Review: screening or case-finding questionnaires used alone are not effective for management of depression
Dr S Gilbody, University of York, Leeds, UK;
What is the effectiveness of screening or case-finding questionnaires used alone for detection and management of depression?
Studies selected compared standardised screening or case-finding instruments for depression with usual care in non-psychiatric settings (eg, general hospital or primary care). Studies that had substantial enhancements in the process of care (eg, case managers, nursing interventions, or collaborative care) were excluded. Outcomes were recognition of depression, use of any intervention for depression (pharmacological or psychosocial intervention or active referral to a specialist), and outcomes of depression.
Medline; EMBASE/Excerpta Medica; CINAHL; Cochrane Depression, Anxiety, and Neurosis Group Trials Register; Cochrane Library; National Health Service Economic Evaluations Database; Database of Reviews of Effectiveness; British Nursing Index and Royal College of Nursing; PsycLIT; and EconLIT (all to Dec 2007) were searched for randomised controlled trials (RCTs). 16 RCTs (n = 7576) met the selection criteria.
Meta-analysis showed that screening and case-finding increased recognition of depression compared with usual care (table). Groups did not differ for use of any intervention for depression (table) or outcome of depression (standardised mean difference −0.02, 95% CI −0.25 to 0.20).
Screening or case-finding questionnaires used alone are not effective for management of depression.
A modified version of this abstract appears in ACP Journal Club.
Gilbody S, Sheldon T, House A. Screening and case-finding instruments for depression: a meta-analysis. CMAJ 2008; 178:997–1003.
Clinical impact ratings: Family/general practice 6/7; General/internal medicine 5/7; Psychiatry 5/7
Depression is a serious public health concern because of high prevalence rates, staggering levels of disability, dramatic economic costs, and, importantly, risk of suicide.1 Despite the potentially devastating impact of depression, it is frequently undetected and untreated in primary care settings.2 In an extensive meta-analysis, Gilbody et al addressed the question of whether use of standardised screening and case-finding instruments improves quality of care. The review included only studies in which screening instruments for depression (intervention) were added to usual care for patients receiving generalised care within predominantly primary care settings. Specifically, this review did not include studies evaluating other programme components that were provided in addition to screening procedures. Other limitations include difficulties assessing methodological bias in RCTs, and, as such, the authors caution readers to regard this review as exploratory and hypothesis-generating. Although the results show a slight advantage in the detection of depression with use of screening tools, the authors state that routine use of screening instruments has limited benefit in the treatment of depression. Studies that have examined the inclusion of focused treatment and longitudinal follow-up in the context of interdisciplinary primary healthcare teams (including case management by nurses) have achieved the best results.3 Given the widespread and serious nature of depression, the findings of Gilbody et al should not discourage nurses in primary care settings from adopting standardised instruments that can aid in the detection of depression. Rather, nurses should continue to engage in careful assessment of depression as part of a package of management strategies and seek out necessary resources beyond diagnosis for successful treatment and follow-up.