Screening or case finding instruments have been advocated as a simple, quick and inexpensive method to improve detection and management of depression in non-specialist settings, such as primary care and the general hospital. However, screening/case finding is just one of a number of strategies that have been advocated to improve the quality of care for depression. The adoption of this seemingly simple and effective strategy should be underpinned by evidence of clinical and cost effectiveness.
To determine the clinical and cost effectiveness of screening and case finding instruments in: (1) improving the recognition of depression; (2) improving the management of depression, and (3) improving the outcome of depression.
The researchers undertook electronic searches of The Cochrane Library (Issue 4, 2004); The Cochrane Depression, Anxiety and Neurosis Group's Register [2004); EMBASE (1980-2004); MEDLINE (1966-2004); CINAHL (to 2004) and PsycLIT (1974-2004). References of all identified studies were searched for further trials, and the researchers contacted authors of trials.
Randomised controlled trials of the administration of case finding/screening instruments for depression and the feedback of the results of these instruments to clinicians, compared with no clinician feedback. Trials had to be conducted in non-mental health settings, such as primary care or the general hospital. Studies that used screening strategies in addition to enhanced care, such as case management and structured follow up, were specifically excluded.
Data collection and analysis
Citations and, where possible, abstracts were independently inspected by researchers, papers ordered, re-inspected and quality assessed. Data were also independently extracted. Data relating to: (1) the recognition of depression; (2) the management of depression and (3) the outcome of depression over time were sought. For dichotomous data the Relative Risk (RR), 95% confidence interval (CI) were calculated on an intention-to-treat basis. For continuous data, weighted and standardised mean difference were calculated. A series of a priori sensitivity analyses relating to the method of administration of questionnaires and population under study were used to examine plausible causes of heterogeneity.
Twelve studies (including 5693 patients) met our inclusion criteria. Synthesis of these data gave the following results:
(1) the recognition of depression: according to case note entries of depression, screening/case finding instruments had borderline impact on the overall recognition of depression by clinicians (relative risk 1.38; 95% confidence interval 1.04 to 1.83). However, substantial heterogeneity was found for this outcome. Screening and feedback, irrespective of baseline score of depression has no impact on the detection of depression (relative risk 1.00; 95% confidence interval 0.89 to 1.13). In contrast, three small positive studies using a two stage selective procedure, whereby patients were screened and only patients scoring above a certain threshold were entered into the trial, did suggest that this approach might be effective (relative risk 2.66; 95% confidence interval 1.78 to 3.96). Separate pooling according to this variable reduced the overall level of heterogeneity. Publication bias was also found for this outcome.
(2) the management of depression: according to case note entries for active interventions and prescription data, a selected subsample of all studies reported this outcome and found that there was there was an overall trend to showing a borderline higher intervention rate amongst those who received feedback of screening/case finding instruments (relative risk 1.35; 95% confidence interval 0.98 to 1.85), although substantial heterogeneity between studies existed for this outcome. This result was dependant upon the presence of one highly positive study.
(3) the outcome of depression: few studies reported the impact of case finding/screening instruments on the actual outcome of depression, and no statistical pooling was possible. However, three out of four studies reported no clinical effect (p<0.05) at either six months or twelve months.
No studies examined the cost effectiveness of screening/case finding as a strategy.
There is substantial evidence that routinely administered case finding/screening questionnaires for depression have minimal impact on the detection, management or outcome of depression by clinicians. Practice guidelines and recommendations to adopt this strategy, in isolation, in order to improve the quality of healthcare should be resisted. The longer term benefits and costs of routine screening/case finding for depression have not been evaluated. A two stage procedure for screening/case finding may be effective, but this needs to be evaluated in a large scale cluster randomised trial, with a prospective economic evaluation.
篩檢及發現患者的工具被推廣為簡易快速便宜的方式,可以協助包含初級醫療院所和一般醫院這非精神病專門醫療院所,來診斷和管理憂鬱症患者. 但是篩檢及發現患者只是改進憂鬱照護的方法之一. 需要臨床和成本效益證據證明應該採用這個看似簡單有效的方式.
研究人員採電子搜尋以下資料庫:Cochrane Library (Issue 4, 2004); The Cochrane Depression, Anxiety and Neurosis Group's Register [2004); EMBASE (1980 – 2004); MEDLINE (1966 – 2004); CINAHL (to 2004)和PsycLIT (1974 – 2004). 搜尋選出的試驗文獻清單,確認是否有其他試驗,研究人員也聯絡試驗作者.
研究人員採電子搜尋以下資料庫:Cochrane Library (Issue 4, 2004); The Cochrane Depression, Anxiety and Neurosis Group's Register [2004); EMBASE (1980 – 2004); MEDLINE (1966 – 2004); CINAHL (to 2004)和PsycLIT (1974 – 2004). 搜尋選出的試驗文獻清單,確認是否有其他試驗,研究人員也聯絡試驗作者.S
隨機對照試驗,一組採用發現憂鬱患者/篩選的工具,醫師對這些工具有評價,另一組沒有醫師評價. 試驗在非精神疾病專門單位進行,如初級醫療院所和一般醫院. 除加強護理外還有採篩檢的試驗,會被排除. 所謂加強護理包含個案管理和有系統的追蹤.
引用文獻和可取得的摘要都由研究人員獨立檢視,將文獻排序,再重新檢閱期品質. 資料也由研究員獨立擷取. 擷取的資料為: (1)對憂鬱症的診斷(2)憂鬱症治療，和(3)一段時間內憂鬱症的治療效果。二元資料則計算其意圖治療患者之RR,和95%信賴區間. 對問卷執行方法,受試族群執行一系列先敏感度分析,研究異質性的可能原因.
有相當證據證明醫師常規使用發現憂鬱病患/ /篩檢問卷,對發現和管理病患及憂鬱症患者治療結果有極小的影響. 應駁斥建議單獨使用這個策酪,增進醫療品質的使用準則和建議. 常規使用發現憂鬱病患/篩檢問卷的較長期效益和成本並沒有經過評估. 一種2階段篩檢/發現病患可能有效,但須有更大規模,有追溯性經濟評估的隨機試驗證實.
此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。