The 'help' question doesn't help when screening for major depression: external validation of the three-question screening test for primary care patients managed for physical complaints

Abstract

BackgroundMajor depression, although frequent in primary care, is commonly hidden behind multiple physical complaints that are often the first and only reason for patient consultation. Major depression can be screened by two validated questions that are easier to use in primary care than the full Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria. A third question, called the 'help' question, improves the specificity without apparently decreasing the sensitivity of this screening procedure. We validated the abbreviated screening procedure for major depression with and without the 'help' question in primary care patients managed for a physical complaint.MethodsThis diagnostic accuracy study used data from the SODA (for 'SOmatisation Depression Anxiety') cohort study conducted by 24 general practitioners (GPs) in western Switzerland that included patients over 18 years of age with at least a single physical complaint at index consultation. Major depression was identified with the full Patient Health Questionnaire. GPs were asked to screen patients for major depression with the three screening questions 1 year after inclusion.ResultsOf 937 patients with at least a single physical complaint, 751 were eligible 1 year after index consultation. Major depression was diagnosed in 69/724 (9.5%) patients. The sensitivity and specificity of the two-question method alone were 91.3% (95% CI 81.4 to 96.4) and 65.0% (95% CI 61.2 to 68.6), respectively. Adding the 'help' question decreased the sensitivity (59.4%; 95% CI 47.0 to 70.9) but improved the specificity (88.2%; 95% CI 85.4 to 90.5) of the three-question method.ConclusionsThe use of two screening questions for major depression was associated with high sensitivity and low specificity in primary care patients presenting a physical complaint. Adding the 'help' question improved the specificity but clearly decreased the sensitivity; when using the 'help' question, four out of ten patients with depression will be missed, compared to only one out of ten with the two-question method. Therefore, the 'help' question is not useful as a screening question, but may help discussing management strategies.

Depression in primary care: part 1—screening and diagnosis

“…The sensitivity and specificity of the two question method alone were 91.3% (81.4% to 96.4%) and 65.0% (61.2% to 68.6%), respectively. Adding the “help” question improved the specificity to 88.2% (85.4% to 90.5%) but decreased the sensitivity to 59.4% (47.0% to 70.9%) 56. Although additional studies are needed to further understand the potential benefits of a “help” question as a screening approach, there is likely value in using it to enable ongoing discussions and treatment planning in the primary care setting.…”

Primary care Screening Questionnaire for Depression: Reliability and validity of a new four-item tool

“…However, a more recent cohort study on their three-question tool (with the help item) had substantially lower sensitivity (59.4%), although specificity was retained (88.2%). 25 Unlike ‘desire for help’ which was added by the Auckland investigators, 24 we chose to ask about ‘lack of energy’, which is the third essential criterion in ICD-10. We asked about insomnia as the fourth question, because insomnia is highly prevalent in depression and easily elicited in primary care.…”

“…The Auckland investigators had earlier added a question on the ‘need for help’ to their two-question screening tool 24 and reported that the sensitivity of the instrument remained high at 96%, and the specificity improved to 89%. However, a more recent cohort study on their three-question tool (with the help item) had substantially lower sensitivity (59.4%), although specificity was retained (88.2%) 25 . Unlike ‘desire for help’ which was added by the Auckland investigators, 24 we chose to ask about ‘lack of energy’, which is the third essential criterion in ICD-10.…”

Diagnostic accuracy of the Whooley depression tool in older adults in UK primary care

“…However, evidence from recent studies does not support using a third 'help' question given the significant decrease in sensitivity. Lombardo et al Lombardo et al (2011) reported a rise in cases of depression being missed: from 1 out of 10 using the two item tool; to 4 out of 10 cases being missed with the use of a 'help' question. Given that other studies (Ryan et al, 2012) also reported significant drops in sensitivity, there is concern that adding a 'help' question to a two-item screening tool will lead to an unacceptable number of missed cases of depression.…”