Accuracy of Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression:individual participant data meta-analysis

OBJECTIVE: To determine the accuracy of the Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression. DESIGN: Individual participant data meta-analysis. DATA SOURCES: Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, and Web of Science (January 2000-February 2015). INCLUSION CRITERIA: Eligible studies compared PHQ-9 scores with major depression diagnoses from validated diagnostic interviews. Primary study data and study level data extracted from primary reports were synthesized. For PHQ-9 cut-off scores 5-15, bivariate random effects meta-analysis was used to estimate pooled sensitivity and specificity, separately, among studies that used semistructured diagnostic interviews, which are designed for administration by clinicians; fully structured interviews, which are designed for lay administration; and the Mini International Neuropsychiatric (MINI) diagnostic interviews, a brief fully structured interview. Sensitivity and specificity were examined among participant subgroups and, separately, using meta-regression, considering all subgroup variables in a single model. RESULTS: Data were obtained for 58 of 72 eligible studies (total n=17 357; major depression cases n=2312). Combined sensitivity and specificity was maximized at a cut-off score of 10 or above among studies using a semistructured interview (29 studies, 6725 participants; sensitivity 0.88, 95% confidence interval 0.83 to 0.92; specificity 0.85, 0.82 to 0.88). Across cut-off scores 5-15, sensitivity with semistructured interviews was 5-22% higher than for fully structured interviews (MINI excluded; 14 studies, 7680 participants) and 2-15% higher than for the MINI (15 studies, 2952 participants). Specificity was similar across diagnostic interviews. The PHQ-9 seems to be similarly sensitive but may be less specific for younger patients than for older patients; a cut-off score of 10 or above can be used regardless of age.. CONCLUSIONS: PHQ-9 sensitivity compared with semistructured diagnostic interviews was greater than in previous conventional meta-analyses that combined reference standards. A cut-off score of 10 or above maximized combined sensitivity and specificity overall and for subgroups. REGISTRATION: PROSPERO CRD42014010673

Probability of major depression diagnostic classification using semi-structured vs. fully structured diagnostic interviews

Background: Different diagnostic interviews are used as reference standards for major depression classification in research. Semi-structured interviews involve clinical judgement, whereas fully structured interviews are completely scripted. The Mini International Neuropsychiatric Interview (MINI), a brief fully structured interview, is also sometimes used. It is not known whether interview method is associated with probability of major depression classification. Aims: To evaluate the association between interview method and odds of major depression classification, controlling for depressive symptom scores and participant characteristics. Method: Data collected for an individual participant data meta-analysis of Patient Health Questionnaire-9 (PHQ-9) diagnostic accuracy were analyzed. Binomial Generalized Linear Mixed Models were fit. Results: 17,158 participants (2,287 major depression cases) from 57 primary studies were analyzed. Among fully structured interviews, odds of major depression were higher for the MINI compared to the Composite International Diagnostic Interview (CIDI) [OR (95% CI) = 2.10 (1.15-3.87)]. Compared to semi-structured interviews, fully structured interviews (MINI excluded) were non-significantly more likely to classify participants with low-level depressive symptoms (PHQ-9 scores 6) as having major depression [OR (95% CI) = 3.13 (0.98-10.00)], similarly likely for moderate-level symptoms (PHQ-9 scores 7-15) [OR (95% CI) = 0.96 (0.56-1.66)], and significantly less likely for high-level symptoms (PHQ-9 scores 16) [OR (95% CI) = 0.50 (0.26-0.97)]. Conclusions: The MINI may identify more depressed cases than the CIDI, and semi- and fully structured interviews may not be interchangeable methods, but these results should be replicated

Data-driven cutoff selection for the patient health questionnaire-9 depression screening tool

Importance: Test accuracy studies often use small datasets to simultaneously select an optimal cutoff score that maximizes test accuracy and generate accuracy estimates. Objective: To evaluate the degree to which using data-driven methods to simultaneously select an optimal Patient Health Questionnaire-9 (PHQ-9) cutoff score and estimate accuracy yields (1) optimal cutoff scores that differ from the population-level optimal cutoff score and (2) biased accuracy estimates. Design, Setting, and Participants: This study used cross-sectional data from an existing individual participant data meta-analysis (IPDMA) database on PHQ-9 screening accuracy to represent a hypothetical population. Studies in the IPDMA database compared participant PHQ-9 scores with a major depression classification. From the IPDMA population, 1000 studies of 100, 200, 500, and 1000 participants each were resampled. Main Outcomes and Measures: For the full IPDMA population and each simulated study, an optimal cutoff score was selected by maximizing the Youden index. Accuracy estimates for optimal cutoff scores in simulated studies were compared with accuracy in the full population. Results: The IPDMA database included 100 primary studies with 44 503 participants (4541 [10%] cases of major depression). The population-level optimal cutoff score was 8 or higher. Optimal cutoff scores in simulated studies ranged from 2 or higher to 21 or higher in samples of 100 participants and 5 or higher to 11 or higher in samples of 1000 participants. The percentage of simulated studies that identified the true optimal cutoff score of 8 or higher was 17% for samples of 100 participants and 33% for samples of 1000 participants. Compared with estimates for a cutoff score of 8 or higher in the population, sensitivity was overestimated by 6.4 (95% CI, 5.7-7.1) percentage points in samples of 100 participants, 4.9 (95% CI, 4.3-5.5) percentage points in samples of 200 participants, 2.2 (95% CI, 1.8-2.6) percentage points in samples of 500 participants, and 1.8 (95% CI, 1.5-2.1) percentage points in samples of 1000 participants. Specificity was within 1 percentage point across sample sizes. Conclusions and Relevance: This study of cross-sectional data found that optimal cutoff scores and accuracy estimates differed substantially from population values when data-driven methods were used to simultaneously identify an optimal cutoff score and estimate accuracy. Users of diagnostic accuracy evidence should evaluate studies of accuracy with caution and ensure that cutoff score recommendations are based on adequately powered research or well-conducted meta-analyses

ASSOCIATION OF WELL-BEING WITH ANXIETY, DEPRESSION, AND FUNCTIONAL IMPAIRMENT FOLLOWING REHABILITATION SERVICES

Abstract Millions of older adults receive rehabilitation services yearly that aim to restore, sustain, or limit decline in functioning. Older adults who receive rehabilitation comprise a vulnerable population that is unfortunately at elevated risk for anxiety, depression, and functional impairment. We hypothesize that lower levels of wellbeing prior to rehabilitation services are associated with a greater risk of having clinically significant anxiety or depressive symptoms, or worsening impairments in self-care or household activities, following rehabilitation. This study uses data from 2015 and 2016 waves of the National Health and Aging Trends Study, and includes 853 participants with information on rehabilitation services, wellbeing, anxiety and depression, and functional impairment, as well as demographic characteristics, socioeconomic status, and health variables. In a series of multivariable logistic analyses with wellbeing serving as our primary independent variable, older adults in the lowest quartile of wellbeing (compared to those in the highest quartile of wellbeing) had greater odds for having anxiety symptoms (OR=3.04; 95% CI: 1.24-7.46), depressive symptoms (OR=6.54; 95% CI: 2.80-15.25), and worsening impairment in self-care (OR=2.15; 95% CI: 1.09-4.23), but not in household activities (OR=1.49; 95% CI: 0.67-3.32). This study’s findings suggest that older adults with low levels of wellbeing at baseline may be more susceptible for having mental illness and functional impairment at follow-up. Conversely, the findings suggest that perhaps those with high levels of wellbeing may be able to experience significant health events with fewer residual consequences. The mechanism by which wellbeing may affect these outcomes is unclear and warrants further investigation.</jats:p

Nursing Home COVID-19 Action Network: Responding With Stress First Aid and Caring for Residents With Dementia

Abstract The GWEP at the University of Rochester (New York) has an established network of nursing homes participating in Project ECHO. This ECHO hub includes geriatric medicine, psychiatry, pharmacy, aging services network and the Alzheimer’s Association focusing on best practices in geriatric mental health and dementia care. With the COVID-19 pandemic, this infrastructure quickly pivoted to expansion of 80 facilities and the addition of expertise in medical direction, trauma informed care, and infectious disease. A stress first aid training module was developed in partnership with Ithaca College and the National Center for PTSD to support front line nursing home workers. Dementia care experts contributed to practical problem-solving in addressing social isolation and mental health. Work now is focusing on vaccination and how to best support trauma-informed needs of residents with dementia.</jats:p

Anxiety and Depression in Older Adult Public Housing Residents: Prevalence, Correlates, and Implications for Care

Thesis (Ph.D.)--University of Rochester. School of Medicine & Dentistry. Dept. of Community and Preventive Medicine, 2011.Background: Anxiety and depression in socioeconomically disadvantaged older adults are frequently unrecognized and untreated. There is a great need for new cost-effective community programs that improve detection and treatment of these late-life mental illnesses. Older adult public housing high-rises are a promising venue to develop and test such programs due to the high concentration of older adults with many risk factors for mental illness. Few studies, however, have taken advantage of the potential opportunities these high-rises offer. Further work is needed to characterize anxiety, depression, mental health needs, and service utilization patterns in this population. Research Aims: This dissertation examined anxiety and depression in older adult residents of public housing high-rises. The objectives of Aim 1 were to estimate the prevalence of syndromal and subsyndromal anxiety and depression, characterize mental health care need, and identify the correlates of anxiety and depression symptom severity. We hypothesized that most residents with mental health care need are not receiving mental health care. The objectives of Aim 2 were to examine the association of anxiety and depression symptom severity with utilization of onsite service coordinator, health, human, and informal services after accounting for predisposing and enabling factors. We hypothesized that mental illness symptom severity is positively correlated with utilization of onsite service coordinator, health, human, and informal services. Study Design: The Rochester Housing Authority has four older adult public housing high-rises in Rochester, NY. In this setting, we conducted a two-phase cross-sectional psychiatric epidemiology study. During the first phase, all residents living in the older adult high-rises received a brief general health questionnaire. We assisted residents in completing the questionnaire because illiteracy may have been a barrier for some. On the questionnaire residents elected whether to participate in the second phase interview. All English-speaking residents aged 60 years and older with capacity to provide informed consent were eligible for the second phase. This second phase consisted of an in-depth, in-person interview that assessed anxiety and depression in the context of the Social Precursor Model. The Social Precursor Model characterized the relationship of psychopathology with participants’ demographics, early and current achievement, social integration, vulnerability/protective factors, life events, and coping methods. Participants’ use of services was determined by self-report and review of the onsite service coordinator records. Anxiety and depression were evaluated categorically (i.e., syndromal and subsyndromal conditions) and dimensionally (i.e., symptom severity). We used the Structured Clinical Interview for the DSM-IV to diagnostically assess anxiety and depression, as well as brief survey scales to measure anxiety and depression symptom severity. Descriptive analyzes and multivariable regression modeling addressed our aims. Results: Phase 1 had 358 participants (65% response) and Phase 2 had 190 participants (62% response among non-Hispanic English-speaking residents). Participation was higher in African Americans, but lower in Hispanic residents. Interview participants had a median age of 66 years, and 58% were female, 80% were black, and 92% lived alone. Thirty-nine (21%) residents had syndromal (n = 33; 17%) or subsyndromal (n = 6; 3%) anxiety. Twenty-eight (15%) residents had syndromal (n = 12; 6%) or subsyndromal (n = 16; 8%) depression. In total, 48 (25%) residents were experiencing a syndromal and/or subsyndromal condition (Aim 1.1). Anxiety and depression severity correlates overlapped considerably and spanned the six stages of the Social Precursor Model. In linear regression analyses, anxiety and depression correlates included age, medical comorbidity, mobility, social support, coping, and recent life events severity; Hispanic ethnicity was an anxiety, but not a depression correlate (Aim 1.2). Of the 59 (31%) residents with mental health care need, 32 (54%) were not receiving mental health care (Aim 1.3). In multivariable regression analyses accounting for predisposing and enabling factors, anxiety and depression symptom severity were associated with utilization of health, human, and informal services, but not onsite service coordinator utilization (Aim 2). Conclusions: To our knowledge, this dissertation is the first to examine subsyndromal anxiety and depression in older adult public housing residents and to conduct an in-depth analysis of the association of anxiety and depression with services utilization. Partial replication of previous research on syndromal psychiatric disorder prevalence, correlates, and mental health care need in this setting is an additional contribution. Findings from this dissertation improve our understanding of the mental health burden and may be instrumental in providing guidance to future interventions in this high-need community