Detection of Depressive Symptoms

Background Knowledge

It has been observed that approximately 12% of patients who experience depression will have a chronic, unremitting course (World Mental Health Survey Consortium, 2004). As the name suggests, a chronic Unremitting course refers to a condition in which one experiences persistent pain for very long durations of time. The issue of chronic illnesses is a burdensome affair to governments and health organizations. They continue to use so much in terms of budgets so as to heal the populace and to retain public health. This is despite efforts to combat diseases that are deemed to be so cruel to the human wellbeing.Since the condition affects many people; they are often on sick leave and this further result in $17 billion loss in terms of lost work days (World Health Organization, 2007).

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The burden of suffering from depression is substantial. Most patients are diagnosed and treated in primary care setting rather than the mental health setting, and depression is one of the most common disorders encountered by primary care providers there is a general criticism of the health care providers’ failure in providing even the minimal treatment for the depression victims. If more evidence-based care is provided, it will result in a significant decline in the rate of disability for the victims of depression (Sanderson et al., 2007).

Depression is one of the medical conditions that have no standard laboratory way of diagnosing. The medical practitioner will often refer to ones medical history and interviews as outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). There are a variety of symptoms that would point to depression. These include sadness and emptiness, no interest in fun, acute changes in weight, insomnia, fatigue and Psychomotor Agitation (Britton et al., 2004).

Depression is quite dangerous when it goes for a long time without been treated as it results to even bigger problems and it has the capacity to create other diseases. This is very critical and efforts have to be made to ensure that the disease does not have a bad impact on people and the population. Suicide, is the most severe of depressive sequelae, has a rate of approximately 3.5% among all cases with major depression, a risk that increases to approximately 15% in people who have required psychiatric hospitalization. Both the chronicity and recurrence of depressive illness play a large role in depression’s heavy disease burden. The more severe a depression becomes and the longer it lasts, the greater the likelihood that the depression will become chronic (World Health Organization, 2003).

Research has continued to demonstrate that the primary care setting is the best place to handle depression and depression related sickness (Bruce et al. 2004; Simon et al. 2000, 2004; Unutzer et al. 2002). When juxtaposed to other developed economies the United States of America has a surplus of professionals and medical specialists. Quite interestingly however, there still is a deficit of primary health care providers (Cooper et al. 2002; World Health Organization, 2003 ).This misdistribution needs to be corrected if there is going to be any significant improvement in the healthcare for the depressed.

Women are more prone to depression than men. According to the research findings, the ratio of women to men that are suffering depression in America is 6.0:3.8. This is a fact that has baffled researchers although most seem to subscribe to the view that estrogen has a significant impact on the stress hormone. Apart from the sex factor, age is also one of the important things to consider. Scientific research has established that the happiness curve is usually “U” shaped. The age of forty four is believed to be the age of depression (World Health Organization, 2007).

There have been many studies conducted with the objective of understanding the etiology of depression. Some have shown that racial/ethnic group identity is an important factor in the prevalence of depression (Kemp, Staples, & Lopez-Aqueres, 1987). Munoz, Gonzalez, & Starkweather (1995) noted that because most Hispanics were low-income and less educated, they were more vulnerable to depression due to greater psychosocial and emotional stressors. Rogler (1989) identified acculturation problems and low socioeconomic status as risk factors for depression for Hispanics. Hispanics were more likely than non-Hispanic Whites to be unemployed, to earn less, to be less educated and to live in poverty (Ramirez & de la Cruz, 2002).

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Potter, Rogler and Moscicki (1995) found that “female gender, disrupted marital status, lower education al achievement, household income, unemployment, and poor physical health,” all of which are more prevalent among Hispanics, African Americans and other ethnic minorities, were predictably related to depression. Additional studies have documented other factors, such as perceived discrimination and stress (Noh & Kasper, 2003; Racism and Health, 2003; Karlsen & Nazroo, 2002), powerlessness and alienation (Romando, 1998), and their relationships to depression.

Hence, the research that documented the etiology of depression strongly supports the research hypothesis that minorities from immigrant groups should have higher rates of depression than Americans. Further, some studies that have examined the broad ethnic category of Hispanic and differential rates of depression have shown that Hispanics are at far greater risk to suffer from depression than Whites or African-Americans.

Frerichs, Aneshensel, and Clark (1981) found that the prevalence of depression was greatest among Hispanics (27.4 percent) and least among Whites (12.9 percent), with Blacks and “Others” at an intermediate level (21.8 percent and 21.2 percent respectively). Ring and Marquis (1991) reported that 28 percent of their sample of Latinos suffered from major depression. Robison et al. (2002) study of a sample of 50 and older Puerto Rican primary care patients reported that between 34 percent to 61 percent screened positive for depression with 12 percent meeting the DSM-IV criteria for major depression. In a study of major depression for a sample of 54 to 65 adults, Dunlop et al. (2003) reported that 7.3 percent of Hispanic, 6.8 percent of African American and 5.2 percent of White suffered from major depression.

Local Problem

Depression is a significant problem worldwide in terms of prevalence. The World Health Organization (2007) has foreseen that by the early 2020’s depression will be second only to ischemic heart disease and will become a global burden of disease. This signals a very bleak future for the people who continue to pursue the medicine that is to be used to cure the infamous disease. Depression remains as valid in the present day as it was in the nineteenth century. Lifetime prevalence levels from community-based surveys range from approximately 5 to 17% (Pignone, et al., 2002).

In primary care settings, the prevalence of major depression is 6% to 8%, and it is one of the most commonly encountered conditions in primary care (Andrews, 2001). These statistics reveal that almost one out of every five people that visit primary healthcare facilities or more generally put, one out of every fifteen people in the entire population are in dire need of medical intervention for depression.

This is so large a number that few countries could afford to treat these people and even more, few would have adequate trained staff (Andrews, 2001). The general public has also increased the pressure on the systems of health providers as they have generally become more optimistic on the need for quality health provision by the primary health providers (Rosenberg, 2002).

As Schnittker (2005) observes, the most prevalent source of data for medical research is the self-rated survey. In this form of survey, the respondents simply check their medical condition from a variety of options such as good, bad, not good, not bad, very good or excellent. This is a non scientific approach and there is therefore need for more scientific research and representation of statistical data.

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Intended Improvement

The purpose of this project is to implement a brief 2-item questionnaire for depression screening in a primary care practice. A secondary aim is to evaluate the acceptability and effectiveness of the screening tool in a culturally and ethnically diverse patient population. The second objective of this research study is to examine whether race/ethnicity impacts self-reported depressive symptoms in primary care population. Participants will be recruited from Englinton Medical, Cystal Ray primary and Physical therapy offices. The identification of the problem and its scope may be effective for early identification and management of depression with people. This may not only decrease the substantial morbidity associated with the current episode but may also decrease the likelihood that the illness will become chronic.

Study Questions

In this research we are going to consider the problem of depression and the rate of its appearance. It is important to understand that the earlier the symptoms of the depression are identified, the more problems may be avoided in the future. The main problems which are going to be considered in the study are as follows. The study is designed to:

  1. Measure the presence of depression;
  2. Understand the etiology of depression.

Ethical Issues

Participants will be recruited from Englinton Medical and Crystal Ray primary physical therapy offices. Initially, informed written consent will be obtained from all willing participants. After obtaining socio-demographic and clinical data, a self- administered PHQ-2 will be completed. It will take 1 min to complete 2-item questionnaire. For those individuals who will answer yes to at least one of the questions, Beck Depression Inventory will be offered to complete. To those who will meet the diagnostic criteria for depression, medical records will be reviewed for previously diagnosed depressive disorders, and patients will be referred to psychiatrist for evaluation and treatment.

Instruments for routine case-finding in primary care settings must be of acceptable quality, brief and easy to use. Patients would complete the test while waiting to see their physician. Most self-administered tests have been designed for routine screening purposes and not as diagnostic aids.


Englinton Medical PC is a private clinic which is aimed at helping people correct some speech problems, support with therapists and physician attendance and treating patients by means of audiologistics (Englinton Medical P.C., 2010).

Crystal Ray Medical P.C. is a medical center which provides all possible services from the day a patient has come up to the full recovery. Rehabilitation facilities are covered by means of patient teaching and treatment on the basis of the stated diagnosis. The hospital has a wide range of specialists who are ready to help. Individually oriented work is the main strategy the center follows as each case is unique and requires special attention (Serving wellness of community, 2010).

Planning the Intervention

Random sampling will be conducted to enrol 100 adults, who visit Englinton Medical P.C and Crystal Ray medical P.C for their routine care. This study aims to find the relationship (non-directional) between two sets of questionnaires, with a predetermined effect size of r =.30 (medium), a significant alpha =.05 and a statistical power of.80, the desired sample size to test these relationships as indicated in Table 3.4.1 is 85 (Cohen,1992). This means that 85 respondents are sufficient to perform this statistical analysis. Total of 100 participants will be recruited in this research study, to provide more effective sample. Participants will be recruited from Englinton Medical P.C and Cystal Ray medical P.C offices, where patients receive physical therapy as a result of MVC. An inclusion criterion includes the following: cognitively intact, speaks and understands English, hearing intact.

The PHQ-2 screen will be scored by summing the affirmative responses, with scores ranging from 0-6. On the Beck Depression Inventory, participants will be scored positive for symptom when the sum of the intensity and frequency will measure 15 or greater.

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Spearman rank correlation will be calculated to assess test-retest reliability for an ordinal scale, while kappa coefficients will be used to determine agreement for individual items.

A quantitative research design will be used for this study. The study will consist of three steps, the first being a short set of questionnaires on socio-demographic and clinical data, the second – 2 item Patient Health Questionnaire. Those who will answer yes to at least one of the questions in 2-item Patient Health Questionnaire will proceed to step three, where they will answer 21 questions from Beck Depression Inventory.

Planning the Study of the Intervention

As it has been mentioned above, 100 adults are interviewed by in 2-item Patient Health Questionnaire. Those who answer affirmatively on at least one question are going to be asked to answer 21 questions from Beck Depression Inventory. The information is going to be analyzed by means of the reference to people who are mostly affected by stresses and depression on the basis of the ethnic origin.

Being aware of the patients’ socio-demographic and clinical data and their current attitude to stressful and depressive situations, it is possible to consider the changes which may be applied to make the expected changes. It is possible to predict that the symptoms and intensity of depression are reduced when family, friends, healthcare providers, and aid agencies provide social support and resources after a traumatic event, including their presence, acceptance, nurturance, tangible assistance, and nonjudgmental empathy (Bruce, M. et al. 2004). The mechanism (Beck Depression Inventory) implemented by Aaron T. Beck is going to be the main mechanism for measuring the depression.

Applying this mechanism on experiment subjects, we are going to check the level of depression of people and to understand where the line when these people are not affected by stress. This mechanism may help prevent people from stress and make rehabilitation process easier.

The study design is the observational qualitative research which predicts the questionnaire of the patients in two city clinics. This research is going to affect the primary outcomes which should be the basis for another research focused on the specific measures taken for treating people subjected to depression. It should be stated one more time that medical records will be reviewed for previously diagnosed depressive disorders to those who will meet the diagnostic criteria for depression, and patients will be referred to psychiatrist for evaluation and treatment.

The internal validity of the study is stressed by means of the wide range of symptoms considered in the research mechanism. Moreover, the Beck Depression Inventory method is valid and highly rated that can support the external validity of the test. It also deserves mentioning that the previous research proves that more an more people are subjected to the depressive conditions.

Reference List

Andrews, G. (2001). Should depression be managed as a chronic disease? BMJ, 322 (7283), 419–421.

Britton, A., et al., (2004). Does access to cardiac investigation and treatment contribute to social and ethnic differences in coronary heart disease? White-hall II prospective cohort study. British MedicalJournal, 32 (9), 318-323.

Bruce, M. et al. (2004). A randomized trial to reduce suicidal ideation and depressive symptoms in older primary care patients: The prospect study. Journal of the American Medical Association, 291, 1081-1091.

Cooper, R. et al. (2002). Economic and demographic trends signal an impending physician shortage. Health Affairs, 21 (2), 140-154.

Dunlop, D. D., Song, J., Lyons, J. S., Manheim, L. M., & Chang, R. W. (2003). Racial/ retirement adults: Ethnic differences in rates of depression among pre- retirement adults. Public Health, 93, 1945-1952.

Englinton Medical PC. (2010). HealthGrades. Web.

Frerichs, R. R., Aneshensel, C. S., & Clark, V. A. (1981). Prevalence of depression in Los Angeles county. American Journal of Epidemiology, 113 (6).

Karlsen, K. & Nazroo, J. Y. (2002). Relation between racial discrimination, social class, and health among ethnic minority. American Journal of Public Health, 92, 624-631.

Kemp, Staples, & Lopez-Aquires, 1987. Epidemiology of depression and dysphoria in Hispanic population. Journal of psychiatry, 35, 920-926.

Munoz, R. F., Gonzalez, G. M., & Starkweather, J. (1995). Automated screening for depression: Toward culturally and linguistically appropriate uses of computerized speech recognition. Hispanic Journal of Behavioral Sciences, 17, 194-208.

Noh, S. & Kasper, V. (2003). Perceived discrimination and depression: Moderating effects of coping acculturation, and ethnic support. American Journal of Public Health, 93, 2328.

Pignone, M. et al. (2002). Systematic Evidence Review. North Carolina: Research Triangle Park.

Potter, L. B., Rogler, L. H., & Moscicki, E. K. (1995). Depression among Puerto Ricans in New York city: The Hispanic health and nutrition examination survey. Social Psychiatry and Psychiatric Epidemiology, 30, 185-193.

Racism and Health. (2003). American Journal of Public Health, 93 (2), 189-255.

Ring, J. M. & Marquis, P. (1991). Depression in the Latino immigrant medical population: An exploratory screening and diagnosis. American Journal of Orthopsychiatry, 61 (2), 298-302.

Robison, J., Gruman, C., Gaztambide, S., & Blank, K. (2002). Screening for depression in middle-aged and older Puerto Rican primary care patients. The Journal of Gerontology.

Rogler, L. H. (1989). The meaning of culturally sensitive research in mental health. American Journal of Psychiatry, 146, 296-303.

Romando, J. (1998). The perceived effects of social alienation on black college students enrolled at a Caucasian southern university. College Student Journal, 32, 228-239.

Rosenberg, E. (2002). The Tyranny of Diagnosis: Specific Entities and Individual Experience. Milbank Quarterly, 80, 237-60.

Sanderson, K. et al. (2003). Reducing the burden of affective disorders: Is evidence- based health care affordable? J Affect Disord 77, 109–125.

Schnittker J. (2005) When mental health becomes health: Age and the shifting meaning of self-evaluations of general health. The Milbank Quarterly, 83 (3), 397-423.

Serving wellness of community one patient at a time. (2010). Crystal Ray Medical. Web.

Simon, G. et al. (2000). Randomized trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care. BMJ, 320, 550-554.

Simon, G. et al. (2004). Telephone psychotherapy and telephone care management for primary care patients starting antidepressant treatment: a randomized controlled trial. Journal of the American Medical Association, 292, 935-42.

World Health Organization. (2003). A Global Review of Primary Health Care: Emerging Messages. Web.

World Health Organization. (2007). Depression. Web.

World Mental Health Survey Consortium. (2004). Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization world mental health surveys, JAMA 291(21), 2581–90.

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