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The Rational Clinical Examination: Evidence-Based Clinical Diagnosis

Depression

Make the Diagnosis: Depression

Prior Probability

Although most depression screening focuses on major depressive disorders, a number of treatable conditions may be detected by depression screening. In primary care, the combined prevalence of depression and dysthymia is approximately 7% to 12% (Table 19-7).

Table 19-7Prevalence of Depression and Dysthymia in Primary Care
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Table 19-7 Prevalence of Depression and Dysthymia in Primary Care
Illness Prevalence, %
Major depressive disorder 4.8-8.6
Dysthymic disorder 2.1-3.7
Depression NOS 4.4-5.4

Abbreviation: NOS, not otherwise specified.

Populations for Whom Depression Should Be Assessed

All adults.

Detecting the Likelihood of Major Depressive Disorder or Dysthymia

See Table 19-8.

Table 19-8Likelihood Ratios for Detecting Major Depressive Disorder
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Table 19-8 Likelihood Ratios for Detecting Major Depressive Disorder
Instrument and Threshold Summary LR+ (95% CI) or Range Summary LR– (95% CI) or Range
PHQ-9 (score ≥ 10 is positive)a 4.9-7.3 0.02-0.14
PRIME-MD (score ≥ 1 is positive) 2.6 (2.1-3.2) 0.15 (0.08-0.28)

Abbreviations: CI, confidence interval; LR+, positive likelihood ratio; LR–, negative likelihood ratio; PHQ-9, 9-item Patient Health Questionnaire; PRIME-MD, Primary Care Evaluation of Mental Disorders.

aData are the range of values across studies; summary statistics were not calculated because 2 thresholds (10 and 11) were used.

Detecting the Likelihood of Major Depressive Disorder

See Table 19-9.

Table 19-9Likelihood Ratios for Detecting Major Depressive Disorder or Dysthymia
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Table 19-9 Likelihood Ratios for Detecting Major Depressive Disorder or Dysthymia
Instrument Summary LR+ (95% CI) Summary LR– (95% CI)
PHQ-9 (score ≥ 10 is positive) 5.9 (4.2-8.3) 0.29 (0.23-0.38)

Abbreviations: CI, confidence interval; LR+, positive likelihood ratio; LR–, negative likelihood ratio; PHQ-9, 9-item Patient Health Questionnaire.

Reference Standard Tests

A structured (eg, Diagnostic Interview Schedule) or semistructured diagnostic interview (eg, Structured Clinical Interview for DSM-IV) to establish diagnoses.

Original Article: Is This Patient Clinically Depressed?

Clinical Scenario

Mr P is a 52-year-old small-business owner with a 5-year history of controlled hypertension, for which he takes a thiazide diuretic. Otherwise, he is in good health. He presents for routine follow-up and notes a 1-month history of mild to moderate bitemporal headaches and feeling fatigued. The headaches occur about twice a week and are relieved by acetaminophen. He denies chest pain or dyspnea on exertion. He notes wryly that the “new economy” has left him feeling a bit “frazzled.”

You wonder whether the headache and fatigue are stress related, a somatic presentation of ...

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Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice, 3rd ed › Chapter 16: The Process of Diagnosis
Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice, 3rd ed › Chapter 17: Differential Diagnosis
Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice, 3rd ed › Chapter 18: Diagnostic Tests

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