Depressive disorders are a major health problem in primary care, and at least half of these disorders remain undetected. 1 There are two recommended approaches to diagnosing depression in primary care: one is to perform routine screening, and the other is to evaluate patients only when the clinical presentation triggers the suspicion of depression. Our aim was to compare these two approaches, and to compare three different screening tools in order to evaluate which would be most appropriate for use in primary care. From among the many available screening tools, we selected three brief, self rating instruments: one disorder-specific (the depression module of the brief patient health questionnaire (B-PHQ, 9 items)), 2 one broad based (the general health questionnaire (GHQ-12, 12 items)), 3 and one that is less restricted to both issues (WHO-5 wellbeing index (WHO-5, 5 items)). 4 Methods and resultsEighteen primary care facilities participated in our prospective cohort study. The study protocol was approved by our local ethics committee. On one given day, all patients who presented in one of the practices were asked to complete the three screening questionnaires before seeing a doctor. The doctors who treated the patients remained blind to the questionnaire results until they had completed a brief "physician's encounter form" to indicate their clinical assessment of their patient's current diagnoses.Within a period not exceeding six days after they had completed the questionnaires, the patients were contacted by telephone for a fully structured, standardised psychiatric interview (composite international diagnostic interview (CIDI)) conducted by a trained psychologist blind to the screening results. We chose the composite international diagnostic interview as the reference standard because its reliability and validity have been established. 5 The interviewing psychologists met a high standard of inter-rater reliability.The main outcome measures were, firstly, the family doctors' performance in detecting depression without any tool to help guide diagnosis decisions and, secondly, the test accuracy of the screening questionnaires. We calculated sensitivity, specificity, and predictive values using two-by-two tables. We used two statistical tests to compare differences of characteristics of test accuracy (table). For 431 patients, all screening questionnaires, the composite international diagnostic interview, and the physician's encounter form were completed. Of these patients, 17% suffered from any depressive disorder and 83% did not. CommentThe sensitivity of the family doctors' unaided clinical diagnoses was 65%. With standard cut-off points, the briefest screening questionnaire (and therefore the most practical to use), the WHO-5, produced significantly greater sensitivity (93%) and a better negative predictive value (98%) than the other questionnaires (see table). However, the brief patient health questionnaire and unaided clinical diagnosis produced better specificity. The brief patient health questionnaire al...

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Recent studies emphasize the negative impact of comorbidity on the course of depression. If undiagnosed, depression and comorbidity contribute to high medical utilization. We aimed to assess (1) prevalences of depression alone and with comorbidity (anxiety/somatoform disorders) in primary care, (2) coexistence of anxiety/somatoform disorders in depressive patients, and (3) diagnostic validity of two screeners regarding depression with versus without comorbidity. We examined 394 primary care outpatients using the Composite International Diagnostic Interview (CIDI), the General Health Questionnaire (GHQ-12), and the Well-Being Index (WHO-5). We conducted configurational frequency analyses to identify nonrandom configurations of the disorders and receiver operating characteristic (ROC)-analyses to assess diagnostic validity of the screeners. Point prevalence of any depressive disorder was 22.8%; with at least one comorbid disorder, 15%; and with two comorbid conditions, 6.1%, which significantly exceeded expected percentage (0.9%, P< or =.0001). Depression without comorbidity occurred significantly less often than expected by chance (P< or =.0007). Comorbidity of depressive and anxiety or somatoform disorders was associated with a high odds ratio (6.25). The screeners were comparable regarding their diagnostic validity for depression with [GHQ-12: area under the curve (AUC)=0.86; WHO-5: AUC=0.88] and without comorbidity (GHQ-12: AUC=0.84; WHO-5: AUC=0.86). It can be concluded that comorbidity between depression and anxiety/somatoform disorders in primary care may occur much more frequently than expected. These results confirm assumptions that the current division between depression and anxiety might be debatable. Validity of screeners tested in our study was not affected by comorbid conditions (e.g., anxiety or somatoform disorders).

Mild depressive syndromes are highly prevalent among primary-care patients. Evidence-based treatment recommendations need to be derived directly from this diagnostically heterogeneous group. The primary aim was to assess the efficacy of sertraline and cognitive-behavioural group therapy for treatment of depressed primary-care patients, the secondary aim was to evaluate if receiving treatment according to free choice is associated with a better outcome than randomization to a particular treatment. We conducted a randomized, placebo-controlled, single-centre, 10-wk trial with five arms: sertraline (flexible dosages up to 200 mg/d) (n = 83); placebo (n = 83); manual-guided cognitive-behavioural group therapy (one individual session and nine group sessions per 90 min) (n = 61); guided self-help group (control condition, n = 59); and treatment with sertraline or cognitive-behavioural group therapy according to patients' choice (n = 82). From 1099 consecutively screened adult patients, 368 formed the intent-to-treat population with milder forms of depression. Primary outcome was a global efficacy measure combining z-converted Hamilton Depression Rating Scale and clinician-rated Inventory for Depressive Symptomatology scores. Sertraline was superior to placebo (p = 0.03). Outcome for guided self-help groups was worse compared to cognitive-behavioural group therapy (p = 0.002) and compared to all other treatment arms including pill placebo (secondary analyses). Outcome in the patients' choice arm was similar to that in the sertraline and cognitive-behavioural group therapy. Overall, sertraline is efficacious in primary-care patients with milder forms of depression. The superiority of cognitive-behavioural group therapy over guided self-help groups might partly be explained by 'nocebo' effects of the latter.

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