There are two ways to describe the causes of agitation and aggression: by the underlying disease state (see Table 1), or the exact pathophysiology that causes the aggression. The DSM-IV-TR has several diagnostic categories describing the relationship between a medical condition or substance and the specific psychiatric symptoms or syndrome they cause. Examples of medical conditions that more commonly cause aggression and agitation symptoms include central nervous system disorders such as head trauma, stroke, tumor, and epilepsy; metabolic disorders such as fluid and electrolyte abnormalities, acid-base abnormalities, thiamine deficiency, hyper- and hypothyroidism, and hypoglycemia; infections such as sepsis, HIV, encephalitis, and urinary tract infections; and others such as systemic lupus erythematosus, postoperative states, especially in transplant or hip replacement procedures, terminal illnesses, and dialysis. Table 2 identifies medications and drugs that may be associated with inducing symptoms of agitation or aggression.

Four characteristics contribute to aggression and violence among people with serious mental illness: acute, poorly controlled mental illness, medication noncompliance, substance abuse, and previous violent behavior. Each is an independent risk factor, and the risk is heightened when factors are combined. People with and without mental illness who use drugs and alcohol have an increased risk for agitation and aggression.

There is no single unifying theory for the underlying pathophysiology of aggression. Brain lesions and changes in neurotransmitter function are two widely accepted theories. As the frontal lobes are responsible for higher order thinking, censoring, disciplining, planning and decision-making, damage to the frontal cortex produces a variety of disinhibited behaviors (patient becomes more agitated or aggressive than prior to receiving medication). Lesions or injury to the basal ganglia, limbic system, thalamus, hypo-thalamus, hippocampus and temporal lobes may also result in abnormal behavior. In a simplistic approach, agents that reduce dopaminergic or noradrenergic tone or increase serotonergic or GABAergic tone decrease aggression (such as any benzodiazepine or antipsychotic agent), no matter what the cause.

There is specific evidence demonstrating an inverse correlation between 5-HIAA, the major meta-bolite of serotonin, and aggressive behaviors.Other theories propose that the mechanism of agitated depression is increased serotonergic responsiveness and decreased GABAergic tone, whereas acute psychosis results from increased dopamine.The pathophysiology is generally more important when planning a long-term strategy to treat the underlying disease rather than when managing an acutely agitated patient who needs immediate attention.

New York, London: The Guilford Press; 1997. 261 pp. with index

ISBN 1-57230-237-2

Anxiety is a profound human experience. Anxiety disorders are universal in human societies, although the diagnostic patterns vary over time and from one place to another. This volume describes some culturally bound anxiety syndromes, but dwells on the diagnostic categories of the Diagnostic and Statistical Manual of Mental Disorders, third (DSM-III), third revised (DSM-III-R) and fourth (DSM-IV) editions. This manual provides diagnostic criteria for panic disorder, phobias, obsessive-compulsive disorder, post-traumatic stress disorder and the generalized anxiety disorder. Twenty-seven prominent psychiatrists, psychologists and experts from related fields contributed to this volume, offering guidelines for diagnosis and culturally informed treatment.

The first part of the book deals with general issues in the cross-cultural treatment of anxiety disorders. The second part of the volume deals with the treatment of specific ethnic groups in the US, including Hispanic-, Caribbean-, Asian- and African-Americans, as well as Orthodox Jews, and Asian-Indian-Americans. The third part of the book examines the relations between psychopharmacology and ethnicity, and modern aspects of the clinical and research agenda in culture and anxiety.

P.J. Guarnaccia addresses risk factors, symptoms of distress, and the diagnosis of post-traumatic stress disorder (PTSD) among refugee groups from Southeast Asia and Central America. PTSD occurs with depressive disorders, and its prevalence rates vary in populations of trauma victims. E. Horwath and M.M. Weissman analyze epidemiological data on anxiety based on DSM-III and DSM-III-R criteria, comparing prevalence rates from the United States with data from other countries. The lifetime prevalence rates of panic disorder are remarkably consistent across community studies and ethnic boundaries. Data on agoraphobia show more variation across studies and cross-culturally.

The chapters in the second part of the book are organized around common themes. These include a description of the culture of the group, its view of mental illness and anxiety, treatment expectations, the possibilities of a therapeutic alliance and family involvement. E. Salman and colleagues examine anxiety disorders of Hispanic-Americans. The authors analyze the culturally bound syndrome of “ataque de nervios,” which is a folk label for loss of control, often with anxiety. The authors stress the need to reconcile the folk diagnoses with the DSM-IV framework.

S.-A. Gopaul-McNicol and J. Brice-Baker compare indigenous and western treatments of anxiety disorders in the Caribbean. G.Y. Iwamasa analyzes demographic and clinical variables in Asian-Americans, who tend to underuse both outpatient and inpatient mental health services. The author points out that, in many Asian ethnic groups, the needs of the family take precedence over those of the individual, that and religion and spirituality are important in everyday family life. CM. Paradis and her colleagues focus on the cognitive-behavioural treatment of anxiety disorders and emotional problems of Orthodox Jews, a minority in their own community. Confidentiality is important in this culture, and mental illness often has to be concealed. The assessment and treatment of patients with strong religious beliefs remain a mental health challenge.

There is still limited information on anxiety disorders in African-Americans. A.M. Neal-Barnett and J. Smith argue that the African-Americans have been targets of misdiagnosis. The authors discuss the clinical importance of spirituality, of the extended family and the therapeutic alliance in the treatment. R. Viswanathan and colleagues stress the fact that some attitudes of patients from the Indian subcontinent tend to be sociocentric rather than egocentric. Family and neighbours are valued, gender and hierarchical roles are rule-bound, and behaviour is influenced by the concept of shame.

In the third part of the volume, I.M. Lesser and colleagues provide a valuable overview of the clinical research on psychopharmacology and ethnicity, mechanism of drug effects and response to treatment. The authors highlight the interplay of ethnic background and genetics, but many of the important variables and relations need more research. In his closing chapter, L.J. Kirmayer reflects on the role of culture in emotional experience, considering the variations of anxiety symptoms in an increasingly ethnically diverse society.

The authors offer an updated and deep insight into factors inherent in the development, manifestation and treatment of anxiety in subjects from different cultures and ethnic groups. The book is well structured and clearly written, though the anxietynculture relations are complex and the evidence is still fragmented. This useful book will interest students and scholars in transcultural psychiatry/psychology and mental health professionals working with patients from ethnic groups.

In most surveys, the number of patients with absolute treatment resistance is very small. In some specialized tertiary referral clinics, only about 7% of patients remain depressed after 1 year of extensive investigations and treatment. However, extensive treatment involves many drug trials, singly and in combination, as well as ECT. Typically, people with absolute treatment resistance are older (mean age about 55), have been depressed for a longer period of time, and have insoluble life problems. Some help can be offered, even to this group of patients. Carefully prescribed, psychostimulants can help to decrease depression and increase energy. In this context, psychostimulants can be seen as psychic painkillers and their use can be compared with that of analgesics in other chronic pain syndromes.

Supportive and cognitive psychotherapy can also be of benefit. Supportive psychotherapy allows depressed patients to carry on in the face of a handicap; cognitive psychotherapy allows some patients to view the world differently, and this can lead to positive thinking and beneficial lifestyle changes, such as regular exercise, cessation of smoking, and reduction of alcohol consumption. Jogging has been reported to have an antidepressant effect.

Conclusion

Treatment-resistant depression is a relative term. All patients can at some point be considered relatively resistant to therapy, depending on how far the physician is willing to go in the patient’s treatment. The appropriate use of tricyclic or heterocyclic antidepressants or MAOIs can relieve the symptoms of at least two thirds of patients. Drug combinations, ECT, or augmentation strategies can, if vigorously applied, reduce the percentage of patients who are truly treatment resistant to about 7%. Considering the morbidity and mortality associated with depression, a vigorous approach to therapy is worthwhile.

Résumé

(French Language)

De nombreux facteurs peuvent influencer le résultat du traitement de la dépression, un problème de santé communautaire important et qui comporte un taux significatif de mortalité et de morbidité. Les deux tiers des patients répondront bien aux antidépresseurs. Les autres seront traités par d’autres moyens. Seuls 7% des patients seront absolument résistants au traitement, mais il est tout de même possible de leur venir en aide.

Managing Mental Health Problems. A Practical Guide for Primary Care

Managing Mental Health Problems.

A Practical Guide for Primary Care

Nick Kates, Marilyn Craven
Hogrefe & Huber Publishers, 12 Bruce Park Ave, Toronto, ON M4P 2S3
1998/390 pp

Strengths

Practical, useful instruction

Weaknesses

Not comprehensive

For a long time, managing mental health problems in primary care has been poorly understood and criticized by physicians not principally involved in primary care. I believe this misunderstanding stems in part from not having defined the skill set unique to family practice. Therefore, the authors have done much to fill that gap in the primary care literature by publishing this book.

The authors are well-known to many family physicians through their links to the psychiatry and family practice departments at McMaster University in Hamilton, Ont. Their involvement in fostering shared mental health care anticipates the growing reality that family physicians are being asked to provide more mental health care. This book offers a solid, practical working definition of the skill set necessary to meet that challenge.

Particularly useful are the many lists, tables, medication summaries, and information sheets that can be useful as patient handouts. Each chapter concludes with a list of “reasonable expecations of the primary care provider.” These are behavioural objectives that, taken collectively, should be a “core curriculum” for any practising family physician.

There are some omissions. The norepinephrine-dopamine modulator class of antidepressents is not covered. The chapter “Mental Health Problems in the Older Patient” deals only with dementia and depression. Some of the management recommendations cannot be followed because the services recommended are not available. For example, mood disorder clinics and basic psychologist and social work support are not available in many parts of rural Canada.

Aside from that, I know I will refer to this practical, useful textbook often.

Answer. I can understand how the stigma of your depression might be a source of distress to you, even though we now have a number of excellent role models of successful mental health professionals who suffer from mood disorders. An excellent example is Dr. Kay Redfield Jamison, author of An Unquiet Mind; Jamison herself suffers from bipolar disorder, and has confronted this publicly and in her writing.

Regarding rates of relapse or recurrence of major depression: the bad news is, major depression tends to be a recurrent illness. As a group, about 55% of individuals with a single episode of major depression will go on to have a second episode. Individuals who have had two episodes have a 70% chance of having a third. The good news is that with appropriate medication and psychotherapy, the outlook is quite favorable. Frank et al (Arch Gen Psychiatry, Dec. 1990) found that when patients with recurrent depression were treated with imipramine 200 mg per day in combination with interpersonal therapy, nearly 80% went for three years without a recurrence of major depression. This has generally been my clinical experience with patients who initially do well on various antidepressants (including Wellbutrin) and are maintained in appropriate psychotherapy.

I am not aware of any studies that have actually determined rates of major depression among mental health professionals. However, there are several studies of professional “burnout” that you may be interested in. Clark et al (Hospital & Community Psychiatry, August 1987) looked at burnout among psychiatrists in community mental health centers and found that 46 of 96 expressed dissatisfaction with their work. Another study of burnout found that among the psychiatric staff of a large HMO, “high emotional exhaustion and depersonalization” were found, based on the Maslach Burnout Inventory (Snibbe et al, Psychol Rep, 1989; 65:775-80). You may also be interested in the article by Cushway & Tyler on “stress in clinical psychologists” (Int J Soc Psychiatry, Summer 1996).

Regarding signs to watch for, this could become a problem if it begins to preoccupy you. Hypervigilance usually creates its own problems, in my experience. Symptoms I am sure you are familiar with-sleep disturbance, loss of appetite, reduced energy, etc. – would be of concern, of course. If it is of any consolation, I have personally known or treated a number of mental health professionals with major depression, and you are far from alone in this respect. Your professional practice organization might have more information and/or referrals for support. Good luck!

Bongar B, Berman AL, Mavis RW, Silverman MM, Harris EA, Pakman WL, editors

New York: The Guilford Press; 1998.197 pp with index

ISBN 1-57230-302-6 (cloth)

This book was written in response to the fact that most psychiatrists lose a patient to suicide sometime during their professional life. Suicide cases are a leading reason for malpractice action against mental health professionals. Dr. Bongar begins by suggesting that this book is “a forum for the exploration of avoiding liability in working with the suicidal patient.” In his introduction, Bongar stresses that the book is not intended as a standard of care, but rather “a rich and wide-ranging set of opinions and guidelines.” However, the book is quite contradictory on this point — Chapters 1, 3 and 4 are dedicated to discussing standards of care and the suicidal patient. Since this book, authored by experts in suicidology, and based on work published in the American Association for Suicidology’s official journal, will have an important impact on the care of suicidal patients, its deficiencies must be addressed.

This book includes 3 chapters based on articles previously published in Suicide and Life-threatening Behavior, and 4 new chapters. The contributors include many of the most prominent American suicidologists, including Drs. Alan Berman, Bruce Bongar, Robert Litman, Ronald Maris, Morton Silverman and Andrew Slaby. Chapter 1 is dedicated to the outpatient management of suicidal patients. It discusses common failure scenarios from malpractice proceedings and goes on to outline an outpatient standard of care. Bongar and coauthors originally published this paper in Suicide and Life-threatening Behavior in 1992. In Chapter 2, Dr. Slaby presents the essential elements of outpatient care of the suicidal patient. However, given its all-encompassing goal, the chapter ends up being a cursory discussion of many important issues. For example, when discussing the management of patients with borderline personality disorder, Dr. Slaby simply concludes, “Clinicians are not gods and are not able to predict or prevent all deaths by suicide. This is most true when they are dealing with Axis II personality disorders.” (page 35). Fortunately, the American Psychiatric Association is developing practice guidelines for the care of patients with borderline personality disorder. This will provide a more comprehensive statement about what is known and not known about the care of these patients. Chapters 3 and 4 are based on articles that were published in 1993 and 1994, respectively, in Suicide and Life-Threatening Behavior. The editors have included a commentary of Chapters 3 and 4 from Dr. Robert Litman, who criticizes Dr. Silverman’s Chapter 4 for providing good clinical practice standards, but not the minimal standards that are often the reference point for court proceedings. Chapter 5 is a new contribution by Drs. Goldblatt, Silverman and Schatz-berg, dealing with the psychopharmacological treatment of suicidal inpatients. However, the chapter is disturbingly incomplete. For example, the value of lithium maintenance treatment in reducing the risk of suicide for bipolar disorder and clozapine treatment in reducing the risk of suicide in schizophrenia are inadequately addressed. These treatments may have important indications in the suicidal behaviour of individuals with these specific diagnoses. Also, the discussion of borderline personality disorder is badly outdated; for instance, their most recent reference is from 1986 and recent evidence for using selective serotonin reuptake inhibitors for individuals with impulsive aggressiveness is ignored. Chapter 6, a new contribution by Dr. Silverman, purports to be a model for psychopharmacological interventions for hospitalized patients. A psychiatrist will find this discussion broad and uninformative. I suspect that the target audience for this chapter is the psychologist, who may find discussion of the steps that are needed to determine appropriate psychopharmacotherapy informative. The last chapter on the risk management of suicidal patients, by Drs. Packman and Harris, contains very practical suggestions for minimizing liability. For example, the authors provide an approach for discussing, at the outset of therapy, breach of confidentiality when a highly suicidal patient is in crisis and there is a need to inform the patient’s family. This chapter is more current, as it discusses the issues of liability in the managed care environment. A document that includes in its title “standard of care” for suicidal patients has the potential to do more harm than good. This book is primarily based on data from malpractice claims to develop “standards of care” for suicidal inpatients and outpatients. As a result, most of the chapters are outdated with regard to recent scientific evidence. The 3 reprinted chapters appear to have been published without any attempt to update the references. The new contributions do not provide a clear statement of the nature of the supporting evidence used to develop their approach, and do not appear to include the evidence based on empirical research. Therefore, this book eschews the scientific evidence that has accumulated to guide clinical practice. Drs. Rudd and Joiner have recently published a paper on the assessment, management and treatment of suicidality based on existing literature, and provide an important alternative to the approach by Bongar and colleagues.

The book is under 200 pages, well produced and contains no production errors. Although this book will attain prominence in the fields of psychiatry and psychology, the reviewer cautions that it has employed a very limited methodology to determine standards of care for suicidal patients. This contribution must be seen as only one facet in the development of the appropriate care for suicidal patients.

The early detection of depression is much more complex and challenging than the detection of other conditions seen in the primary care physician’s office. Perhaps the most significant reason for this is how the natural history of depression differs from that of most conditions for which there are effective measures for prevention or early detection. The successful early detection of diseases or of patients at risk for adverse events has generally involved conditions that follow a continuous or progressive course and are detectable in the presymptomatic phase. Examples are cervical cancer (the Papanicolaou smear), breast cancer (clinical breast examination and mammography) and hypertension (screening for elevated blood pressure). The natural history of depression is not one of a continuous, unresolving disorder with a defined and detectable presymptomatic phase. In many cases the depression progresses continuously, becomes severe and is readily detected clinically. However, in some cases of mild and, indeed, more severe depression patients improve without specific intervention (or even recognition).

A second problem relates to the role that symptoms play in depression. The goal of early detection is to identify disorders in the presymptomatic stage. This is usually most successful when the condition has a relatively long presymptomatic stage, there are good objective confirmatory diagnostic tests and the symptoms often occur only at an advanced stage. In a sense depression has none of these three characteristics. It is diagnosed essentially on clinical grounds, the early stages are associated with symptoms (often nonspecific), and the “presymptomatic” stage (even if there is one) is not necessarily prolonged, at least relative to other conditions. Since many early symptoms of depression also occur in other conditions (both physical and psychologic) the early detection of depression becomes even more complicated. Therefore, the development of an effective, accurate instrument is extremely difficult.

As Canada becomes increasingly multicultural additional problems arise concerning the use of early detection tests. During their development most instruments are not evaluated across a variety of cultures. Because the presentation of depression and the significance of associated symptoms can vary between cultural groups the routine use of early detection instruments may be difficult for physicians who care for people of different cultural and ethnic backgrounds.

Finally, several problems remain with the detection instruments themselves. Few of those that have been more carefully developed are specific for depression. Those that do focus on depression often have important development and testing shortcomings. Several instruments have been designed to detect the early stages of psychologic distress but are not diagnostically specific for depression or do not assess its severity. In addition, with some instruments the patients’ responses cannot easily be synthesized into a clinically useful score. Many tests do not achieve the sensitivity and specificity required to be considered successful.

Conclusions

From the primary care physician’s point of view the current situation is relatively clear-cut, though far from ideal. The available evidence does not support routine screening for the early detection of depression. In fact, studies that have evaluated the effectiveness of screening instruments in clinical practice tend to argue against their use at present. None the less, depression is an extremely important and common condition and deserves careful attention from primary care clinicians. The literature indicates that important episodes of depression are being missed. Hence, the problem is far from resolved.

Future directions

Clinicians must continue to be sensitive to and aware of the early stages of depression and carefully pursue their suspicions. Further research and development is required before the widespread routine use of even the best test can be recommended as part of the periodic health examination. Work is required in instrument development, particularly in light of the natural history of depression. Other avenues and approaches to early detection must be explored. Possibly the most useful approach would be a simple “diagnostic” test physicians could use in the office if they are concerned that a patient is in the early stages of depression. This may be more efficient than routine testing of all patients. Further work to improve the identification of people at high risk should have considerable benefit as well. Because early detection instruments may have some value in the elderly population more studies to evaluate early detection and subsequent management in this age group may prove valuable.

Résumé

(French Language)

La morbidité estimative de la dépression dans l’ensemble de la population va de 3,5% à 27%. Cette maladie très pénible amène souvent le suicide. Le traitement est efficace dans la plupart des cas; cependant de graves épisodes dépressifs échappent au diagnostic. Afin de savoir si la visite médicale périodique devrait comporter la recherche systématique des symptômes précoces de dépression nous retraçons dans MEDLINE et Science Citation Index les études comparatives aléatoires de l’usage de questionnaires à cette fin. Nous retenons sept outils qui répondent à nos critères de qualité: le Beck Dépression Inventory, la Center for Epidemiologic Studies Dépression Scale, la Zung Self-Assessment Dépression Scale, le Gêneral Health Questionnaire, la Hopkins Symptom Checklist, le Mental Health Inventory et la Hospital Anxiety and Dépression Scale. Les quatre essais comparatifs aléatoires ne militent pas suffisamment pour le dépistage systématique. Le diagnostic précoce de la dépression est difficile vu le génie évolutif de la maladie, la variabilité de sa symptomatologie, la diversité culturelle du Canada et l’insuffisance des outils de dépistage. Si le médecin de première ligne doit être à l’affût de la dépression on ne peut lui recommander à cette fin l’emploi d’outils de dépistage qui ne seraient pas plus perfectionnés et fondés sur de meilleurs travaux de recherche que ceux dont on dispose actuellement.

The critical question with any intervention for early detection and treatment is whether it does more good than harm as compared with the results of later diagnosis and intervention. The appropriate research tool for answering such a question is the randomized controlled trial. A MEDLINE search of the literature and subsequent secondary searches identified only four trials of sufficient methodologic quality. In each study the basic question was whether the routine testing of patients just before seeing their physician provided any benefit in terms of detection and management of depression beyond that achieved through the usual clinical evaluation. The evaluation of effectiveness incorporated the explicit criteria of Sackett, Haynes and Tugwell.

In a study by Shapiro and associates 1242 patients attending an inner-city primary care teaching facility over 4 months completed the GHQ (General Health Questionnaire) while waiting to see their physician. In addition, each patient underwent a structured interview (the Diagnostic Interview Schedule [DIS]) at home within 2 weeks after visiting their physician. The 488 subjects (39%) with positive GHQ scores were randomly assigned to one of three groups: (a) no feedback to the physician, (b) provision of the GHQ results to the physician immediately after completion of the questionnaire and (c) provision of the DIS findings to the physician immediately after the interview. Of the patients with negative GHQ results 40% were randomly assigned to one of two groups: (a) no feedback and (b) provision of the findings to the physician immediately after the questionnaire. The GHQ and the DIS were repeated after a 6-month follow-up for 6 months.

The provision of GHQ information had no statistically significant effect on the physician’s diagnosis. Among patients over 65 years of age there was a statistically significant increase in the detection rate. However, there was no ultimate effect on patient management, even in the elderly group. Shapiro and associates speculated that the GHQ data may have had a marginal impact for patients with low to medium GHQ scores when the physician was uncertain about the symptoms and complaints.

Hoeper and collaborators used the GHQ (General Health Questionnaire) to screen 1469 patients in a Wisconsin primary care office over a 5-month period. The people were then randomly assigned to either a group in which the physician received the score at the end of the visit or one in which the physician received no information. Physicians completed a standardized record tailored to address mental health issues. Knowledge of a positive GHQ result had no effect on the rate of detecting psychologic distress. The GHQ identified 28% of the patients as having psychologic distress; however, only 16% were identified by the physicians. The impact on management and patient outcome was not assessed. Furthermore, there was no description of patient selection or an attempt to assess the bias of using a special record.

Zung and colleagues asked 1086 patients over a 12-month period to complete the SDS (Zung Self-Assessment Depression Scale) in the waiting room of their family physician. Of the 143 patients (13%) with positive scores 102 were randomly allocated to a group in which the physician was immediately informed of the results and subsequently applied a structured interview during the patient’s visit; the other 41 were allocated to a group in which the physician was not told of the results. At follow-up 4 weeks later the patients were reassessed with the SDS and the charts reviewed for indications that the physician suspected or was treating depression. Among those whose physician was notified of the results 68% had charts indicating physician awareness of depression, as compared with only 15% of those whose physician was not informed. After reassessment at 4 weeks 64% of the identified patients showed clinical improvement, as compared with 18% of those who were in the unidentified (and untreated) group.

Unfortunately, the study by Zung and colleages has several major design flaws and provides inadequate evidence to support its conclusions. Not only was there insufficient validity testing of the SDS (Zung Self-Assessment Depression Scale) but also the study period was extremely brief. There was no indication of patient selection or of the proportion of patients who agreed to participate. Most important, there was a considerable loss to follow-up, so that the results represented only a small portion of the patients entered into the study.

In a rather complex study in Britain a general practitioner had 1093 consecutive patients complete the GHQ in the waiting room before their visit. In addition, the physician briefly assessed their psychologic status during the visit. For half the patients the physician reviewed the GHQ results at the end of the visit and extended the discussion as necessary. The others served as control subjects, the physician receiving no GHQ (General Health Questionnaire) results. After 1 year all of the patients were asked to complete the GHQ again, underwent a brief clinical assessment and were interviewed to assess the duration and severity of any psychiatric symptoms during the preceding year. On the basis of these findings the patients were labelled (retrospectively) as having transient, mild or severe psychologic problems.

During the study period 16% of the patients were treated for new episodes of psychiatric distress without data from the GHQ (General Health Questionnaire). An additional 11% were identified as a result of the GHQ results and further discussion with the physician. Patients with severe problems diagnosed as a result of the GHQ results provided to the physician at the initial visit had lower GHQ scores at 1 year than the control subjects with severe problems.

Although the investigators viewed this approach as being beneficial, there were several methodologic flaws. The control subjects selected for comparison were identified retrospectively, whereas the treatment patients were selected prospectively. The outcome measures relied heavily on patient recall over the preceding 1 year. The methods used to assess the effect of management were relatively indirect.

Although these four trials represent the best evidence currently available, they fail to provide adequate evidence to support the benefit of routine screening for the early detection of depression.

Instruments for routine case-finding in primary care settings must be of acceptable quality, brief and easy to use. Presumably the patients would complete the test while waiting to see their physician. Most self-administered tests have been designed for routine screening purposes and not as diagnostic aids. Some tests have been developed for settings in which the prevalence of depression is higher than in primary care. Because a lower prevalence decreases the positive predictive value, instruments may appear less effective when used in the primary care setting.

In reviewing the literature on self-administered instruments we applied the following criteria.

• Is there a sound conceptual basis on which the instrument was developed, and is this credible?

• Is it intended to detect solely depression or other emotional problems as well?

• Does it measure the severity of depression?

• Has it been tested across a broad spectrum of patients, especially those in primary care or in the community?

• Is it feasible and easy to apply in a clinical setting?

• Is there evidence to support its sensitivity to changes in clinical status?

• Is there evidence to support its reliability?

• Is there evidence that it is a valid measure for the early detection of depression?

A search of MEDLINE and the Science Citation Index identified six instruments that met those criteria sufficiently well to warrant a more in-depth review. A review by Wells provided additional information.

Beck Depression Inventory (BDI)

The BDI was designed specifically for use in clinical settings to identify depression as well as to measure its depth. The test has been used in many different situations with people suffering from various disabilities. The original 21-item version has been scaled down to 13 items. It is generally self-administered, takes less than 10 minutes to complete and asks people to describe their emotional state during the previous week. The total score allows classification into five levels, from normal mental status to severe depression.

The methodologic properties have been extensively assessed, and the performance characteristics are quite good. The BDI (Beck Depression Inventory) is sensitive to change over time with treatment. Reliability studies have shown a coefficient α of 0.73 to 0.92, and concurrent validity studies that compared the BDI with clinical ratings and other scales have shown correlation coefficients of 0.60 to 0.74.

Center for Epidemiologic Studies Depression Scale (CES-D)

This instrument was developed to measure depressive symptoms in the general population. It has been used in clinical settings as well. High scores reflect the distress that accompanies depression but are not diagnostic of depression. The 20-item scale is simple to understand and easy to administer.

The CES-D is sensitive to change in clinical status. Reliability studies have reported a coefficient α of 0.84 to 0.90. Validity studies, in both clinical and community populations, have shown coefficients of correlation with other measures, including structured psychiatric interviews, of 0.51 to 0.89. In studies involving depressed patients the sensitivity has been as high as 91% and the specificity 56%. However, in the general population the sensitivity was only 64%. This relates in part to the instrument’s ability to identify people with symptoms suggestive of psychologic distress rather than to detect clinical depression.

Zung Self-Assessment Depression Scale (SDS)

This brief, self-administered instrument measures the presence and the severity of depressive symptoms but is not a diagnostic tool. Although the SDS is popular there has been almost no empiric testing of the selected items. The heavy weighting of items addressing physical symptoms makes its use difficult among patients whose symptoms are caused by physical disorders.

The SDS (Zung Self-Assessment Depression Scale) is sensitive to change in clinical status, but its reliability has been inadequately evaluated. Validity studies comparing the SDS with other scales, as well as global ratings by psychiatrists, have revealed correlation coefficients of 0.40 to 0.80.

General Health Questionnaire (GHQ)

This instrument, designed specifically to detect psychiatric disorders in primary care, has a subscore for depression. It has been widely used in primary care settings. The original version had 60 questions, but shorter versions of 30, 28, 20 and 12 items have been developed. Areas assessed by the original version included depression and anxiety, social functioning, psychophysiologic symptoms, general health and vague aches and pains.

The internal consistency of the GHQ has been from 80% to 90% and the coefficients of correlation with global clinical assessments of psychopathology 0.55 to 0.83. The overall sensitivity has been about 68% and the specificity 81%.

Hopkins Symptom Checklist

The current 25-question version, shortened from the original 90-question version, measures only depression and anxiety and has been designed for use in primary care settings. The original version was intended for use in studies of psychotherapy and chemotherapy among psychiatric patients. The instrument is sensitive to changes in clinical status. Studies assessing its measurement properties have demonstrated an internal consistency as high as 95%, and coefficients of correlation with psychiatrists’ global ratings of severity of depression have been 0.70 to 0.77. The correlation has been shown to be lower for scores of severely depressed patients.

Mental Health Inventory (MHI)

The MHI was developed to measure mental health in the Rand Health Insurance Experiment. The original 38-question format has not been changed, and an extremely brief 5-question version is available. The internal consistency has been in the range of 96%. Although the MHI is not specific for depression, studies have shown that it does predict the future use of mental health services.

Hospital Anxiety and Depression Scale (HADS)

Designed for use in nonpsychiatric hospital clinics this brief scale identifies only depression and anxiety and measures their severity. It consists of seven items for each component. Only psychiatric symptoms are targetted; thus, symptoms that might be attributed to physical or emotional problems are avoided. The sensitivity to change has not been assessed. Internal consistency has been 30% to 60%; coefficients of correlation with other instruments, as well as clinical assessment, have been as high as 0.79 for the depression component. Although short and feasible, the HADS has not been extensively tested or widely used in North America.

All physicians must be sensitive to verbal and nonverbal cues that might reflect an episode of depression. Whether a brief, systematic assessment for undeclared depression should be an integral part of the periodic health examination of asymptomatic patients has yet to be determined.

In 1979 the Canadian Task Force on the Periodic Health Examination stated that there was fair evidence to exclude early systematic assessments of depression from the periodic health examination. In reassessing the situation 10 years later we paid particular attention to the quality of early detection instruments currently available, the evidence of the effectiveness of early detection efforts and the features that impede early detection.

Burden of illness

Community surveys of the prevalence of depression have generated estimates of 3.5% to 27%. Clearly, such estimates are affected by the choice of criteria defining depression, the population studied, the assessment methods and the time frame. Our understanding of the epidemiologic features of depression has improved considerably over the past decade. Carefully performed surveys have suggested that 15% to 30% of adults experience clinically significant depression at some point in their lives. The Epidemiologic Catchment Area Study, a landmark survey involving over 18 000 people, identified a 6-month prevalence rate of 2.2% to 3.5% for major depression. These data are supported by findings from studies in family practice and ambulatory care settings that showed depression ranking high among all conditions encountered.

The lifetime prevalence of depression is roughly twice as high for women as for men. The peak prevalence among women occurs between 35 and 45 years of age. Among men the prevalence increases with age. First-degree relatives of people with depression are more likely to become depressed. In Canada in 1986 suicide accounted for an estimated 97 600 potential life-years lost among males and 25 300 among females, the associated direct and indirect costs being $1.6 billion per year. It has been suggested that identifiable depression is causally related to 60% of suicides.

Is depression being recognized?

Depressed patients may present with various complaints, which makes recognition a challenge, particularly in the early stages of depression. In one review of 400 depressed patients in a primary care setting, only 49% presented with a psychologic complaint. In another primary care study depression went unrecognized in about 50% of patients who presented with nonpsychologic complaints yet who met the standardized clinical criteria for major depression. However, although other studies have confirmed that depression is easily missed, they have suggested that many patients have self-limited mild depression. Many overlooked cases may be identified subsequently; however, these data suggest potential benefit if an effective means of early recognition were available.

Is effective treatment available?

Once recognized most cases of depression can be treated effectively. The mainstays of therapy have been tricyclic and “new-generation” antidepressants and psychotherapy. Tricyclic antidepressants have long been considered to be effective and to decrease somewhat the risk of early relapse. Similar support exists for monoamine oxidase inhibitors, but the potential side effects have limited their use. Psychotherapy, although widely practised and generally accepted as being effective, is more difficult to study, and the results of evaluations are often harder to interpret than those of drug trials. Most reviews of randomized controlled trials and meta-analyses, however, do support the effectiveness of psychotherapy. Combined treatment with antidepressants and psychotherapy may produce better outcomes than either treatment alone.

The use of lithium to treat bipolar disorders and the controversial role of electroconvulsive therapy will not be included in this review.