#203 Got Depression? I can answer that in two questions!

CLINICAL QUESTION

QUESTION CLINIQUE

What is the diagnostic accuracy of the 2-question screen for identifying depression in primary care?

BOTTOM LINE

RÉSULTAT FINAL

The 2-question screen is good at ruling out (but not ruling in) depression in primary care. Up to 50% of patients will test positive and should have more thorough evaluation to confirm depression diagnosis. Whether screening alters outcomes is debatable, but the 2-question screen may be reasonable for case-finding or screening higher risk patients.

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EVIDENCE

DONNÉES PROBANTES

2-Question Screen (positive screen=yes to ≥1 question, negative=no to both):

“During the past month have you often been bothered by:
1. Feeling down, depressed or hopeless?
2. Having little interest or pleasure in doing things?”

Primary care: Three cohort studies^1-3 (total 1,893 patients), 23-37% of patients tested positive to screening, 5-18% actually had depression:

Sensitivity: 96-97% (if no to both questions, depression ruled out ~96% of time).
Specificity: 57-78% (if yes to ≥1 question, patients are depressed ~70% of time).

Systematic reviews of different short depression screens^4,5 or pertaining to only geriatric patients⁶ found similar results, but up to half of geriatric patients may test positive.⁷ No studies evaluating the effects of screening on patient outcomes in North American context were found. Context:

Since the 2-question screen is better at ruling-out than ruling-in depression, when a patient answers “yes” to ≥1 question, more formal evaluation (example Patient Health Questionnaire (PHQ)-9 or Geriatric Depression Scale) is needed to diagnose depression.
- Example: In adults, PHQ-9 score ³10 has a sensitivity and specificity of 88%:^8,9
  - PHQ-9: Range of scores 0-27, higher worse.
Adding “Is this something with which you would like help?”2 or frequency of symptoms to the 2-question screen (example PHQ-2) may improve depression diagnosis.^5,10,11
- Asking only 1-question not as accurate in identifying depression.⁴
Guidelines differ on depression screening recommendations from screening all adults12 to not screening at all,13 to only those with a history of depression, chronic health problems, or post-partum women.¹⁴
- Effectiveness of screening depends on disease prevalence and impacts opportunity cost.
People with chronic illnesses,15 substance abuse history, First Nations descent, and post-partum women have higher depression rates.¹⁴

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January 15, 2018

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Author(s)

Auteur(s)

Caitlin R Finley BHSc MSc
Michael Kolber BSc MD CCFP MSc

1. Arroll B, Khin N, Kerse N. BMJ. 2003; 327:1144-6.

2. Arroll B, Goodyear-Smith F, Kerse N, et al. BMJ. 2005; 331:884.

3. Whooley M, Alvins AL, Miranda J, et al. J Gen Internal Med. 1997; 12:439-45.

4. Mitchell AJ, Coyne JC. Br J Gen Pract. 2007; 57:144-51.

5. Mitchell AJ, Yadegarfar M, Gill J, et al. B J Psych Open. 2016; 2:127-38.

6. Tsoi KKF, Chan JYC, Hirai HW, et al. Br J Psychiatry. 2017; 210:255-60.

7. Bosanquet K, Mitchell N, Gabe R, et al. J Affect Disord. 2015; 182:39-43.

8. Kroenke K, Spitzer RL, Williams JBW. J Gen Intern Med. 2001; 16:606-13.

9. The Patient Health Questionnaire (PHQ-9) 1999 Pfizer. Available at: http://www.cqaimh.org/pdf/tool_phq9.pdf. Last Accessed: August 28, 2017.

10. Arroll B, Goodyear-Smith F, Crengle S, et al. Ann Fam Med. 2010; 8:348-53.

11. Kroenke K, Spitzer RL, Williams JBW. Med Care. 2003; 41:1284-92.

12. Siu AL, US Preventive Services Task Force. JAMA. 2016; 315:380-7.

13. Canadian Task Force on Preventive Health Care. CMAJ. 2013; 185:775-82.

14. National Collaborating Centre for Mental Health. NICE Clinical Guidelines, no. 90. British Psychological Society; 2009. Available at: https://www.nice.org.uk/guidance/cg90/chapter/Key-priorities-for-implementation. Last Accessed: August 28, 2017.

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