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Research

Screening for depression: a systematic review and meta-analysis

Homa Keshavarz, Donna Fitzpatrick-Lewis, David L. Streiner, Rice Maureen, Usman Ali, Harry S. Shannon and Parminder Raina
December 17, 2013 1 (4) E159-E167; DOI: https://doi.org/10.9778/cmajo.20130030
Homa Keshavarz
1McMaster Evidence Review and Synthesis Centre and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.
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Donna Fitzpatrick-Lewis
2McMaster Evidence Review and Synthesis Centre and School of Nursing, McMaster University, Hamilton Ont.
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David L. Streiner
3Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ont.
4Department of Psychiatry, University of Toronto, Toronto, Ont.
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Rice Maureen
1McMaster Evidence Review and Synthesis Centre and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.
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Usman Ali
1McMaster Evidence Review and Synthesis Centre and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.
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Harry S. Shannon
1McMaster Evidence Review and Synthesis Centre and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.
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Parminder Raina
1McMaster Evidence Review and Synthesis Centre and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.
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  • Figure 1:
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    Figure 1:

    Identification and evaluation of studies for a systematic review of screening for depression.

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    Figure 2:

    Meta-analysis of the effect of community-based suicide prevention programs, including screening for depression, on suicide rates reported in cohort studies. CI = confidence interval; RRR = ratio of rate ratios (rate ratio for intervention divided by rate ratio for control), where RRR less than 1.0 indicates a benefit of suicide prevention programs; SE = standard error.

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    Figure 3:

    Meta-analysis of the effect of community-based suicide prevention programs, including screening for depression, on suicide rates by sex, as reported in cohort studies. CI = confidence interval; RRR = ratio of rate ratios (rate ratio for intervention divided by rate ratio for control), where RRR less than 1.0 indicates a benefit of suicide prevention programs; SE = standard error.

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    Table 1: Characteristics of studies included in a meta-analysis of the benefit of screening for depression
    Study populationOutcomes
    StudyDescriptionDefinitionEvaluationDefinitionResults
    Oyama et al.19 (5-yr quasi-experimental study in Matsudai, Japan [rural])Total person-years: 11 567 for intervention, 15 055 for control
    Age, mean: NR
    Age, range: ≥□65 yr
    Age, median: NR
    Sex, female: 57.6%
    Ethnicity: Japanese
    Education: NR
    Dx: major and minor depression
    Older (≥ 65 yr) residents in 6 rural municipalities of southwest and central Japan
    Intervention: mental health workshop, referral to general practitioner or follow-up interview with PHN
    Exclusions: severely disabled or hospitalized cases were excluded from the study
    Screening instrument: SDS
    Other rating: RDC
    Confirmatory exam: ICD-9
    No. of follow-ups: 10
    No. of stages: two 10-yr
    Main outcome:
    Change in risk of completed suicide
    Age-adjusted IRRs of completed suicide before and after intervention or control
    Main outcome:
    Risk of completed suicide in intervention area reduced by 70% among women, no significant change among men
    Intervention: IRR 1.02 (95% CI 0.49–2.13) for men and 0.30 (95% CI 0.14–0.67) for women
    Control: No significant change
    Oyama et al.20 (10-yr quasi-experimental study in Yasuzuka, Japan [rural])Total person- years: 9791 for intervention, 16 032 for control
    Age, mean: NR
    Age, range: ≥□65 yr
    Age, median: NR
    Sex, female: NR
    Ethnicity: Japanese
    Education: NR
    Dx: major and minor depression
    Older (≥ 65 yr) residents of agricultural rural area in Japan with high suicide rate
    Intervention: (a) public health education from 1991 to 2000 and (b) screening for depression with follow-up from 1991 to 1997
    Exclusions: NR
    Screening instrument: SDS
    Other rating: RDC
    Confirmatory exam: ICD-9
    No. of follow-ups: 7
    No. of stages: two 10-yr
    Main outcome:
    Change in risk of completed suicide
    Age-adjusted IRRs of completed suicide before and after intervention or control
    Main outcome:
    Risk of completed suicide in intervention area reduced by 64% among women, no significant change among men
    Intervention: IRR 0.51 (95% CI 0.22–1.19) for men and 0.36 (95% CI 0.14–0.93) for women
    Control: No significant change
    Oyama et al.17 (10-yr quasi-experimental study in Joboji town, Japan [rural])Total person- years: 9721 for intervention, 17 166 for control
    Age, mean: NR
    Age, range: ≥□65 yr
    Age, median: NR
    Sex, female: 50.8%
    Ethnicity: Japanese
    Education: NR
    Dx: depression (unspecified)
    Older (≥ 65 yr) residents of agricultural rural area in Japan with high suicide rate
    Intervention: 2-step depression screening performed by PHN and psychiatrist with follow-up by psychiatrist every 3 yr in targeted district of intervention municipality, health education and emphasis on suicide taboo every year in 10-yr period from 1990
    Exclusions: Older people receiving social welfare
    Screening instrument: SDS
    Other rating: SADD
    Confirmatory exam: ICD-9
    No of follow-ups: 10
    No. of stages: three 5-yr
    Main outcome:
    Change in suicide rates
    Age-adjusted IRRs of completed suicide before and after intervention or control
    Main outcome:
    Risk of suicide in intervention area reduced by 73% among men and by 76% among women during implementation decade (relative to pre-implementation decade)
    Intervention: IRR 0.27 (95% CI 0.08–0.88) for men and 0.24 (95% CI 0.11–0.52) for women
    Control: No significant change
    Oyama et al.18 (5-yr quasi-experimental study in Nagawa town, Japan [rural])Total person- years: 1982 for intervention, 16 754 for control
    Age, mean: NR
    Age, range: ≥□65 yr
    Age, median: NR
    Sex, female: 59%–60.8%
    Ethnicity: Japanese
    Education: NR
    Dx: depression (unspecified)
    Older (≥ 65 yr) residents of agricultural rural area in Japan with high suicide rate
    Intervention: 2-step screening for depression and follow-up by PHN, mental health workshop 3 or 4 times a year, group activity program once a month
    Exclusions: NR
    Screening instrument: SDS
    Other rating: RDC
    Confirmatory exam: ICD-9
    No. of follow-ups: 6
    No. of stages: two 6-yr
    Main outcome:
    Change in risk of completed suicide
    Age-adjusted IRRs of completed suicide before and after intervention or control
    Main outcome:
    Risk of suicide in intervention area reduced by 74% among women, no significant change among men
    Intervention: IRR 0.48 (90% CI 0.10–2.31) for men and 0.26 (90% CI 0.07–0.98) for women
    Control: No significant change
    Oyama et al.21 (5-yr quasi-experimental study in 6 rural municipalities of the Sanpachi Second Medical Zone, Japan [rural])Total person-years: 28 838 for intervention, 27 633 for control
    Age, mean: NR
    Age, range: ≥□60 yr
    Age, median: NR
    Sex, female: 57.5%
    Ethnicity: Japanese
    Education: NR
    Dx: depression (unspecified)
    Older (≥ 60 yr) residents living in 6 rural municipalities of Sanpachi Second Medical Zone of Japan (mostly agricultural region with high suicide rate)
    Intervention: (a) health education and (b) screening for depression with follow-up, using community resources of primary care and public health nursing
    Exclusions: NR
    Screening instrument: CES-D, DSS, SDS, GDS-5
    Other rating: CIDI
    Confirmatory exam: ICD-10
    No. of follow-ups: 2
    No. of stages: two 2-yr
    Main outcome:
    Change in risk of completed suicide
    Age-adjusted IRRs of completed suicide before and after intervention or control
    Main outcome:
    Risk of suicide in intervention region reduced by 61% among men; no significant change among women
    Intervention: IRR 0.39 (90% CI 0.18–0.87) for men and 0.49 (90% CI 0.19–1.22) for women
    Control: No significant change

    Note: CES-D = Center for Epidemiologic Studies Depression Scale, CI = confidence interval, CIDI = Composite International Diagnostic Interview, DSS = Depression and Suicide Screen, Dx = diagnosis, GDS-5 = 5-item Geriatric Depression Scale,22 ICD = International Statistical Classification of Diseases, IRR = incidence rate ratio, NR = not reported, PHN = public health nurse, RDC = Research Diagnostic Criteria, SADD = schedules of Standardized Assessment of Patient with Depressive Disorders, SDS = Self-rating Depression Scale.23

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      Table 2: GRADE evidence profile for the effect of community-based suicide prevention programs, including screening for depression, on the incidence of suicide
      Quality assessmentNo. of patients/person- yearsEffectQualityImportance
      No. of studiesDesignRisk of biasInconsistencyIndirectnessImprecisionOther considerationsScreening
      (older persons)
      ControlRelative
      (95% CI)
      Absolute
      Overall (follow-up 4–20 yr; assessed with community-based depression screening)
      517–21ObservationalNo serious risk of bias*No serious inconsistency†Very serious‡No serious imprecision§None¶65/70 053
      (0.09%)
      145/113324
      (0.13%)
      RRR 0.50 (0.32–0.78)1 fewer per 1000 (range 0 fewer to 1 fewer)Very lowCritical

      Note: CI = confidence interval, RRR = ratio of rate ratios. 
*The quality assessment tools identified a few concerns (e.g., selection of non-exposed cohort, blinding and reporting of withdrawals and drop-outs); however, the evidence was not downgraded for these reasons.
†Heterogeneity statistics were not significant: τ2 = 0.05, χ2 = 5.04, df = 4 (p = 0.28); I2 = 2%.
‡Directness was downgraded because of concerns about population characteristics. The included papers all involved older populations in rural areas of Japan, which are unlikely to be representative of Canadians at average or high risk for depression. Directness was downgraded further because of concerns regarding community-based screening for depression: The studies included in the analysis evaluated the effectiveness of community-based programs to screen for depression, which incorporated screening for depression, follow-up with mental health care or psychiatric treatment, and health education in the community setting. As such, any observed reduction in suicide rates could not be attributed solely to the screening component of these programs. 
§The number of events was small (< 300, which is the threshold rule-of-thumb value for dichotomous outcomes); however, with regard to the specific outcome, the evidence was not downgraded.
¶Funnel plot of the comparison indicated potential asymmetry and thus potential publication bias. However, the number of papers (n = 5) was too small to assess publication bias with confidence (≥ 10 papers being the threshold rule-of-thumb value).

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      Screening for depression: a systematic review and meta-analysis
      Homa Keshavarz, Donna Fitzpatrick-Lewis, David L. Streiner, Rice Maureen, Usman Ali, Harry S. Shannon, Parminder Raina
      Oct 2013, 1 (4) E159-E167; DOI: 10.9778/cmajo.20130030

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      Screening for depression: a systematic review and meta-analysis
      Homa Keshavarz, Donna Fitzpatrick-Lewis, David L. Streiner, Rice Maureen, Usman Ali, Harry S. Shannon, Parminder Raina
      Oct 2013, 1 (4) E159-E167; DOI: 10.9778/cmajo.20130030
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