Review
Diagnostic validity and added value of the geriatric depression scale for depression in primary care: A meta-analysis of GDS30 and GDS15

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Abstract

Background

The Geriatric Depression Scale (GDS) has been evaluated in hospital settings but its validity and added value in primary care is uncertain. We therefore conducted a meta-analysis analysing the diagnostic accuracy, clinical utility and added value of the GDS in primary care.

Methods

A comprehensive search identified 69 studies that measured the diagnostic validity of the GDS against a semi-structured psychiatric interview and of these 17 analyses (in 14 publications) took place in primary care. Seven studies examined the GDS30 and 10 studies examined the GDS15. Heterogeneity was moderate to high, therefore random effects meta-analysis was used.

Results

Diagnostic accuracy of the GDS30 after meta-analytic weighting was given by a sensitivity of 77.4% (95% CI = 66.3% to 86.8%) and a specificity = 65.4% (95% CI = 44.2% to 83.8%). For the GDS15 the sensitivity was 81.3% (95% CI = 77.2% to 85.2%) and specificity = 78.4% (95% CI = 71.2% to 84.8%). The fraction correctly identified (also known as efficiency) by the GDS15 was significantly higher than the GDS30 (77.6% vs 71.2%, Chi2 = 24.8 P < 0.0001). The clinical utility of both the GDS30 and GDS15 was “poor” for case-finding (UI+ 0.29, UI+ 0.32 respectively). However the GDS15 was rated as “good” for screening (UI− 0.75) whereas the GDS30 was “adequate” (UI− 0.60). Concerning added value, when identification using the GDS was compared with general practitioners' ability to diagnose late-life depressions unassisted by tools, at a prevalence of 15% the GDS30 had no added benefit whereas the GDS15 helped identify an additional 4 cases per 100 primary care attendees and also helped rule-out an additional 4 non-cases per 100 attendees. Thus we estimate the potential gain of the GDS15 in primary care to be 8% over unassisted clinical detection but at a cost of 3–4 minutes of extra time per appointment.

Conclusion

The GDS yields potential added value in primary care. We recommend the GDS15 but not the GDS30 in the diagnosis of late-life depression in primary care.

Introduction

Depression in late-life is both common and persistent (Friedman et al., 2007, Gilchrist and Gunn, 2007). Several studies have shown that the majority of care for older people with depression occurs in primary care (Cooper-Patrick et al., 1994, Harman et al., 2003, Pincus et al., 1998, Unutzer et al., 1999, Harman et al., 2006). Recent evidence suggests that only one third of patients recover within 1 year (Licht-Strunk et al., 2009a, Licht-Strunk et al., 2009b) and the majority have depressive symptoms for two or more years (Unutzer et al., 2003). In some circumstances the prognosis of late-life depression is inferior to the prognosis of mid-life depressions (Mitchell and Subramaniam, 2005). Comparative work suggests that late-life depression is associated with a poorer quality of life, reduced social functioning, worsening of physical morbidity and, in some settings, higher than expected mortality than mid-life depression (Schulz et al., 2002, Cole, 2007).

There is ongoing concern about the recognition of depression in late-life. In the large Canadian Community Health Survey Cycle involving 7736 individuals, only one third of people with major depression (or depressive symptoms) sought help from a psychiatrist, family physician or other professionals for mental health problems in a 1 year period (Cole et al., 2008). It is therefore important for clinicians, especially general practitioners (GPs) to identify late-life depression in order to avoid under-treatment (Licht-Strunk et al., 2009a, Licht-Strunk et al., 2009b). Yet it is well known that late-life depressions are significantly under-diagnosed by non-psychiatrists (Harman et al., 2001, Shah and Harris, 1997, Mulsant and Ganguli, 1999) although the exact magnitude of the problem is not clear. Under-treatment appears to be more significant in older than in younger depressed patients (Crystal et al., 2003). Rates of under-treatment for late-life depression also appear to be higher for men, in those with transient depressive symptoms and in ethnic minority groups (Unutzer et al., 2003, Unutzer et al., 2000, Harman et al., 2004). In one study only 29% reported appropriate depression treatment and only 8% had received psychological treatments in the past 3 months. In an attempt to improve recognition numerous scales have been tested in older people with variable success (Watson and Pignone, 2003, Watson et al., 2004). The most popular scale for late-life depression is the geriatric depression screen (GDS). The GDS was originally developed as a 30-item questionnaire (GDS30) in a simple yes/no response format (Yesavage et al., 1983). It was purposely designed with few somatic symptoms which might otherwise cause problems for diagnoses in older people. In 1986 Sheik and Yesavage developed a 15-item short form in order to improve acceptability (Sheikh and Yesavage, 1986). Recently even shorter one, four, five or 10-item versions had been developed but none validated in primary care (Almeida and Almeida, 1999, Galaria et al., 2000, Hoyl et al., 1999 Van Marwijk et al., 1995, D'Ath et al., 1994). Although Sheikh and Yesavage showed that scores on the GDS15 had a high correlation with the original GDS30 (r = 0.84), the sample size was small and the authors did not provide any cut-off values or diagnostic validity for the shortened GDS against a robust criterion standard. Several published reviews have examined the overall accuracy of the GDS largely in nursing home and secondary care (Mui et al., 2001, Mui et al., 2003, Stiles and Mc Garrahan, 1998, Wancata et al., 2006). Wancata et al. (2006) examined 42 papers (including 9 in primary care) published up to 2004 and using simple pooling found a sensitivity of 75.3% and a specificity of 77.0% for the GDS30 and a sensitivity of 80.5% and specificity of 75.0% for the GDS15 across diverse setting. However the value of the GDS in primary care is still uncertain despite increasing attention on brief methods that are highly acceptable but retain adequate accuracy (Mitchell and Coyne, 2007).

The aim of this study was therefore (a) to evaluate the accuracy and clinical utility of the geriatric depression scale in the detection of robustly defined depression in primary care and (b) to evaluate the added value of the GDS when compared to routine clinical identification of GPs.

Section snippets

Inclusion/exclusion criteria

The principle inclusion criteria were studies that examined the diagnostic validity of the GDS in the detection of depression in older people defined by a semi-structured psychiatric interview. We defined late-life depression as any depression occurring at the age of 55 years or older, according to the prevailing convention (Mitchell and Subramaniam, 2005). In order to calculate added value we also examined the routine (unassisted) diagnostic ability for GPs (that is without specific help from

Accuracy

In order to examine diagnostic accuracy we examined the discriminatory value of the GDS at an optimal cut-off (if receiver operator curve data reported) or otherwise using the cut-off supplied by the primary authors. Overall accuracy was calculated as the proportion of all cases who were either true positives or true negatives, known as the fraction correct (FC) or efficiency of a test (Grimes and Schulz, 2002). An FC above 60% can be considered “adequate” and above 80% can be considered

Study description and methods

From 1080 initial hits we identified 69 studies pertaining to the diagnostic accuracy or validity of the GDS against a robust semi-structured interview; of which 17 analyses (in 14 publications) took place in primary care (Table 1). Seven studies examined the GDS30 (Blank et al., 2004, Fernandez San Martin et al., 2002, Evans and Katona, 1993, Robison et al., 2002, Lyness et al., 1997, Sanchez-Garcia et al., 2008, Van Marwijk et al., 1995) and 10 studies examined the GDS15 (Abas et al., 1998,

Discussion

This is the first attempt to synthesize the validity and added value of the GDS in primary care. Added value is an important aspect of tool performance measured against clinical diagnoses without the tool. When defined by robust semi-structured psychiatric interviews we found the prevalence of late-life depression to be 17.1%. This is slightly higher than in the West Friesland study of 5686 older primary care attendees who were evaluated with the PRIME-MD (Licht-Strunk et al., 2005). However we

Role of funding source

Nothing declared.

Conflict of interest

No conflict declared.

Acknowledgements

Many thanks to the staff of the medical library, Leicester General Hospital.

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