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PRIMARY CARE: B Arroll, F Goodyear-Smith, N Kerse, T Fishman, and J Gunn Effect of the addition of a "help" question to two screening questions on specificity for diagnosis of depression in general practice: diagnostic validity study BMJ 2005; 331: 884 [Abstract] [Full text]

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improving diagnosis of depression in chronic disease

Richard L Davies   (16 October 2005)

GPs Ability Unaided and Help Question Alone Appears As Good As 3 Questions

Alex J Mitchell   (17 October 2005)

Using the additional "help" screening question for depression; how can it improve the specificity without affecting the sensitivity?

Paul Vaucher, Patrick Lombardo, Bernard Favrat, Bernard Burnand, Lilli Herzig   (20 May 2009)

improving diagnosis of depression in chronic disease 16 October 2005
Richard L Davies, General Practitioner 703 Leeds and Bradford Road, Stanningley, Pudsey, Leeds LS28 6PE Send response to journal: Re: improving diagnosis of depression in chronic disease	Dear editor, The paper by Arroll (1) outlines a simple and fast screening tool for depression. They suggest it is used during new patient medicals but it could also be used during routine medication reviews. It would be simple to add the three questions to the diabetic or coronary heart disease review template alongside smoking status and body mass index. Reading "The patients jounrney:Rheumatoid arthritis" by Carol Simpson and Chloe Franks (2) depression is a dominant concern to patients. Screening for the psychological consequences of the illness could help build a stronger working relationship with the patient by adressing patients concerns while also screening for a major complication of arthrtis. (1) Arroll V, Goodyear-Smith F, Kerse N, Fishman T, Jane Gunn. Effect of the addition of a "help" question to two screening questions on specificity for diagnosis of depression in general practice:diagnostic validity study.BMJ 2005;331:884-886 (2)Carol Simpson, Chloe Franks, Catherine Morrison, Heidi Lempp. The patients Journey: rheumatoid arthritis.BMJ 2005;331:887-889. Competing interests: None declared
GPs Ability Unaided and Help Question Alone Appears As Good As 3 Questions 17 October 2005
Alex J Mitchell, Consulant in Liaison Psychiatry Leicester General Hospital, Leicester LE5 4PW Send response to journal: Re: GPs Ability Unaided and Help Question Alone Appears As Good As 3 Questions	I have great admimiration for the new study by Bruce Arroll and colleagues, in part due to the excellent sample size and in part due to the authors attempt to compare different test methods to GP’s detection rate alone. It is surprising how few studies of putative diagnostic tests include a comparison with “diagnosis-as-usual” or in other words the clinicians routine ability. However, I would like to raise a few points that are either unclear or deserve comment. The authors state that GP’s sensitivity of 79% is an improvement on that previously reported. The figure quoted is an improvement, but I suggest that the comparison with older studies is unfair for the following reason. In this study “The patient showed the general practitioner his or her written responses to the screening and help questions. The general practitioners could ask any questions.”. The GP arm of the study was therefore screening tool plus clinical ability rather than unaided clinical ability alone. This also may explain why the overall performance of the GP arm (by PPV to NPV differential or by likelihood ratio) appears comparable or even better than the 3-question test. Indeed, if the authors maintain that GPs were not influenced by the availability of the 3-question test, then the possible value of the test appears mathematically negligible. Can the authors also explain why the help question alone was quite successful? The authors state that the help question was phrased “is this something with which you would like help?” Surely the offer of help question was conducted only after a patient had read question 1 and 2 in which case the “diagnostic test” is not really the help question alone but a summation of Q1 2 and 3 with post-hoc separation of items. Taken at face value, in performance terms the help question ALONE does as well as any other combination suggesting that a single item may suffice after all. But herein lies a conundrum because in order to extract maximum diagnostic accuracy from a single item question, such a question may need to be phrased “Do you want help today or in the future for often feeling low, down or hopeless during the last month or in the same period have been bothered by little interest or pleasure in doing things (footnote state yes if any condition applies).” Clearly, there are problems in clinical practice summing various stems into a long tortuous question. It will be interesting to see if a meta-analysis currently being conducted reveals the benefits of the ultra-short (1, 2 or 3 question) approach to diagnosing depression. Competing interests: None declared
Using the additional "help" screening question for depression; how can it improve the specificity without affecting the sensitivity? 20 May 2009
Paul Vaucher, Clinical Trialist (MSc CT) Institute of General Medicine, University of Lausanne, Bugnon 44, 1011 Lausanne, SWITZERLAND, Patrick Lombardo, Bernard Favrat, Bernard Burnand, Lilli Herzig Send response to journal: Re: Using the additional "help" screening question for depression; how can it improve the specificity without affecting the sensitivity?	Arroll et al [1] have assessed the usefulness of adding a “help question” to the previously tested [2] two screening questions for depression. Patients were considered as positive if they answered “yes” to either one of the two screening questions and “yes” to the help question. Authors concluded that adding the help question increases the specificity without changing the sensitivity. Looking at their results more closely, we would like to understand how authors came up with what appears to us to be inconsistent. Using two tests combined with the condition “AND” should increase the specificity and optimally conserve the lowest sensitivity of each test taken alone. Arroll et al. reported a sensitivity of 74.5% for the help question alone. This is inconsistent with their reported sensitivity for the combined three screening questions which is of 96%. Looking more closely at the published table 1 [1], it is possible to calculate that only two false negative results for the two-screening questions was observed. From table 2 we also learned that 12 depressed patients answered negatively to the help question. This should mean that at least 10 and at most 12 depressed patients answered positively to the two screening questions without asking for help. Combining both the screening questions and the help question, authors should therefore find between 33 and 35 true positive patients. Table 1 however reports that all 45 patients responded positively. We therefore wonder what happened to the 10 patients who were supposed to have answered negatively to the help question but positively to the two screening questions? We are also surprised that depressed patients apparently never consider they do not need any help. We therefore believe Arroll et al’s reporting to be potentially misleading. If the sensitivity of the help question alone was to be confirmed, this could have important clinical implication if practitioners were to falsely acknowledge this test to conserve a high sensitivity. By using these published results, GPs could underestimate the number of false negative and not investigate depression for patients needing care. References 1. Arroll B, Khin N, Kerse N. Screening for depression in primary care with two verbally asked questions: cross sectional study. BMJ. 2003 Nov 15;327(7424):1144-6. 2. Arroll B, Goodyear-Smith F, Kerse N, Fishman T, Gunn J. Effect of the addition of a "help" question to two screening questions on specificity for diagnosis of depression in general practice: diagnostic validity study. BMJ. 2005 Oct 15;331(7521):884. Competing interests: We have tested the validity of the "help" screening questions for depression in patients followed-up in general practice (SODA study). Our results, we are about to publish, are in contradiction with those of Arroll et al. We are therefore trying to understand why.