NIHR Signal Two simple questions help GPs rule out depression

Published on 23 March 2016

The Whooley questions are useful for ruling out depression in that few people who answer no to both questions are depressed according to a ‘gold standard’ diagnostic interview. A positive screen is indicated by the person answering “yes” to one or both of the Whooley questions and for these people the diagnostic interview will still be necessary to diagnose the condition.

The two simple questions are; 1) have you felt down or depressed or hopeless? and 2) have you been bothered by little interest or pleasure in doing things? - in the past month.

The questions are already recommended by NICE to identify people who may be at higher risk of depression, prior to further assessment. These people include those with long-term conditions and women before or after birth. Therefore this systematic review provides more detail on the evidence behind current practice.

The researchers also wanted to see if adding a third question asking ‘is this something you feel you need or want help with?’ (and variations to this question) improved the diagnostic performance of the questions. There were few studies and a lack of standardisation to this “help” question, and this meant the researchers were unable to draw firm conclusions about its addition to the two standard Whooley questions.

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Why was this study needed?

Depression affects large numbers of people, approximately 1 in 4 women and 1 in 10 men. Primary care, such as general practice, is often where people first present with depression. Though diagnosis is sometimes missed. Improving early detection of depression is important as it can be more easily treated, and reduces the risk of progression to more severe symptoms. Early detection and successful treatment in primary care is also likely to benefit the health system in terms of cost and resource. The prevalence rate expected in the general at risk population in whom the test might be used, is thought to be less than 20%.

The questions are currently used to indicate whether a person may be depressed and should be further assessed. However, the precise diagnostic accuracy of the Whooley questions and the additional third question is not currently clear, so this review aimed to pool all available evidence comparing the performance of both two and three questions against “gold standard” diagnostic tools.

What did this study do?

This systematic review and meta-analysis identified ten randomised controlled trials conducted in different countries (one UK-based study). They were carried out in primary, secondary and community settings and contained between 89 and 1025 people each. The questions were also administered by a range of individuals, from psychiatrists to GPs. Some were done by self-assessment.

The included studies were quality assessed using the QUADAS-2 tool. No studies were at a low risk of bias across all sections of QUADAS-2; some were at an unclear risk because, for example, it was unclear in some studies if patients were excluded if they were known to be depressed. This systematic review used a wide range of sources to identify studies that were similar enough to be reliably compared in their analysis (I2=24.1%).

What did it find?

  • The Whooley questions correctly identified 95% of people with depression, with a combined sensitivity of 0.95 across all studies (95% confidence interval [CI] 0.88 to 0.97). This is a useful sensitivity for a test as it means very few of those with depression test negative (5% false negative)
  • The Whooley questions also correctly identified 65% of people who did not have depression, with a combined specificity of 0.65 (95% CI 0.56 to 0.74). This means that about 35% of people without depression mightstill test positive using the questions but as they are then further assessed, these people come to little harm.
  • In terms of the ability of the test to rule out or rule in depression the pooled positive likelihood ratio of 2.78 (95% CI 2.16 to 3.57) and the pooled negative likelihood ratio of 0.07 (95% CI 0.03 to 0.16) mean that the questions are best at ruling out depression.
  • In the setting of general practice, with less than 20% prevalence of depression, a negative result on the questions (two no’s) effectively means the chance of having depression is reduced from 20% to less than 2%.
  • There were insufficient studies to conclude whether or not an additional question asking the person if these are feelings they would like help with would be useful or not.

What does current guidance say on this issue?

NICE guidelines (2009) recommend that health professionals consider asking the two Whooley questions to anyone who may be at higher risk of depression. In particular, people who have previously had depression, have a long-term physical health condition causing some impairment, women during pregnancy and the postnatal period. If a person answers yes to either of these questions, they should be referred for a formal depression assessment by a qualified professional (which could be their GP).

What are the implications?

This systematic review reinforces the current use of the questions. Given that depression is a common condition, this finding should be valuable to clinicians in general practice for use with patients they have concerns about. Despite its modest specificity, which means that many people who score positively will not meet diagnostic criteria for depression, the test retains value in its ability to rule out the target condition. Healthcare professionals not using the questions could consider using them. The Whooley questions’ ability to rule out depression has potential resource implications if positive Whooley results lead to more people without depression undergoing further costly assessment. This resource implication may be offset by savings from treating people earlier, however, without an economic analysis it is difficult to say for sure.

The current evidence for the use of an additional help question is not consistent and there is, as yet, insufficient data to recommend its use for case finding. As it may encourage the patient to take an active role in making decisions about their own treatment, it might have other benefits in addition to its effect on diagnostic accuracy. Further research on a standardised form of the additional question would be useful.

Citation and Funding

Bosanquet K, Bailey D, Gilbody S,et al. Diagnostic accuracy of the Whooley questions for the identification of depression: a diagnostic meta-analysis. BMJ Open. 2015;5(12):e008913.

No funding information was provided for this study.

Bibliography

NICE. Depression in adults: recognition and management. CG90. London: National Institute for Health and Care Excellence; 2009.

NICE. Depression in adults with chronic physical health problem: recognition and management. CG91. London: National Institute for Health and Care Excellence; 2009.

NICE. Antenatal and postnatal mental health: clinical management and service guidance. CG192. London: National Institute for Health and Care Excellence; 2014.

QUADAS. QUADAS-2 [internet]. Bristol: University of Bristol; 2011.

Why was this study needed?

Depression affects large numbers of people, approximately 1 in 4 women and 1 in 10 men. Primary care, such as general practice, is often where people first present with depression. Though diagnosis is sometimes missed. Improving early detection of depression is important as it can be more easily treated, and reduces the risk of progression to more severe symptoms. Early detection and successful treatment in primary care is also likely to benefit the health system in terms of cost and resource. The prevalence rate expected in the general at risk population in whom the test might be used, is thought to be less than 20%.

The questions are currently used to indicate whether a person may be depressed and should be further assessed. However, the precise diagnostic accuracy of the Whooley questions and the additional third question is not currently clear, so this review aimed to pool all available evidence comparing the performance of both two and three questions against “gold standard” diagnostic tools.

What did this study do?

This systematic review and meta-analysis identified ten randomised controlled trials conducted in different countries (one UK-based study). They were carried out in primary, secondary and community settings and contained between 89 and 1025 people each. The questions were also administered by a range of individuals, from psychiatrists to GPs. Some were done by self-assessment.

The included studies were quality assessed using the QUADAS-2 tool. No studies were at a low risk of bias across all sections of QUADAS-2; some were at an unclear risk because, for example, it was unclear in some studies if patients were excluded if they were known to be depressed. This systematic review used a wide range of sources to identify studies that were similar enough to be reliably compared in their analysis (I2=24.1%).

What did it find?

  • The Whooley questions correctly identified 95% of people with depression, with a combined sensitivity of 0.95 across all studies (95% confidence interval [CI] 0.88 to 0.97). This is a useful sensitivity for a test as it means very few of those with depression test negative (5% false negative)
  • The Whooley questions also correctly identified 65% of people who did not have depression, with a combined specificity of 0.65 (95% CI 0.56 to 0.74). This means that about 35% of people without depression mightstill test positive using the questions but as they are then further assessed, these people come to little harm.
  • In terms of the ability of the test to rule out or rule in depression the pooled positive likelihood ratio of 2.78 (95% CI 2.16 to 3.57) and the pooled negative likelihood ratio of 0.07 (95% CI 0.03 to 0.16) mean that the questions are best at ruling out depression.
  • In the setting of general practice, with less than 20% prevalence of depression, a negative result on the questions (two no’s) effectively means the chance of having depression is reduced from 20% to less than 2%.
  • There were insufficient studies to conclude whether or not an additional question asking the person if these are feelings they would like help with would be useful or not.

What does current guidance say on this issue?

NICE guidelines (2009) recommend that health professionals consider asking the two Whooley questions to anyone who may be at higher risk of depression. In particular, people who have previously had depression, have a long-term physical health condition causing some impairment, women during pregnancy and the postnatal period. If a person answers yes to either of these questions, they should be referred for a formal depression assessment by a qualified professional (which could be their GP).

What are the implications?

This systematic review reinforces the current use of the questions. Given that depression is a common condition, this finding should be valuable to clinicians in general practice for use with patients they have concerns about. Despite its modest specificity, which means that many people who score positively will not meet diagnostic criteria for depression, the test retains value in its ability to rule out the target condition. Healthcare professionals not using the questions could consider using them. The Whooley questions’ ability to rule out depression has potential resource implications if positive Whooley results lead to more people without depression undergoing further costly assessment. This resource implication may be offset by savings from treating people earlier, however, without an economic analysis it is difficult to say for sure.

The current evidence for the use of an additional help question is not consistent and there is, as yet, insufficient data to recommend its use for case finding. As it may encourage the patient to take an active role in making decisions about their own treatment, it might have other benefits in addition to its effect on diagnostic accuracy. Further research on a standardised form of the additional question would be useful.

Citation and Funding

Bosanquet K, Bailey D, Gilbody S,et al. Diagnostic accuracy of the Whooley questions for the identification of depression: a diagnostic meta-analysis. BMJ Open. 2015;5(12):e008913.

No funding information was provided for this study.

Bibliography

NICE. Depression in adults: recognition and management. CG90. London: National Institute for Health and Care Excellence; 2009.

NICE. Depression in adults with chronic physical health problem: recognition and management. CG91. London: National Institute for Health and Care Excellence; 2009.

NICE. Antenatal and postnatal mental health: clinical management and service guidance. CG192. London: National Institute for Health and Care Excellence; 2014.

QUADAS. QUADAS-2 [internet]. Bristol: University of Bristol; 2011.

Diagnostic accuracy of the Whooley questions for the identification of depression: A diagnostic meta-analysis.

Published on 10 December 2015

Bosanquet, K; Bailey, D; Gilbody, S; Harden, M; Manea, L; Nutbrown, S; McMillan, D;

BMJ Open , 2015

Objectives To determine the diagnostic accuracy of the Whooley questions in the identification of depression; and, to examine the effect of an additional ‘help’ question. Design Systematic review with random effects bivariate diagnostic meta-analysis. Search strategies included electronic databases, examination of reference lists, and forward citation searches. Inclusion criteria Studies were included that provided sufficient data to calculate the diagnostic accuracy of the Whooley questions against a gold standard diagnosis of major depression. Data extraction Descriptive information, methodological quality criteria, and 2×2 contingency tables were extracted. Results Ten studies met inclusion criteria. Pooled sensitivity was 0.95 (95% CI 0.88 to 0.97) and pooled specificity was 0.65 (95% CI 0.56 to 0.74). Heterogeneity was low (I2=24.1%). Primary care subgroup analysis gave broadly similar results. Four of the ten studies provided information on the effect of an additional help question. The addition of this question did not consistently improve specificity while retaining high sensitivity as reported in the original validation study. Conclusions The two-item Whooley questions have high sensitivity and modest specificity in the detection of depression. The current evidence for the use of an additional help question is not consistent and there is, as yet, insufficient data to recommend its use for screening or case finding.

Sensitivity is also called the true positive rate and refers to the ability of a test to correctly identify people who have the condition being tested for. 100% sensitivity (or 1.0) will successfully identify all people with the condition.

Specificity is also referred to as the true negative rate, meaning the ability of a test to correctly identify people who do not have the condition. 100% specificity (or 1.0) means the test successfully identifies all people without the condition.

Positive likelihood ratio is the probability that someone with the condition would test positive, divided by the probability that someone without the condition would test positive. A positive likelihood ratio greater than one indicates that the result is associated with the presence of the condition. The higher the better.

Negative likelihood ratio is the probability that someone with the condition would test negative, divided by the probability that someone without the condition would test negative. A negative likelihood ratio less than one indicates that the result is associated with the absence of the condition. The lower the better.

Expert commentary

It is reassuring that the findings in this systematic review confirm the Whooley questions as being sensitive, but not specific, in detecting depression. However, this is an unsurprising consequence of the relationship between the Whooley questions and ‘gold standard’ criteria for depression. There is a danger that tools such as this can unthinkingly reinforce a belief in a dichotomous threshold for the presence or absence of depression, rather than acknowledging the continuum of depressive symptoms and severity that is seen. Use of the Whooley questions at least means depression is being considered (and so a good start) but they are not a substitute for a full clinical assessment.

Professor Ian M Anderson, Professor of Psychiatry, The University of Manchester