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Screening for anxiety and depression in elderly medical outpatients

Age and Ageing, Nov, 1994 by Rachel M. Neal, Robert C. Baldwin

Summary

In a study of 45 consecutive new outpatients at geriatric medicine clinics, 17.8% were diagnosed as depressed and 2.2% as anxious using the Geriatric Mental Status Schedule. Of two screening instruments, the Geriatric Depression Scale (GDS), in either 30-item or 15-item version, performed well and the depression sub-scale of Goldberg and Bridges' screening questionnaire for depression and anxiety in medical settings was adequate. The anxiety sub-scale of the latter was poor. Detection by geriatricians of depression and anxiety disorders was poor. It is recommended that a short screening instrument for the detection of depression, such as the GDS, be incorporated into the clinic setting. As yet there is no satisfactory screening questionnaire for detecting anxiety disorders.

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Introduction

Estimates of the prevalence of depression in elderly medically ill inpatients vary between 9% and 45% [1-6]. Detection of these disorders by medical and/or nursing staff is poor [6-8]. Less is known about the prevalence of depression among elderly outpatient attenders. Two studies of mainly male Veterans' Administration hospital clinic attenders in America found prevalence rates of 29% and 38% [9, 10].

The prevalence of anxiety among elderly people with physical illness has been estimated at about 10% [11]. However, in contrast with depression, anxiety is rarely the cause of a psychiatric referral of ill elderly people [11] and there has been little systematic research either into its prevalence or its effects among older people.

We have recently reported on the rates of depression and its detection or otherwise by doctors and nurses in a geriatric medicine inpatient service [6]. The Geriatric Depression Scale (GDS) [12] was found to perform adequately as a screening instrument in this setting. The aim of the current study was firstly to see if the GDS was equally effective among outpatient attenders and secondly to evaluate the effectiveness of a simple anxiety rating scale. The instruments chosen were the 30-item GDS and a short questionnaire designed by Goldberg and Bridges (GBS) to detect anxiety and depression in medical settings [13]. The latter, like the GDS, uses a simple 'yes/no' format. It has 18 questions subdivided into two groups of nine covering anxiety and depression, respectively. It is designed to detect change over the past month. No other existing questionnaires were felt appropriate for the detection of anxiety. In particular, the Hospital Anxiety and Depression Scale (HADS) has recently been found to be poor at detecting anxiety disorders among geriatric medical inpatients [14]. Lastly, physician detection of these disorders was ascertained.

Method

The study group comprised outpatients at the Department of Medicine for the Elderly at Manchester Royal Infirmary. The entry criteria were: (1) age over 65; (2) first referral to the clinic; or (3) re-referrals only if not seen within the preceding 6 months (to reduce bias from earlier knowledge of a patient). Exclusion criteria were: (1) patients unable to give consent; (2) patients too cognitively impaired to co-operate with the test procedures (but dementia per se was not an exclusion).

On arrival at the clinic the purpose of the study was explained and consent obtained. Demographic data and details of the presenting medical condition (from both hospital notes and the referer's letter) were recorded. In the clinic the patient was asked to complete the 30-item GDS and the 18-item GBS. Assistance was given by a relative or third party in cases of poor visual acuity or motor difficulty.

The GDS and the GBS were then validated using the Geriatric Mental Status Schedule (GMSS) [15]. Arrangements were made to administer this at home by R.M.N. on a laptop computer [161. The GMSS is a standardized psychiatric interview with an associated computerized diagnostic program AGECAT [16], which assigns symptoms according to clusters in two stages. Stage 1 GMSS-AGECAT output produces five levels of severity for each of eight categories of symptoms: organic, schizophrenia and related psychoses, mania, hypochondriasis, anxiety, depression, obsessional neurosis and phobia. A level of severity above 3 is indicative of clinically relevant symptomatology and is known as syndromal case level.

Stage 2 GMSS output assigns a formal psychiatric diagnosis diagnostic case level), using a logical decision tree which gives preference to organic disorders. This diagnosis correlates with what a psychiatrist would call a 'case'.

R.C.B. undertook the training in the use of the GMSS of R.M.N., who after a tutorial first rated four training videos (all correctly) and was considered trained after agreement on a minimum of six consecutive cases drawn randomly from the Old Age Psychiatry Department's assessment and day hospital areas.

Lastly, to the medical casenotes was attached a form to be completed by the physician after his/her assessment asking: (a) whether there was evidence of psychiatric disorder (using the same eight categories as the GMSS stage I output); and (b) what, if any, treatment was indicated. Options were: drugs, psychotherapy and counselling. Clinicians were asked to rank multiple responses. The results were analysed using the Statistical Package for Social Sciences (SPSS).

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Screening for anxiety and depression in elderly medical outpatients

Age and Ageing, Nov, 1994 by Rachel M. Neal, Robert C. Baldwin

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