Gilbody S, House A O, Sheldon T A
Department of Health Sciences, University of York, York, UK YO10 5DD.
Cochrane Database Syst Rev. 2005 Oct 19;2005(4):CD002792. doi: 10.1002/14651858.CD002792.pub2.
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.
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.
AUTHORS' CONCLUSIONS: 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.
筛查或病例发现工具被视为一种简单、快速且经济的方法，用以改善在非专科环境（如基层医疗和综合医院）中对抑郁症的检测与管理。然而，筛查/病例发现只是众多旨在提高抑郁症护理质量的策略之一。采用这一看似简单有效的策略应以临床和成本效益证据为支撑。
确定筛查和病例发现工具在以下方面的临床和成本效益：（1）提高对抑郁症的识别；（2）改善抑郁症的管理；（3）改善抑郁症的治疗效果。
研究人员对Cochrane图书馆（2004年第4期）、Cochrane抑郁症、焦虑症和神经症研究组登记册[2004年]、EMBASE（1980 - 2004年）、MEDLINE（1966 - 2004年）、CINAHL（截至2004年）和PsycLIT（1974 - 2004年）进行了电子检索。对所有已识别研究的参考文献进行进一步试验检索，并与试验作者进行联系。
将用于抑郁症病例发现/筛查工具的施用以及这些工具结果反馈给临床医生的随机对照试验，与无临床医生反馈的情况进行比较。试验必须在非精神卫生环境（如基层医疗或综合医院）中进行。特别排除那些除了强化护理（如病例管理和结构化随访）之外还使用筛查策略的研究。
研究人员独立检查文献引用，如有可能还检查摘要，订购论文、再次检查并进行质量评估。数据也进行独立提取。收集与以下方面相关的数据：（1）抑郁症的识别；（2）抑郁症的管理；（3）随时间推移抑郁症的治疗效果。对于二分数据，在意向性分析基础上计算相对风险（RR）及95%置信区间（CI）。对于连续数据，计算加权和标准化均数差。采用一系列与问卷施测方法和所研究人群相关的先验敏感性分析来检查异质性的可能原因。
12项研究（包括5693名患者）符合我们的纳入标准。对这些数据的综合分析得出以下结果：（1）抑郁症的识别：根据抑郁症病例记录条目，筛查/病例发现工具对临床医生对抑郁症的总体识别有临界影响（相对风险1.38；95%置信区间1.04至1.83）。然而，该结果存在显著异质性。无论抑郁症基线评分如何，筛查和反馈对抑郁症的检测均无影响（相对风险1.00；95%置信区间0.89至1.13）。相比之下，三项采用两阶段选择程序的小型阳性研究表明，该方法可能有效（相对风险2.66；95%置信区间1.78至3.96），即先对患者进行筛查，仅将得分高于特定阈值的患者纳入试验。根据此变量进行单独合并可降低总体异质性水平。此结果也存在发表偏倚。（2）抑郁症的管理：根据主动干预的病例记录条目和处方数据，所有研究的一个选定子样本报告了此结果，发现总体趋势显示，在那些收到筛查/病例发现工具反馈的患者中，干预率略高（相对风险1.35；95%置信区间0.98至1.85），尽管各研究之间对此结果存在显著异质性。该结果取决于一项高度阳性的研究。（3）抑郁症的治疗效果：很少有研究报告病例发现/筛查工具对抑郁症实际治疗效果的影响，且无法进行统计合并。然而，四分之三的研究报告在六个月或十二个月时均无临床效果（p<0.05）。没有研究考察筛查/病例发现作为一种策略的成本效益。
有充分证据表明，常规使用的抑郁症病例发现/筛查问卷对临床医生对抑郁症的检测、管理或治疗效果影响甚微。应抵制仅为提高医疗质量而孤立采用此策略的实践指南和建议。抑郁症常规筛查/病例发现的长期效益和成本尚未得到评估。两阶段的筛查/病例发现程序可能有效，但这需要在大规模整群随机试验中进行评估，并进行前瞻性经济评估。
