Psychiatry and Primary CareUsing five questions to screen for five common mental disorders in primary care: diagnostic accuracy of the Anxiety and Depression Detector☆
Introduction
Over the past decade, the bridge between medical and mental health care has become increasingly solid, as has the primary care provider's role in psychiatric care. Approximately 20% of primary care patients have had at least one diagnosable mental disorder in the past year [1], and 10–25% have a current anxiety or depressive disorder [2], [3]. Perhaps more importantly, emotionally distressed patients are several times more likely to see a medical provider than a mental health specialist [4]. The individual and societal costs for anxiety and depressive disorders, including decrements in functioning [3], [5], [6], [7], [8], lost work and productivity [5], [9], and increased health care costs [10], [11], [12], [13], [14], [15] underscore the need for treatment. Unfortunately, treatment is received by less than half of emotionally distressed primary care patients [5], [7]. The research community has responded to the need for treatment by developing programs designed for the primary care setting [16], [17], [18], [19].
Before patients can be treated, however, they must be identified. In the absence of systematic screening, 30–40% [2], [20], [21], [22], [23] of patients with anxiety and depression are identified in primary care settings. Some reviews of published studies indicate that screening, on its own, does not improve patient outcomes [24], [25], [26]. Other reviews, however, concluded that there are beneficial effects of providing screening results to clinicians, with larger benefits when screening is combined with effective treatment and follow-up [27], [28], [29]. Recently, the United States Preventive Services Task Force (USPSTF) [27] published their recommendation that depression screening take place when appropriate diagnosis, treatment and follow-up are available.
The literature described above has focused almost exclusively on depression in primary care, whereas anxiety disorders have been virtually ignored. In fact, there is little controversy surrounding the issue of screening for anxiety because guidelines, or even suggestions, for screening for anxiety are almost nonexistent [30]. This is despite the fact that, when compared with depression, anxiety disorders are similarly prevalent [3], [7] and patients with anxiety disorders suffer from decrements in functioning similar to patients with depression [5], [31] or chronic diseases such as diabetes and congestive heart failure [31].
In considering the implementation of a screening program, one clear barrier is that the current screens are either lengthy [32], [33], [34], [35] (even a scale such as the nine-item PHQ-9 [36] is probably too long when screening for multiple disorders), focus on a single disorder (e.g., panic disorder) [37] or both [38], [39]. Several studies have indicated that a lengthy instrument is not necessary. For example, in a review of 18 studies reporting the properties of nine screening instruments for depression, ranging in length from 2 to 28 items, there were no differences in sensitivities or specificities of the screening instruments, leading the authors to conclude that one screen was as good as another, and choice of screening instrument could be based on the clinician's preferences and reasons for use [40]. Although others [41] have suggested using a series of single items (followed by longer assessments to assign diagnoses) to screen for multiple disorders, the psychometric properties of screens assessing multiple disorders, each with a single item, have not been assessed. An approach that has come close, however, is the identification of a few items that serve as clinical predictors, such as a general anxiety or depression screen, recent stress, a count of physical symptoms or relationship difficulties, the combination of which may identify primary care patients with psychiatric needs [45], [46].
Are there patient characteristics, such as gender or ethnicity, that reliably influence the effectiveness of a screening instrument? To the best of our knowledge, prior studies have not set out to evaluate the effects of patient characteristics on screening results. The present study examined this question while assessing the diagnostic accuracy of a very brief five-item screening questionnaire for anxiety and depressive disorders in primary care.
Section snippets
Method
The study was conducted as part of the Collaborative Care for Anxiety and Panic (CCAP) study [16], [17], [42] and included patients from university-affiliated primary care clinics in Seattle and southern California. A total of 12,724 patients were approached and asked to participate in the study by one of 52 undergraduate research assistants during a visit to one of the clinics. Screening took place at various days and times over a 25-month period with a special effort made to sample from all
Results
Approximately 62% of participating patients were female, and 38% were male. Patients ranged in age from 18 to 79 (mean=41.49, S.D.=12.48). The sample was fairly well educated, with 5% having less than a high school education, 17% having a high school diploma, 35% having completed technical school or some college, 27% having a college degree and 16% identifying graduate school as their highest level of education. Patients were asked to identify themselves as belonging to one or more of the
Discussion
This study addressed the need for a brief, efficient screen for common anxiety and depressive disorders in primary care. The results suggest that five items can effectively screen for panic disorder, PTSD, social phobia, GAD and depression in primary care. When combined, we call these five items the Anxiety and Depression Detector (ADD). The five items of the ADD were administered across two screening questionnaires, each with three items. For the screening questionnaires, sensitivities ranged
Acknowledgments
We would like to gratefully acknowledge the helpful support of the primary care providers who acted as facilitators of this study in their clinics: David Dugdale, MD; Daniel Lessler, MD; Michelle Bholat, MD, MPH; Burt Liebross, MD; Jennifer Wu, MD; Martin Schulman, MD.
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This research was supported in part by grants from the National Institutes of Health awarded to Drs. Stein (#MH57835, #MH64122), Craske (#MH58915) and Roy-Byrne (#MH57858, #MH065324).