Family Practice Vol. 19, No. 5, 520-522
© Oxford University Press 2002
Health Services Research |
Can routine information improve case finding of depression among 65 to 74 year olds in primary care?
Family Practice, Western College, Cotham Road, Bristol BS6 6DF,
a School of Nursing, University of Nottingham, Queens Medical Centre, Nottingham and
b Department of Epidemiology and Public Health, University of Leicester, 22–28 Princess Road West, Leicester, UK.
U Freudenstein, Family Practice, Western College, Cotham Road, Bristol BS6 6DF; E-mail: base{at}joanduli.freeserve.co.uk
Freudenstein U, Arthur A, Matthews R and Jagger C. Can routine information improve case finding of depression among 65 to 74 year olds in primary care? Family Practice 2002; 19: 520–522.
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Abstract |
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Background. The identification of groups with higher prevalence of major depression allows for more cost-effective investigation and treatment.
Objectives. The aim of this study was to examine whether the identification of patient groups with a higher prevalence of depression through information routinely available in primary care can increase the efficiency of active case finding.
Methods. A cross-sectional two-stage survey was carried out of 2633 community residents between the age of 65 and 74 consisting of a structured interview with concurrent audit of general practice records. The 15-item geriatric depression scale (GDS-15) was used as a screening tool for depression. Individuals scoring 
4 on the GDS-15 were offered a clinical interview using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN).
Results. There were 1912 (72.6%) participants in the first stage interview, of whom 134 had GDS-15 scores 4 and were invited to take part in the second stage. Of these, 90 participants (67.2%) agreed to the clinical interview. To detect one case of major depression, the number needing to be assessed was 63 for the whole sample. The number needing to be assessed was lower among those receiving antidepressants (nine), frequent GP attenders (12) and those living alone (32).
Conclusion. Although depression is more common among various subgroups, our data show that the investigation of each high prevalence subgroup would detect only a minority of all cases in the total population. It is not possible to rely on active case finding in high prevalence subgroups for a high detection rate of depression in a practice population.
Keywords. Aged, depression, diagnosis, primary health care.
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Introduction |
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Although there is conflicting evidence over the level of under-detection of late life depression in primary care,1,2 the recent British National Service Framework (NSF) for Older People has called for the early detection and diagnosis of mental health problems among older people.3 As yet, there is no agreement on the most effective method of case finding. Universal screening of all patients over a specific age will provide the greatest yield of cases of depression. However, a potentially more efficient use of resources is the targeting of subgroups with an increased risk of depression. In this paper, we report the ability of routinely collected information in primary care to identify patients aged 65–74 years with depression.
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Methods |
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The study population included all patients aged between 65 and 74 years registered with a large general practice in Melton Mowbray, Leicestershire, UK. Nursing home residents were excluded. The study design was a two-stage survey and concurrent audit of general practice records.
Participants in the first stage were interviewed in their home by trained interviewers. Those found to be moderately or severely cognitively impaired subsequently were excluded from the study, scoring 
8 on the CAPE I/O.4 Depressive symptoms were identified using the 15-item version of the Geriatric Depression Scale (GDS-15).5
Those with a GDS-15 score of 4 were invited to take part in a second stage interview carried out by the lead investigator (UF), using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN).6 Cases of major depression were in accordance with ICD-10 criteria.
The audit of primary care records was carried out by a trained nurse for all those in the study population, with the exception of those who actively refused the research team access to their medical records. To determine the number of depressed individuals in each subgroup, we adjusted for non-participation in the SCAN interview assuming the proportion of depressed individuals among non-participants was the same as in participants. To calculate an estimate of the prevalence of depression, we applied sampling weights to account for the two-stage sampling design.7
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Results |
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A total of 1912 of the eligible 2633 individuals (72.6%) participated in the first stage interview, with 16 scoring
8 on the CAPE I/O and therefore excluded. Of the remaining 1896, 134 scored 4 on the GDS-15 and were invited to take part in the second stage, with 90 patients (67.2%) agreeing to undergo a SCAN interview. Participants (n = 90) in the second stage SCAN interview did not differ significantly from non-participants (n = 44). The number of cases of major depression identified among the 90 participants in the SCAN interview was 20. When non-participation in SCAN interview was adjusted for, the prevalence of major depression was estimated as 1.6% [95% confidence interval (CI) 1.1–2.1%].
To identify one case of depression, it would be necessary to assess 63 (95% CI 48–93) patients with the GDS-15 scale (Table 1
). By targeting those who live alone, the number required to complete the GDS-15 to detect one case would be 32 (95% CI 22–58) patients. To identify one case of major depression in those who frequently attend their GP (three or more times in 1 month), 12 would need to be assessed (95% CI 11–13). However, because this group represents only 4.2% of the total practice population, targeting frequent GP attenders would identify less than a quarter (7/30) of all cases of major depression.
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Discussion |
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The aim of this study was to identify subgroups with a higher prevalence of depression who might be appropriate targets for active case finding. Our data show that the investigation of each high prevalence subgroup would detect only a minority of all cases in the total population. However, applying these methods to the whole practice population would be both time-consuming and costly.
Nursing home residents were excluded because their number is small within this age group and any case-finding strategy is likely to adopt a different approach for non-community-dwelling older people. We focused on major depressive episodes to the exclusion of lesser depressive symptoms, as a number of studies in adults have failed to show a significant benefit from drug treatment or psychotherapy among patients with lesser depressive symptoms.8,9
The over-75 health checks are a potential vehicle for picking up depression through use of simple scores such as the GDS-15 to identify patients who need further investigation by their GP. However, the aforementioned NSF for older people is aimed at all those aged 65 years and over. Our findings suggest that using routinely collected data to target groups for identification with these methods is unlikely to be able to identify late life depression among those aged 65–74 years. We have focused on data readily available in primary care, and this restricts the nature of the groups that can be targeted. Perhaps unsurprisingly, the prevalence of major depression was highest among those receiving antidepressants. However, failure of antidepressant medication requires detection in order to explore other treatment options, and this subgroup should not be overlooked.
Late life depression is strongly associated with physical co-morbidity10 and, as more practices routinely record information on morbidity, these groups may allow more efficient targeting of depression than we were able to. The SCAN psychiatric interview used in the second stage of the study is unlikely to be a feasible tool for routine use in primary care. Further research is needed to look at methods of standardizing the way GPs diagnose late life depression.
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Acknowledgments |
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We would like to thank the partners, staff and patients of Latham House Medical Practice. We are grateful to Jayne Wilson for auditing of medical records, Peta Halls and Jane Johnson for carrying out patient interviews, Diane Hampson, Sarah Gilbert and Joy Slater for clerical support, and Danny Kirby for computing management. The Regional Office of the NHS Executive Trent (Research and Development) funded this research.
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References |
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3 Secretary of State for Health. Older People—National Service Framework. London: Department of Health, 2001.
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