Use of brief depression screening tools in primary care: consideration of heterogeneity in performance in different patient groups Verena Henkel a, *, Roland Mergl a , Ralf Kohnen b , Antje-Kathrin Allgaier a , Hans-Ju ¨rgen Mo ¨ller a , Ulrich Hegerl a a Department of Psychiatry, Ludwig-Maximilians-University Munich, Nußbaumstr. 7, D-80336 Munich, Germany b Institute for Medical Research Management and Biometrics (IMEREM), Scheurlstr. 21, D-90478 Nuremberg, Germany Received 8 December 2003; accepted 11 February 2004 Abstract Heterogeneity of performance of screening tools in different patient groups has rarely been considered in the literature on depression screening in primary care. The objectives of the present study were to assess and to compare diagnostic accuracy of three screening questionnaires (Brief Patient Health Questionnaire, General Health Questionnaire-12, WHO-5) in identifying depression across various patient subpopulations and to assess the accuracy of the unaided clinical assessment of primary care physicians in the same subgroups. We conducted a cross-sectional validation study in 448 primary care patients. Two-by-two tables as well as receiver operating characteristics were applied. Results indicated that diagnostic accuracy (sensitivity, specificity) of the three screening instruments as well as of the clinical diagnoses differed in the various patient groups. Superiority of one screening tool over the other depends on the subgroup considered. Gender, age, form (subtype), and severity of depression influence the test characteristics of a screening tool. This should be considered if routine depression screening should be widely introduced. Of course, the benefit of routine screening also depends on efforts made for treatment and monitoring of patients in whom depression was diagnosed. © 2004 Elsevier Inc. All rights reserved. Keywords: Depression; Primary health care; Screening; Subgroup analyses 1. Introduction Depression has emerged as one of the leading causes of disability worldwide [1]. In developed countries, depressed persons are much more likely to visit a primary care phy- sician than a mental health professional [2]. Depressive disorders are among the most common conditions in pri- mary care, yet very often are missed [2– 4]. However, a primary care physician’s ability to detect depression might not be as poor as has been suggested because moderate and severe major depression may be detected with rather high efficiency, whereas underdetection seems to be prevalent for minor depression [5]. Several authors have described diverse barriers to the diagnosis of depression in primary care [2– 4]. Patients tend to be ashamed to admit to depressive symptoms and fear the stigma that is unfortunately still attached to it. Furthermore, they often focus on physical complaints or nonspecific de- pressive symptoms [6]. Difficulties on the part of the pri- mary care doctors to ask frankly about psychological symp- toms may also play a role. This situation demands a search for a practical solution, especially since, for most patients, depression has a remitting or chronic course [7,8]. In this context, there is an ongoing debate about the usefulness of routine screening programs. On the one hand, there are studies and meta-analyses suggesting screening to be of little benefit in terms of improving the outcomes of patients with depression in general medical care settings [9]. It has been indicated that under conditions of routine care, iden- tification of depressed patients does not reliably improve outcomes [10]. Other authors have shown that short-term outcomes can be improved through the commitment of substantial resources and sustained efforts [11]. Thus, im- plementation of screening itself would not be useful, but would require additional modifications of routine care. Nevertheless, there are straightforward and seemingly compelling arguments for routine screening: * Corresponding author. Tel.: +49-89-5160-5558; fax: +49-89-5160- 5542. E-mail address: verena.henkel@psy.med.uni-muenchen.de (V. Hen- kel). General Hospital Psychiatry 26 (2004) 190 –198 0163-8343/04/$ – see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2004.02.003