Quick Screen Test Valid, Efficient in Detecting Psychiatric Illness in Primary Care
March 16, 2010 (Updated March 18, 2010) — The My Mood Monitor (M-3) checklist is a valid, efficient, and feasible tool for screening patients for multiple common psychiatric illnesses in primary care and has a diagnostic accuracy that equals that of currently used single-disorder screens. It can also be filled out by patients in the waiting room in less than 5 minutes, and the majority of practitioners are able to review the checklist in 30 seconds or less.
Bradley Gaynes, MD, MPH, from the University of North Carolina School of Medicine, Chapel Hill, and colleagues found that compared with the Mini International Neuropsychiatric Interview, the reference standard, the M-3 checklist had a sensitivity of 0.84 for depression and a specificity of 0.80.
"This means that the M-3 checklist will successfully identify 84% of patients who have major depressive disorder, which is its sensitivity, and successfully identify 80% of those who do not have major depressive disorder, which is its specificity," Dr. Gaynes told Medscape Psychiatry. For bipolar spectrum disorder, the M-3 checklist had a sensitivity of 0.88 and a specificity of 0.70.
The anxiety module had a sensitivity of 0.82 and a specificity of 0.76, whereas sensitivity for posttraumatic stress disorder (PTSD) was 0.88 and specificity was 0.76. As a screen for any psychiatric disorder, the sensitivity of the M-3 was 0.83, and the specificity was 0.76.
According to investigators, 83% of clinicians reviewed the checklist in 30 or fewer seconds, and 80% thought it was helpful in reviewing patients' emotional health.
The study was published in the March/April issue of the Annals of Family Medicine.
Designed Specifically for General Practitioners
The questions asked on the M-3 checklist were developed by a group of experienced mental health clinicians and were specifically designed for use in primary care settings. The completed tool consists of a 23-item self-report symptom checklist that asks patients whether they have experienced symptoms of major depressive disorder, generalized anxiety disorder, panic disorder, social anxiety disorder, PTSD, or obsessive-compulsive disorder during the last 2 weeks.
The checklist also asks patients about a lifetime history of symptoms of bipolar spectrum disorder, as well as additional functional impairment questions. The wording and grammar of the M-3 checklist are at a sixth-grade reading level.
Investigators enrolled 647 consecutive adult patients who were seeking primary care at an academic family medicine clinic between July 2007 and February 2008. "We used a 2-step scoring procedure to make screening more efficient and within 30 days of the index visit, a research assistant administered the Mini International Neuropsychiatric Interview...to participating patients by telephone," the investigators write.
The Mini International Neuropsychiatric Interview is a reliable and valid diagnostic instrument serving as the reference standard to evaluate the performance of the M-3.
As the authors note, they used the functional impairment questions of the M-3 as a "first-stage" screen, and the remaining checklist symptoms were then scored for only those patients whose screen was positive for functional impairment. This so-called "gateway" method was felt to provide the best balance of increasing sensitivity and specificity of the M-3 checklist while permitting a quick, visually intuitive method for scoring by hand.
First-Step Screen
Investigators note that the "first-step" screen for functional impairment eliminated 349, or 53.9%, of the 647 participants from the checklist scoring process — 38 (10.9%) of whom nevertheless met Mini International Neuropsychiatric Interview criteria for a psychiatric diagnosis, the authors add. Of the remaining 298 patients who passed through the "gate" and who completed the symptom checklist, 186, or 62.4%, had a psychiatric diagnosis.
Indeed, those who passed through the "gate" were nearly 6 times more likely to have a psychiatric diagnosis than those who did not pass through the gate (P < .001). For the depression module, a positive screen was more than 4 times more likely to come from a patient with a depressive disorder than from a patient without one. "Further," investigators add, "given a 16% prevalence of depression in our population...a patient with a positive screen had a post-test odds for depression of approximately...40%." Overall, 287 patients, or 44% of the 647 enrolled in the study, were positive on the M-3 checklist, indicating that as a general screen, the M-3 had a positive predictive value of 0.65 and a negative predictive value of 0.89 for any mood or anxiety disorder. M-3 Psychometrics for Specific Diagnoses and for Any Diagnosis by Mini International Neuropsychiatric Interview Test Result Depression Bipolar Anxiety PTSD Any Diagnosis Sensitivity (95% confidence interval) 0.84 (0.77 - 0.89) 0.88 (0.77 - 0.95) 0.82 (0/75 - 0.87) 0.88 (0.74 - 0.96) 0.83 (0.77 - 0.88) Specificity (95% confidence interval) 0.80 (0.76 - 0.83) 0.70 (0.66 - 0.74) 0.78 (0.74 - 0.81) 0.76 (0.73 - 0.80) 0.76 (0.72 - 0.80) Positive M-3 screen 34% 35% 39% 28% 44% Diagnosed by Mini International Neuropsychiatric Interview 22% 9% 28% 6% 35% Having completed the M-3 checklist, approximately 70% of patients indicated that they subsequently talked to their physician about mood or feelings, and 63% of all participants said that the M-3 checklist had helped them to bring up the subject of mood or feelings with their physicians. "Many patients are reticent to initiate discussion of psychological distress with their primary care primary, so this tool helps allow patients initiate a discussion with their primary care provider," said Dr. Gaynes. "But it also helps the primary care physician to discuss the possibility of a psychiatric diagnosis with patients, and patients even have access to this tool online so that they could fill it out and then bring the form into their clinic as well." A Step Forward Michael Klinkman, MD, University of Michigan Depression Center, Ann Arbor, told Medscape Psychiatry that the M-3 checklist is a "good step forward" but that it still does not address all the screening needs in a primary care center. "It does a good job of taking and condensing the questions we use to try and identify patients with depressive disorder, but it does not confirm a diagnosis," he said. For example, if patients screen positive for bipolar disorder on the M-3 checklist, they still have less than a 1 in 4 chance of having that disorder because the symptoms used in the screening test are lifetime symptoms. and if patients answer yes, that doesn’t mean they are having symptoms now. "As long as physicians understand this and they have a place where they can refer patients to in order to get the rest of the screening done, it’s fine, but the checklist still leaves a lot of work for primary care physicians to do, and too many times, they do not have access to mental health experts to complete this process," Dr. Klinkman said. Data collection was supported by a grant from M-3 information. Dr. Gaynes has reported that he received grants and research support from the National Institute of Mental Health and the Agency for Healthcare Research and Quality. Dr. Klinkman has disclosed no relevant financial relationships. Ann Fam Med. 2010;8:160-169.
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