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

doi:10.9778/cmajo.20130030

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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 population			Outcomes
Study	Description	Definition	Evaluation	Definition	Results
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 assessment							No. of patients/person- years		Effect		Quality		Importance
No. of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Screening (older persons)	Control	Relative (95% CI)	Absolute	Quality		Importance
Overall (follow-up 4–20 yr; assessed with community-based depression screening)
5¹⁷^–²¹	Observational	No 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 low	Critical

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).