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Mastering depression in primary care(version 22) |
World Health Organization, WHO, Regional Office for Europe Psychiatric Research Unit, Frederiksborg General Hospital
WHO-Five Well-being Index Word document
The Major (ICD-10) Depression Inventory (MDI) word
document| Whole population |
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WHO-5 <50 |
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MDI |
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Doctor's interview. Confirmation of diagnosis (ICD-10 or DSM-IV) |
Within the frame of clinical psychiatry it is well-known that a major portion of people with depression are most often not treated optimally or not treated at all, despite the existence of a large amount of clinical literature for optimal medical treatment on handling depression and reducing the suicide rate. The problem is partly that a significant number of people who suffer from depression do not consult a doctor. Also, few general practitioners (GPs) are well equipped to diagnose and measure outcome of treatment of the large heterogeneous group of patients.
Non-compliance of people is a further problem. This occurs both at the beginning of the treatment, when many people suffer from side-effects, and at a later stage, when symptoms start to disappear and people no longer feel ill. In both these situations, a significant number of people drop out of treatment. If treatment is interrupted during the latter phase, people often have a relapse within a short time, resulting in loss of the ability to work, reduced quality of life and leading, in some cases, to suicide.
Overview
This Info Pack was developed to assist the GP to
To recognize and diagnose depression, the following two-stage screening procedure is recommended:
Introduction to the WHO-Five Well-being Index
The WHO-Five WHO-Five Well-being Index is a brief questionnaire with 5 items which is filled in by the patient. The 5 items reflect the presence and absence of positive wellbeing related to quality of life. The measurement of positive well-being rather than depressive symptomatology is shown to be more effective and in addition considered to be more acceptable to the patient. Lack of positive well-being is an indication of possible depression.
Application
The WHO-Five Well-being Index can be used to screen all people for depression/reduced quality of life.
Screening for well-being should be standard procedure, in the same manner as screening for hypertension. The index should be filled in by the person in the physician's waiting room or during the consultation. Once the person has completed the form, results can be interpreted immediately by visually inspecting the answers.
Scoring
The raw score is calculated by totalling the figures of the five answers. The raw score ranges from 0 to 25, 0 representing worst possible quality of life and 25 representing best possible quality of life.
In order to judge the course of events or the impact of interventions, a percentage score ranging from 00/0 to 100%, the raw score is multiplied by 4. A percentage score of 0% represents worst possible quality of life , whereas a score of 100% represents best possible quality of life (a 100/o difference then demonstrates significant change).
Interpretation
It is recommended to proceed to stage 2 and administer the Major Depression Inventory, if the person has answered 0 or 1 in any of the 5 items, or if the patients percentage score is less than 50.
Introduction to the Major Depression Inventory
The Major Depression Inventory (MDI) contains 10 items reflecting the presence or absence of depressive symptoms according to ICD-10. This inventory is used to evaluate if a person is suffering from depression. It is filled in by the person and subsequently scored by the GP.
Application
If the person shows decreased positive well-being in Stage 1, the Major Depression Inventory should be administered.
If the patient's score on the MDI suggests the presence of depression, the diagnosis of depression should be confirmed through a specific interview with the patient. The Doctor's Interview tool can be used for this purpose.
Scoring
The scoring sheet is used by the GP to diagnose depression on the basis of the patient's answers to the Major Depression Inventory according to lCD-10 and DSM-IV criteria.
A doctor's interview tool is provided to help the physician confirm diagnoses indicated by the Major Depression Inventory. The doctor's interview is structured according to criteria A, B and C, as explained briefly below.
Criteria
| A | The symptoms should have lasted at least two weeks and have been present most
of the time or all of the time. Hence, criterion A can be directly estimated by the MDI |
| B | Focuses on the first three symptoms of
the MDI B1:Depressed mood, B2: Decreased energy: B3: Loss of interest |
| C | Includes the remaining seven symptoms of the MDI. The diagnostic decision algorithm uses the 3 B criteria and 7 C criteria. This allows for diagnosis of mild, moderate, and severe depression according to ICD-10 criteria or major depression according to DSM-IV. 'Yes' means that the individual symptom has been present during the last two weeks 'most of the time' or 'all of the time'. |
Re-administering the WHO-Five Well-being Index and the Major Depression Inventory during and following antidepressive treatment allows for reliable monitoring of treatment progress and outcome.
Results of the WHO-Five Well-being Index are reported as percentage scores ranging for 0% to 100%. A change of 10% is considered to be reflecting a clinically significant change.
Results of the Major Depression Inventory are reported as the numerical score, which ranges from 0 to 50.
Entering monitoring data for all people into a paper-based or computerized database allows for reliable evaluation of treatment efficacy.
Please indicate for each of the five statements which is closest to how you have been feeling over the last two weeks. Notice that higher numbers mean better well-being.
Example: If you have felt cheerful and in good spirits more than half of the
time during the last two weeks, put a tick in the box with the number 3 in the
upper right corner.
| Over the last two weeks | All of the time | Most of the time | More than half of the time | Less than half of the time | Some of the time | At no time | |
| 1 | I have felt cheerful and in good spirits | 5 | 4 | 3 | 2 | 1 | 0 |
| 2 | I have felt calm and relaxed | 5 | 4 | 3 | 2 | 1 | 0 |
| 3 | I have felt active and vigorous | 5 | 4 | 3 | 2 | 1 | 0 |
| 4 | I woke up feeling fresh and rested | 5 | 4 | 3 | 2 | 1 | 0 |
| 5 | My daily life has been filled with things that interest me | 5 | 4 | 3 | 2 | 1 | 0 |
Scoring:
The raw score is calculated by totalling the figures of the five answers. The raw score ranges from 0 to 25, 0 representing worst possible and 25 representing best possible quality of life.
To obtain a percentage score ranging from 0 to 100, the raw score is multiplied by 4. A percentage score of 0 represents worst possible, whereas a score of 100 represents best possible quality of life.
Interpretation
It is recommended to administer the Major Depression (lCD-10) Inventory if the raw score is below 13 or if the patient has answered 0 to 1 to any of the five items. A score below 13 indicates poor wellbeing and is an indication for testing for depression under ICD-l0.
Monitoring change
In order to monitor possible changes in wellbeing, the percentage score is used. A 10% difference indicates a significant change (ref. John Ware, 1995).
The following questions ask about how you have been feeling over the last two weeks.
Please put a tick in the box which is closest to how you have been feeling.
Example: If you have felt in low spirits or sad slightly more than half of the
time during the last two weeks put a tick in the third box from the left in the
first row.
| How much of the time... | All of the time | Most of the time | More than half of the time | Less than half of the time | Some of the time | At no time | |
| 1 | Have you felt in low spirits or sad? | 5 | 4 | 3 | 2 | 1 | 0 |
| 2 | Have you lost interest in your daily activities? | 5 | 4 | 3 | 2 | 1 | 0 |
| 3 | Have you felt lacking in energy and strength? | 5 | 4 | 3 | 2 | 1 | 0 |
| 4 | Have you felt less self-confident? | 5 | 4 | 3 | 2 | 1 | 0 |
| 5 | Have you had a bad conscience or feelings of guilt? | 5 | 4 | 3 | 2 | 1 | 0 |
| 6 | Have you felt that life wasn't worth living? | 5 | 4 | 3 | 2 | 1 | 0 |
| 7 | Have you had difficulty in concentrating, e.g. when reading the newspaper or watching television? | 5 | 4 | 3 | 2 | 1 | 0 |
| 8a | Have you felt very restless? | 5 | 4 | 3 | 2 | 1 | 0 |
| 8b | Have you felt subdued? | 5 | 4 | 3 | 2 | 1 | 0 |
| 9 | Have you had trouble sleeping at night? | 5 | 4 | 3 | 2 | 1 | 0 |
| 10a | Have you suffered from reduced appetite? | 5 | 4 | 3 | 2 | 1 | 0 |
| 10b | Have you suffered from increased appetite? | 5 | 4 | 3 | 2 | 1 | 0 |
The Major (ICD-10) Depression Inventory (MDI) word
document
Each item is scored on a Likert scale from 0 to 5
*For Items 8 and 10, choose the subitem (a or b) with the highest score.
Diagnosis of depression
A score of 4 or 5 points in at least
| 2 of the first 3 items | + | 2 of the first 7 items | Mild depression | ICD-10 | |
| 2 of the first 3 items | + | 4 of the first 7 items | Moderate depression | ICD-10 | |
| all of the first 3 items | + | 5 of the first 7 items | Severe depression | ICD-10 | |
| 1 of the first 2 items | + | 5 of all 9 items | Major depression | DSM-IV |
For DSM-IV major depression diagnosis: The number of items is reduced to nine, as item 4 is part of item 5. The item with the highest score is included (item 4 or 5).
WHO/ICD-10 depressive episode: Criteria A & B
Criterion A
The statements or symptoms (see criteria B and C) should have lasted at least two weeks most of the time, e.g., a score of 1 or less on the WHO-Five Well-being Index.
Criterion B
Include the three symptoms B1 (depressed mood), B2 (decreased energy), and B3 (loss of interest).
With reference to the WHO-Five Well-being Index the procedure is:
"In the WHO-Five you said that ..."
If the person has scored 0 - 2 on item 1: "Does this mean that most of the time
you have been depressed?"
| B1 | Depressed mood | Yes | No |
If the person has scored 0 - 2 on item 3 or 4: "Does this mean that most of the
time you have had low energy?"
| B2 | Decreased energy | Yes | No |
If the person has scored 0 - 2 on item 5: "Does this mean that most of the time
you have had no interest in things?"
| B3 | Loss of interest | Yes | No |
Criterion C
WHO/ICD-10 depressive episode
"For the last two weeks, have you had any of the following symptoms most of the
time?"
| C1 | Poor appetite and/or weight loss? | Yes | No |
| C2 | Trouble sleeping every night? | Yes | No |
| C3 | Talk or move more slowly than normal, or more restless than usual? | Yes | No |
| C4 | Low self-confidence or worthlessness? | Yes | No |
| C5 | Feelings of self-reproach or guilt? | Yes | No |
| C6 | Diminished ability to concentrate? | Yes | No |
| C8 | Recurrent thoughts of death? | Yes | No |
Diagnostic decision algorithm
ICD-10 and DSM-IV diagnoses of depression
| Symptoms | F32.0* Mild depression |
F32.1* Moderate depression |
F32.2* Severe depression |
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| B1 | Depressed mood? | 2 boxes with YES | 2 boxes with YES | 2 boxes with YES |
| B2 | Decreased energy? | |||
| B3 | Loss of interest? | |||
| Cl | Poor appetite or weight loss? | 2 boxes with YES | 4 boxes with YES | 5 boxes with YES |
| C2 | Insomnia? | |||
| C3 | Psychomotor retardation or agitation? | |||
| C4 | Worthlessness? | |||
| C5 | Guilt? | |||
| C6 | Diminished ability to concentrate? | |||
| C7 | Suicidal thoughts? | |||
| Total B1-C7 Major depression | 5 boxes with YES | 5 boxes with YES | 5 boxes with YES | |
http://www.who.dk/document/e60246.pdf (depcare project, report)