Use substitute diagnostic criteria for depression in medically ill. (Endicott Soulution More Applicable).

ALBUQUERQUE -- The use of substitute diagnostic criteria for depression lessens overdiagnosis in medically ill patients, Elizabeth Dettmer, Ph.D., said at a psychiatric symposium sponsored by the University of New Mexico.

Physicians receive mixed messages about depression in the medically ill. On the one hand, experts insist it is common, greatly underdiagnosed, and undertreated. They complain that many physicians still hold to the outdated conviction that depression is a normal response to cancer, end-stage renal disease, rheumatoid arthritis, or other serious diseases.

But it's also claimed that depression is easily overdiagnosed in this setting because of symptom overlap. That is, some of the classic somatic symptoms physicians rely upon in diagnosing depression-sleep disturbance, loss of appetite, fatigue, inability to concentrate-are also present in a great many physically ill patients who don't have any kind of depression.

Both arguments are valid. Up to one-third of patients hospitalized for medical problems have depressive symptoms. But in many cases this is an adjustment reaction, and the symptoms improve substantially in about 3 days. It's important to try to bring diagnostic clarity to this issue because solid evidence shows that major depression in patients with concomitant physical illness not only causes emotional suffering, it adversely affects medical outcomes, said Dr. Dettmer, director of behavioral medicine at the Albuquerque Veterans Affairs Medical Center.

The solution created by Jean Endicott, Ph.D., of Columbia University, New York, was to change the diagnostic criteria for depression to make them more applicable to a medically ill population. It's a strategy that relies more upon the cognitive and affective symptoms of depression while deemphasizing the neurovegetative symptoms.

The Endicott substitutive criteria have been field tested by several investigators and found to be a big improvement over the standard criteria listed in the DSMIV, Dr. Dettmer said.

The DSM-IV criteria for major depressive disorder require that a patient experience pervasive sadness and/or loss of interest in activities for 2 or more weeks. Plus, the patient must meet at least four of eight additional criteria that some physicians remember using the acronym SIGECAPS. Dr. Endicott changed what several of these letters stand for while maintaining the requirement that four or more SIGECAPS criteria be met.

The DSM-IV and Endicott criteria for major depression are based upon face-to-face clinical interviews. An alternative approach to assessing patients for depression involves self-report measures. Two that are particularly well suited for use in medical patients are the widely used Beck Depression Inventory (BDI) and the Center for Epidemiologic Studies Depression Scale (CES-D).

Both are quickly administered instruments. The BDI consists of 21 questions; the CES-D contains 20. The emphasis is on assessment of cognition and mood, as is desirable in patients with physical illness.

An alternative ultrafast case-finding tool that's attractive is what's known as the two-question instrument. It was developed by Dr. Mary A. Whooley, a general internist at University of California, San Francisco.

The two questions: During the past month, have you often been bothered by feeling down, depressed, or hopeless? During the past month, have you often been bothered by little interest or pleasure in doing things?

The two-question instrument has been tested in 536 patients who presented to an urgent care clinic at a veterans affairs hospital. A positive response to either had a sensitivity of 96% and a 57% specificity for the diagnosis of major depression, a performance comparable to that of six other common case-finding instruments tested, including the CES-D and Beck Depression Inventory.