ‐ Nelson, 1988.
Greenberg 2003
    1. Greenberg PE, Kessler RC. The economic burden of depression in the United States: how did it change between 1990 and 2000?. Journal of Clinical Psychiatry 2003;64:1465‐75. - PubMed
Gulliford 1999
    1. Gulliford MC, Ukoumunne OC, Chinn S. Components of variance and intraclass correlations for the design of community‐based surveys and intervention studies: data from the Health Survey for England 1994. American Journal Of Epidemiology 1999;149:876‐83. - PubMed
Higgins 2003
    1. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta‐analyses. BMJ 2003;327:557‐60. - PMC - PubMed
Hoeper 1984
    1. Hoeper EW, Nycz GR, Kessler JD, Pierce WE. The usefulness of screening for mental illness. Lancet 1984;1:33‐5. - PubMed
Jadad 1996
    1. Jadad AR, Moore RA, Carroll D. Assessing the quality of reports of randomized clinical trials: Is blinding necessary?. Controlled Clinical Trials 1996;17:1‐12. - PubMed
Katon 1996
    1. Katon W. The impact of major depression on chronic medical illness. General Hospital Psychiatry 1996;18:215–9. - PubMed
Kessler 1999
    1. Kessler D, Lloyd K, Lewis G, Gray DP. Cross sectional study of symptom attribution and recognition of depression and anxiety in primary care. BMJ 1999;318:436‐40. - PMC - PubMed
Knottnerus 2002
    1. Knottnerus JA, Weel C. Evaluation of diagnostic procedures. BMJ 2002;324:477‐80. - PMC - PubMed
Mant 1990
    1. Mant D, Fowler G. Mass screening: theory and ethics. BMJ 1990;300:916‐8. - PMC - PubMed
Meakin 1992
    1. Meakin CJ. Screening for depression in the medically ill. British Journal of Psychiatry 1992;160:212‐6. - PubMed
NICE 2004
    1. National Institute for Clinical Excellence. Depression: core interventions in the management of depression in primary and secondary care. London: HMSO, 2004.
Petticrew 1999
    1. Petticrew M, Gilbody SM, Sheldon TA. Relation between hostility and coronary heart diseaese. BMJ 1999;319:917‐8. - PMC - PubMed
Pignone 2002
    1. Pignone MP, Gaynes BN, Rushton JL, Burchell CM, Orleans CT, Mulrow CD. Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine 2002;136:765‐76. - PubMed
Roethlisberger 1939
    1. Roethlisberger FJ, Dickinson WJ. Management and the Worker. Cambridge, MA: Harvard University Press, 1939.
Sackett 1991
    1. Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical Epidemiology: A basic science for clinical medicine. Boston, MA.: Little, Brown and Company, 1991.
Schulz 1995
    1. Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias: dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 1995;273:408‐12. - PubMed
Simon 1997
    1. Simon GE, Katzelnick DJ. Depression, use of medical services and cost‐offset effects. Journal of Psychosomatic Research 1997;42:333‐4. - PubMed
Singleton 2001
    1. Singleton N, Bumpstead R, O'Brien M, Lee A, Meltzer HY. Office of National Statistics: Psychiatric Morbidity Among Adults Living in Private Households. London: HMSO, 2001. - PubMed
Thompson 2000
    1. Thompson C, Kinmonth J, Stevens L, Peveler RC, Stevens A, Ostler KJ, et al. Effects of a clinical‐practice guideline and practice‐based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial. Lancet 2000;355:50‐7. - PubMed
Ukoumunne 1999
    1. Ukoumunne OC, Gulliford MC, Chinn S, Sterne JA, Burney PG, Donner A. Methods in health service research. Evaluation of health interventions at area and organisation level. BMJ 1999;319:376‐9. - PMC - PubMed
Von Korff 2001
    1. Korff M, Goldberg D. Improving outcomes of depression: the whole process of care needs to be enhanced. BMJ 2001;323:948‐9. - PMC - PubMed
Ware 1993
    1. Ware JE, Snoww KK, Kosinski M, Gandek B. SF‐36 Health Survey: Manual and Interpretation Guide. Boston, MA.: The Health Institute, New England Medical Centre., 1993.
Wells 1989
    1. Wells KB, Stewart A, Hays RD, Burnam MA, Rogers W, Daniels M, et al. The functioning and well‐being of depressed patients. Results from the Medical Outcomes Study. JAMA 1989;262:914‐9. - PubMed
Williams 2002
    1. Williams JW, Pignone M, Ramirez G, Stellato CP. Identifying depression in primary care: a literature synthesis of case‐finding instruments. General Hospital Psychiatry 2002;24:225–37. - PubMed
Wright 1994
    1. Wright A. Should general practitioners be testing for depression?. British Journal of General Practice 1994;44:132‐5. - PMC - PubMed
Young 1987
    1. Young JB, Chamberlain MA. The contribution of the Stanford Health Assessmetn questionnaire in rheumatology clinics. Clinical Rehabilitation 1987;1:97‐100.
Zung 1965
    1. Zung WW. A self rating depression rating scale. Archives of General Psychiatry 1965;12:63‐70. - PubMed

Publication types