Research report
Can general practitioners identify people with distress and mild depression? A meta-analysis of clinical accuracy

https://doi.org/10.1016/j.jad.2010.07.028Get rights and content

Abstract

Background

There is increasing emphasis on distress and mild depression but uncertainty regarding how well general practitioners (GPs) identify these conditions. Further, the proportion of attendees suffering distress is also unclear.

Aim

To quantify the rate of distress in primary care and to clarify the ability of GPs to identify distressed and/or mildly depressed individuals using their clinical skills.

Methods

Meta-analysis of clinical recognition of distress and mild depression defined on a continuum (severity scale) or categorically (semi-structured interview).

Results

From 157 studies that examined the ability of GPs to diagnose any emotional or mental disorder, we identified 23 that focused on defined distress and 9 that reported on mild depression.

The prevalence of broadly defined distress was 37.4% (n = 23, 95% CI = 29.5% to 45.5) although it was 47.3% (n = 14, 95% CI = 38.0% to 56.7%) using self-report methods. GPs correctly identified distressed individuals in 48.4% (n = 21, 95% CI = 42.6% to 54.2%) of presentations and identified non-distressed people in 79.4% (n = 21, 95% CI = 74.3% to 84.1%) of presentations without distress. GPs correctly identified 33.8% (95% CI = 27.3% to 40.7%) of people with mild depression and had a detection specificity of 80.6% (95% CI = 66.4% to 91.6%) for the non-depressed. Clinicians' ability to recognize mild depression was significantly lower than their ability to recognize moderate–severe depression.

Out of 100 consecutive presentations, a typical GP making a single assessment would correctly identify 19 out of 39 people with distress, missing 20. He or she would correctly re-assure 48 out of 61 people without distress, falsely label 13 people as distressed. For mild depression, out of 100 consecutive presentations, a typical GP would correctly identify 4 out of 11 people with mild depression, missing 7. GPs would correctly re-assure 72 out of 89 people without distress, falsely diagnosing 19.

Conclusions

Clinicians have considerable difficulty accurately identifying distress and mild depression in primary care with only one in three people correctly diagnosed. Clinicians are better able to identify distress than mild depression but success remains limited. However not all such individuals want professional help, and some people who are overlooked get help elsewhere, or improve spontaneously, therefore the implications of these detection problems are not yet clear.

Introduction

Mild mental disorders are increasingly recognized as clinically significant (Backenstrass et al., 2007). People with major depression experience cumulatively more subthreshold symptoms than syndromal episodes (Furukawa et al., 2009). Further, depressive disorders that do not meet diagnostic criteria for major depression as well as those only just meeting criteria are associated with significant morbidity, functional impairment and reduced quality of life (Pincus et al., 1999, Wagner et al., 2000, Preisig et al., 2001, Cuijpers et al., 2004). Recognition and treatment of mild cases might prevent a substantial proportion of future serious cases (Kessler et al., 2003a, Cuijpers & Smit, 2004, Lyness et al., 2006). That said minor depression and distress can be resolved without professional help (Hermens et al., 2004, Forsell, 2007). Beyond depression, distress has similar clinical and prognostic implications (Bultz et al., 2007). Distress refers to significant emotional upset that is common to a range of psychological and psychiatric conditions. In fact a greater proportion of primary care attendees suffer distress than suffer depression. In one study, 28.4% of attendees reported emotional distress but less than half of these reported discussing emotional distress with their primary care physician in the past year (Gross et al., 2007a). Using the HADS total score, de Waal et al. (2005) found distress in 27% of 1500 primary care attendees (de Waal et al., 2005). There is a close relationship between distress and poor mental health (Ustun and Von Korff, 1995). High rates of distress are a risk factor for functional impairment (Klapow et al., 2002). In recent years General Practitioners (GPs) have been observed to have limited success in identifying clear psychiatric disorders such as depression and anxiety (Hirschfeld et al., 1997, Wittchen et al., 2002, Weisberg et al., 2007, Mitchell et al., 2009). However, an alternative approach is to view symptoms of depression on a continuum with the majority suffering mild disorder or subsyndromal conditions (symptoms insufficient to meet operational criteria) (Backenstrass et al., 2006, Prisciandaro & Roberts, 2005). Many suggest that the focus of detection should not be a psychiatric disorder per se but rather the attempt to identify people suffering broadly defined distress who require professional help (Saraceno et al., 1994, Mulder, 2008). Against this some argue that screening has not proven successful and further that detection of mild disorders has equivocal benefits (Palmer & Coyne, 2003, Magruder & Yeager, 2009).

Individuals meeting criteria of a depressive episode but with 4 or 5 symptoms are defined as mild depression in ICD10. In DSMIV mild major depression is defined as those with symptoms barely meet criteria for major depression and result in little distress or interference with the patient's ability to work, study or socialize. Those with core symptoms not fulfilling full criteria are labelled with minor depression. One difficulty, however, is that the definition of distress has not been robustly operationalized in ICD10 or DSMIV. Distress is often used as marker of clinical significance in relation to generalized anxiety disorder, PTSD, dysthymia and depression. Indeed broadly defined distress may not be compatible with an operational definition but may be better graded on a severity scale (Goldberg, 1992). To date most methods that have been developed to evaluate distress have been evaluated in general hospital settings (Forsell, 2007, Derogatis, 1994, Hausam et al., 1998, Roth et al., 1998, Seelert et al., 1999, Ritsner et al., 2002). For example, the US National Comprehensive Cancer Network (NCCN) developed a definition of distress1 along with a single item visual-analogue scale (NCCN, 2007). In primary care, the most common scale to elicit distress is the General Health Questionnaire (GHQ). The GHQ is a self report questionnaire designed to identify distress associated with common mental disorders. The main formats are the GHQ-60, GHQ-30, GHQ-28 and the GHQ-12. Its sensitivity and specificity appear to be close to 80% when measured against a structured interview (Goldberg & Williams, 1988, Makowska et al., 2002, Schmitz et al., 1999a, Schmitz et al., 1999b, Bell et al., 2005). Several alternative tools have also been validated and these include the Hopkins Symptom Check-List (SCL-90-R) (Derogatis, 1977) and the Kessler Psychological Distress Scale K10 (Kessler et al., 2002). The SCL-90-R is a 90 item instrument that aims to evaluate a broad range of psychological problems including somatization, obsessive–compulsive, interpersonal sensitivity, depression, anxiety, anger–hostility, phobic anxiety, psychotism, and paranoid ideation. The Kessler (K10) is a simple measure of psychological distress. The Kessler K10 involves 10 questions about emotional states each with a five-level response scale. The measure is often used as a brief screen for distress or any mental disorder (Kessler et al., 2003b). In a primary care sample of 422 attendees both the SCL90R and the GHQ12 showed similar validity against the SCID (SCL-90-R: mean AUC = 0.75; GHQ: mean AUC = 0.73) (Schmitz et al., 1999c).

Given the uncertainty about distress in primary care, the aim of this quantitative data synthesis was 1. To clarify the typical rate of distress in primary care (prevalence) 2. To summarize the ability of primary care clinicians to detect distressed patients 3. To clarify the ability of clinicians to detect mild depression in primary care settings (either alone or in comparison with non-mild cases).

Section snippets

Inclusion/exclusion criteria

The principle inclusion criterion was the examination of the clinical ability of GPs to detect defined mild mental disorder. We focussed on distress and mild depression as a preliminary search revealed insufficient studies for a meta-analysis anxiety disorders. We separated results for outcomes defined by severity scale from those using research interview (see Tables 1 and 2 for details of criterion standard).

We were interested in unassisted clinical diagnoses without systematic help from

Study description and methods

We identified 157 potential studies but 86 did not adequately define a group with distress or mild depression and 39 studies did not have data on unassisted clinical accuracy of GPs but concerned screening evaluations. We excluded one study measuring distress via CES-D (Chung et al., 2003). We excluded one study where GPs were responsible for generating the gold standard (Jencks, 1985). One large scale comparison of the GHQ12 with the CIDI-PC was excluded as extractable data was not presented

Comment

There has been no previous attempt to summarize how well clinicians in primary care are able to identify people with mild mental disorders, specifically mild depression and distress. Indeed the proportion of attendees suffering distress has itself been unclear although the largest studies suggest at least a quarter have significant distress (de Waal et al., 2005, Ustun & Von Korff, 1995). This meta-analysis of 17,783 individuals found an even higher rate of distress between 37.4% and 44.1% with

Role of funding source

None.

Conflicts of interest

None.

Acknowledgements

Many thanks to the staff of the medical library, Leicester General Hospital.

References (107)

  • A.J. Mitchell et al.

    Clinical diagnosis of depression in primary care

    Lancet

    (2009)
  • M. Olfson et al.

    Recognition of emotional distress in physically healthy primary care patients who perceive poor physical health

    General Hospital Psychiatry

    (1995)
  • S.C. Palmer et al.

    Screening for depression in medical care—Pitfalls, alternatives, and revised priorities

    Journal of Psychosomatic Research

    (2003)
  • M.A. Prins et al.

    Health beliefs and perceived need for mental health care of anxiety and depression—The patients' perspective explored

    Clinical Psychology Review

    (2008)
  • J. Rabinowitz et al.

    Primary care physicians' detection of psychological distress among elderly patients

    American Journal of Geriatric Psychiatry

    (2005)
  • M. Ritsner et al.

    Assessing psychological distress in psychiatric patients: Validation of the Talbieh Brief Distress Inventory

    Comprehensive Psychiatry

    (2002)
  • E. Rosenberg et al.

    Determinants of the diagnosis of psychological problems by primary care physicians in patients with normal GHQ-28 scores

    General Hospital Psychiatry

    (2002)
  • B. Saraceno et al.

    Consequences of mental distress recognition in general-practice in Italy—A follow-up-study

    Social Science & Medicine

    (1994)
  • B.G. Tiemens et al.

    Diagnosis of depression by primary care physicians versus a structured diagnostic interview. Understanding discordance

    Gen Hosp Psychiatry

    (1999)
  • M. Van der Pasch et al.

    Communication in general practice: Recognition and treatment of mental illness

    Patient Education and Counseling

    (1998)
  • D.J.F. Van Schaik et al.

    Patients' preferences in the treatment of depressive disorder in primary care

    General Hospital Psychiatry

    (2004)
  • P.F.M. Verhaak et al.

    Patients with a psychiatric disorder in general practice: Determinants of general practitioners' psychological diagnosis

    General Hospital Psychiatry

    (2006)
  • R.T. Ackermann et al.

    Rational treatment choices for non-major depressions in primary care: An evidence-based review

    J Gen Intern Med

    (2002)
  • DSM-IV: Diagnostic and statistical manual of mental disorders

    (1994)
  • M. Backenstrass et al.

    The care of patients with subthreshold depression in primary care: Is it all that bad? A qualitative study on the views of general practitioners and patients

    BMC Health Services Research

    (2007)
  • T. Bell et al.

    Factors associated with being a false positive on the General Health Questionnaire

    Social Psychiatry and Psychiatric Epidemiology

    (2005)
  • D.S. Brody et al.

    Patients' perspectives on the management of emotional distress in primary care settings

    J Gen Intern Med

    (1997)
  • B.D. Bultz et al.

    Distress—The sixth vital sign in cancer care: Implications for treating older adults undergoing chemotherapy

    Geriatrics and Aging

    (2007)
  • J. Bushnell

    Frequency of consultations and general practitioner recognition of psychological symptoms

    British Journal of General Practice

    (2004)
  • H. Chung et al.

    Depressive symptoms and psychiatric distress in low income Asian and Latino primary care patients: Prevalence and recognition

    Community Mental Health Journal

    (2003)
  • J.C. Coyne et al.

    The relationship of distress to mood disturbance in primary care and psychiatric populations

    Journal of Consulting and Clinical Psychology

    (1997)
  • P. Cuijpers et al.

    Subthreshold depression as a risk indicator for major depressive disorder: A systematic review of prospective studies

    Acta Psychiatr Scand

    (2004)
  • P. Cuijpers et al.

    Psychological treatments of subthreshold depression: A meta-analytic review

    Acta Psychiatrica Scandinavica

    (2007)
  • L.R. Derogatis

    SCL-90-R, administration, scoring, and procedures manual for the revised version

    (1977)
  • L.R. Derogatis

    Symptom Checklist-90-R: Administration, scoring, and procedures manual

    (1994)
  • Y. Forsell

    A three-year follow-up of major depression, dysthymia, minor depression and subsyndromal depression: Results from a population-based study

    Depress Anxiety

    (2007)
  • T.A. Furukawa et al.

    How many well vs. unwell days can you expect over 10 years, once you become depressed?

    Acta Psychiatr Scand

    (2009)
  • J. Gellatly et al.

    What makes self-help interventions effective in the management of depressive symptoms? Meta-analysis and meta-regression

    Psychological Medicine

    (2007)
  • D.P. Goldberg et al.

    The User's Guide to the General Health Questionnaire

    (1988)
  • D.P. Goldberg et al.

    The validity of two versions of the GHQ in the WHO study of mental illness in general health care

    Psychological Medicine

    (1997)
  • R. Gross et al.

    Primary care physicians' discussion of emotional distress and patient satisfaction

    International Journal of Psychiatry in Medicine

    (2007)
  • R. Gross et al.

    The association between inquiry about emotional distress and women's satisfaction with their family physician: Findings from a national survey

    Women & Health

    (2007)
  • D.M. Haller et al.

    The identification of young people's emotional distress: a study in primary care

    Br J Gen Pract

    (2009)
  • R.R. Hausam et al.

    The psychological vital sign: Implementation of a computerized psychological distress assessment tool in primary care

    Journal of the American Medical Informatics Association

    (1998)
  • M.L.M. Hermens et al.

    Clinical effectiveness of usual care with or without antidepressant medication for primary care patients with minor or mild-major depression: A randomized equivalence trial

    BMC Medicine

    (2007)
  • R. Hirschfeld et al.

    The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression

    JAMA

    (1997)
  • J.L. Jackson et al.

    Outcome and impact of mental disorders in primary care at 5 years

    Psychosomatic Medicine

    (2007)
  • S.F. Jencks

    Recognition of mental distress and diagnosis of mental disorder in primary care

    JAMA

    (1985)
  • L.L. Judd et al.

    Subsyndromal symptomatic depression: A new mood disorder?

    Journal of Clinical Psychiatry

    (1994)
  • D. Kessler et al.

    Cross sectional study of symptom attribution and recognition of depression: An anxiety in primary care

    British Medical Journal

    (1999)
  • Cited by (0)

    View full text