LITERATURE REVIEW

The student will complete the following items and submit a Word doc to the assignment link.

Provide a title that conveys or describes the assignment.
Literature Review – Provide the key terms used to guide the search for the evidence and provide at least five (5) summaries of research studies to support the evidence.
Critical Appraisal of Literature – Discuss the strengths and weaknesses of the evidence, what is known from the evidence and any gaps in knowledge from the research evidence.
References – Cite a minimum of five scholarly references in APA 6th ed format.

PICOT formatted Clinical Project Questions
P: In the home health setting of patients aged range 60-75 with depression symptoms.
I: Does the PHQ-2 depression screen versus the GDS-15 assist in early identification of symptom severity and monitor symptom changes for clinical depression.
C: Using GDS-15 screening tool VS PHQ-2 SCREEN
O: to improve identification of the clinical depression in the elderly by 100%.
T: in the initial office visit and over a 6 month period?

For the purpose of this paper, the relevant and credible evidence-based research studies that will support the project proposal include:

PLEASE INCLUDE THE FOLLOWING

STUDY: OBJECTIVE OF THE STUDY, LEVEL OF EVIDENCE, IRB HUMAN SUBJECT STATEMENT

METHOD AND ANALYSIS: METHOD OF DATA COLLECTION, VARIABLES – IDENTIFY EACH VARIABLE AND HOW MEASURED, DEPENDENT
INDEPENDENT, METHOD OF DATA ANALYSIS, ESTABLISHED P VALUE:

SAMPLE: POPULATION, RECRUITMENT, DESCRIPTIVE STATISTICS OF THE PARTICIPANTS, IMPLICATIONS OF PRACTICE

FINDINGS: MAJOR FINDINGS, INCLUDE ACTUAL AND STATISTICAL RESULTS WITH ASSOCIATED P VALUES: IMPLICATION FOR PRACTICE

STRENGHTS AND WEAKNESS: STRENGTHS, LIMITATIONS GAPS/FUTURE STUDY

THESE ARE THE FOLLOWING ARTICLES/STUDIES:

Tsoi, K. K., Chan, J. Y., Hirai, H. W., & Wong, S. Y. (2017). Comparison of diagnostic performance of Two-Question Screen and 15 depression screening instruments for older adults: systematic review and meta-analysis. The British Journal of Psychiatry, 210(4), 255-260.

The study has compared the diagnostic performance of GDS-15 and PHQ-2 as screening instruments among older adults. The study is a meta-analysis and systematic review that aims at evaluating the diagnostic accuracy of PHQ-2 and GDS-15 while evaluating the specificity and sensitivity of the primary outcomes.

Manea, L., Gilbody, S., Hewitt, C., North, A., Plummer, F., Richardson, R., … & McMillan, D. (2016). Identifying depression with the PHQ-2: A diagnostic meta-analysis. Journal of Affective Disorders, 203, 382-395.

This study has focused on the use of PHQ-2 which is a very brief instrument to identify depression. The study is a systematic review that was carried out to evaluate the studies that had examined the diagnostic performance of PHQ-2 as a major depression detecting tool.

Balsamo, M., Cataldi, F., Carlucci, L., Padulo, C., & Fairfield, B. (2018). Assessment of late-life depression via self-report measures: a review. Clinical interventions in aging, 13, 2021.

The study has focused on psychometric performance of GDS-15 in assessing depression among cognitively intact patients over 65 years. The review includes self-report depression measures that are current and commonly being used for geropsychological practices. The study has indicated that GDS-15 is an effective instrument for rating the severity of depression and monitoring the patient progress.

Chen, I. P., Liu, S. I., Huang, H. C., Sun, F. J., Huang, C. R., Sung, M. R., & Huang, Y. P. (2016). Validation of the Patient Health Questionnaire for depression screening among the elderly patients in Taiwan. International Journal of Gerontology, 10(4), 193-197.

The study aimed to assess the validity, reliability and factor structure of the PHQ-2 for screening major depression among elderly. The study was carried among elderly in Taiwan. The results indicated that PHQ-2 is reliable and valid to screen depression among the elderly and is a better alternative to GDS-15 scale. The screening accuracy of PHQ-2 was acceptable since it demonstrated good specificity and sensitivity.

Durmaz, B., Soysal, P., Ellidokuz, H., & Isik, A. T. (2018). Validity and reliability of geriatric depression scale-15 (short form) in Turkish older adults. Northern clinics of Istanbul, 5(3), 216.

The study aimed at assessing the reliability and validity of GDS-15 among Turkish older adults. The results of the study have indicated that GDS-15 is a beneficial scale in evaluating depression among older adults. GDS-15 is brief, time-effective, and simple with an optimal balance of specific and sensitivity in determining patients with major depression.

Critical Appraisal of Literature
Critical appraisal of the literature is considered as the process of evaluating reliability, validity, and applicability as it links to the PICOT question. Supporting evidence from multiple evidence-based research articles has supported screening for major depression among older adults. Evidence from the results indicates that screening for depression should rely on highly specific screening tools such as GDS-15 and PHQ-2 rather than using clinical judgment to determine depressive symptoms among the elderly. GDS-15 has been considered reliable and valid tools for screening the elderly for major depression in homecare health settings. According to (Tsoi et al.,2017) the psychometric performance of both GDS-15 along with the relative brevity and ease of use has made more reliable and attractive in screening for depression among older adults. The supporting evidence from the literature has indicated that GDS-15 is essential in detecting major depression as well as monitoring the symptom changes.
Develop an EBP Standard
Evidence-based practice involves the integration of the most effective research evidence with patient values and clinical expertise. The EBP will involve the formulation of the question in order to recognize a problem and assess the need for change. The PICOT question in this case will be utilized to formulate a researchable clinical question with an evidence-based practice framework. The next step will be to gather evidence from both external and internal evidence. The external evidence will be gathered from scientific literature the internal evidence will be gathered from patients through a randomized control trial to determine the effectiveness of the intervention. The third step will be to critically analyze the gathered evidence. Ideally, analysis of the evidence will be conducted to determine the reliability and validity of GDS-15 and PHQ-2 in facilitating early identification of clinical depression as well as managing symptoms among the elderly. The fourth step is to develop the intervention plan which entails designing the most effective screening tool for the homecare settings to help in identifying clinical depression and managing symptoms among the elderly. The fifth step is to implement and assess the intervention plan. This will include evaluating the outcomes of the project and analyze how the process of identifying depression among the elderly in the homecare settings has improved. The last step is to integrate and maintain the intervention through shared recommendations among stakeholders to integrate the intervention plan into the homecare settings standard of practice.
Implications
EBP is an intervention with strong scientific proof that offers positive outcomes for varying disease disorders. EBP for the elderly with depression are essential since they can improve function and health as well as lower symptoms of major depression. The Evidence-based intervention plan will be completed in a homecare setting through a randomized selection of subjects to evaluate the effectiveness in improved identification of major depression among the elderly.
Expectations
The outcome of the project is expected to offer intervention for depression screening among the elderly within home healthcare settings. The current method is utilized for the identification of major depression among the patients is clinical judgment. Therefore, the project aims to establish which of the two, PHQ-9 and GDS-15 is accurate and reliable identifying depression among the elderly. A potential randomized trial will offer meaningful evidence about the feasibility and effectiveness of PHQ-9 and GDS-15 screening tools in identifying clinical depression and managing symptoms among the elderly. Therefore, the research-based evidence is expected to offer improved interventions for routine screening protocol to assist in early identification of symptom severity and monitor symptoms changes for clinical depression.

ANSWER

Introduction of the Study

Depression is a common diagnosis in older adults, which is often accompanied by other medical conditions like heart disease, cancer, and disabilities, among many others. The elderly, adults above the age of 60 are also often under a series of medication which their side effects may be a contribution to their depression. Additionally, the same population diagnosed with depression means that they are at an increased harm level of cardiac diseases and death. Health practitioners have had to come up with better, more efficient, and accurate methods of screening.

The Patient Health Questionnaire 2-item (PHQ-2) is a tool used for the process of screening major symptoms of depression. The tool comprises two questions that inquire the degree to which a patient has or is experiencing a depressed mood and anhedonia, which refers to the inability to feel pleasure in initial activities that were pleasurable over a period of two weeks. The purpose of the PHQ-2 tool does not include a final diagnosis or monitoring of severity but rather the first identification of depression in a patient. The Geriatric Depression Scale (GDS-15) is another self-report tool that measures depression and, in particular on older adults. It comprises 15 questions answered with Yes/No responses were 0 to 4 stands for a normal patient, 5 to 8 a mildly depressed patient, 9 to 11 moderately depressed and 12 to 15 severely depressed individuals.

Research on the two tools indicates that screening for depression should rely on highly specific screening tools such as GDS-15 and PHQ-2 rather than using clinical judgment to determine depressive symptoms among the elderly. This paper uses the PICOT formatted clinical project questions to perform an analysis on research that addresses diagnosis of a population between the years 60 to 75, with the intervention being an application of either GDS-15 or PHQ-2 diagnosis tools, the comparison between the two screening tools, the outcome aims at the improvement of identification of the clinical depression in the elderly by 100% and the time is the initial office visit and over a six month period.

Method and Analysis

Five studies are included in this literature review, all contributing to the discussion of applying GDS-15 and PHQ-2 screening tools on older adults. In the first study, This study combines diagnostic accuracy comprising the specificity and sensitivity to compare PHQ-2 and GDS-15 to other diagnosis instruments. The study analyses use four scientific databases in search for studies that point to the accuracy levels of commonly used screening tools and then scrutinizes them to come to a conclusive decision of the most efficient and accurate tool. A rating scale is used for the quality assessment using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and a framework provided by Cochrane Diagnostic Test Accuracy Working Group.

The studies similarly performs a systematic review of studies that investigate PHQ-2 and GDS-15 and their performance in the detection of depression. The study combines findings from PsychINFO, PubMed, MEDLINE, and Google Scholar databases. A standard scoring system is used to rate PHQ-2 against a gold-standard diagnostic interview and reported data on the performance of the tool. A review of peer-reviewed journals, databases searches, and test manuals to determine the validity of PHQ-2 and GDS-15 as a depression diagnostic tool. The search terms for the investigation included ‘depression,’ ‘depression disorder,’ ‘GDS-15 Screening Tool’, ‘PHQ-2 Screening Tool’, ‘Comparison of Depression Assessment Tools’, and ‘Older Adults.’ Studies included in the assessment report original research, perform research within the last seven years and includes the most recent depression screen tools available, the participants are included in both clinical and non-clinical trials, and the study was written and published in English. The specific measures with regards to the screen tools included an analysis of the tool’s sensitivity, which comprises the diagnosis that results in the unwell diagnosis, specificity which comprises the diagnosis that results in the healthy diagnosis, and the diagnostic odds ratio, which is the ration of the unwell to the healthy.

Findings

The first study by Tsoi et al., (2017) is Comparison of diagnostic performance of Two-Question Screen and 15 depression screening instruments for older adults: systematic review and meta-analysis. The objective of this study is to evaluate the accuracy of PHQ-2 as a tool used to screen depression in older adults and compare the accuracy levels to other tools. The study applies the literature review design of other studies that detailed the PHQ-2 accuracy through sensitivity and specificity. The study performed 132 studies with 46506 participants that evaluated 16 screening tools. For data collection 63 out of the 132 studied used different versions of the Geriatric Depression Scale (GDS) while six used the PHQ-2 screen which is referred to as the two-question screen. The dependant variables was the sensitivity and specificity of the tools used while the independent variables included the various screening tools used. The study out that in the PHQ-2 test, the sensitivity was 91.8% (95% CI 85.2-95.6) while the specificity was 67.7% (95% CI 58.1-76.0). The PHQ-2 screening tool help up in comparison to other screening instruments including clinician scales. The poorest performance was the one-question screen test. The absolute conclusion of the study was that the PHQ-2 screening tool is highly recommendable for older adults as a depression screening tool.

The second study by Manea et al., (2016) is Identifying depression with the PHQ-2. It aims to apply the PHQ-2 screening tool and document its efficiency in the initial detection of depression in older adults. The study design is a systematic review in data from Embase, Grey, Medline and PsychINFO literature databases. A standard measurement system was used on the PHQ-2 tool and the collected data compared to a gold standard interview diagnostic tool. The dependant values were the specificity, sensitivity and the diagnostic ration while the independent variables was the gold standard diagnostic interview results. Findings from 21 studies with a total participant attendance rate of 11,175 that 1529 suffered depression from the gold standard tool. Results from the study indicated that the PHQ-2 tool has lower sensitivity in comparison to a gold standard tool and a lower specificity as well. However, the PHQ-2 tool indicated efficiency and accurate diagnosis but missed with a few positive depression diagnosis. On negative diagnosis the PHQ-2 tool was accurate. The absolute conclusion was that the PHQ-2 screening tool is recommendable but not to the level of a gold standard tool.

The third study by Balsamo et al., (2018) is Assessment of late-life depression via self-report measures. The study applied a study design of literature review of common self-report tools for screen depression. For each tool the aim was to establish reliability in terms convergence, divergence and factorial validity. The review applied a multistep selection criteria detailed in the figure below:

The findings indicated that the outcome of the efficiency of a toll was highly dependable on the cognitive status of the participant. The GDS-15 screening tool was preferable to older adults aged above 65 years old and the mildly impaired participants. The outcome was also subject to the clinical presentation where older adults could also present other somatic symptoms that cannot be explained and could deny low mood and loss of pleasure. The absolute conclusion was the clinical judgement offers more accuracy in comparison to any screening tool.

Figure 1: Flowchart of Review Procedure for Self-Report Depression Screening Tools.

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6199213/figure/f1-cia-13-2021/?report=objectonly

The fourth study is by Chen et al., is Validation of the Patient Health Questionnaire for depression screening among the elderly patients in Taiwan. The study aims at performing an assessment of validity, reliability and factor structure of the PHQ-9 screen tool and its two subscales, PHQ-2 and PHQ-1, in the initials screening of depression in older adults and habitants of Taiwan. The study comprised 634 participants all above the age of 60 where they all filled in a PHQ-9 questionnaire. A control tool, the Short Form of Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF) was used. The finding indicated that the PHQ-9 screening toll was consistent in diagnosis, reliable and valid as a clinical tool in comparison to the control tool. Comparison between PHQ-9 and Q-LES-Q-SF showed moderate differences which in comparison to the SCAN gold standard demonstrated accuracy and acceptability. Sensitivity and Specifity of 0.93 and 0.90 of the PHQ-9 was recorded. The ultimate conclusion was that the two subscales the PHQ-2 and PHQ-1 could be proper alternatives to the GDS-15 depression screening tool.

The fifth study is Durmaz et al., (2018) is Validity and reliability of geriatric depression scale-15 (short form) in Turkish older adults. The aim of the study was to assess the validity, the reliability of the GDS-15 in comparison to the Diagnostic and Statistical Manual of Mental Disorders-fifth edition (DSM-5) in older adults. A sample participant population of 329 individuals was used where they undertook the two tests and the results were recorded. The GDS-15 findings indicated the sensitivity at 92%, specificity at 91%, positive predictive value at 76%, and negative predictive value at 97%. This was an indication that the GDS-15 scale is as valid and a reliable screen tool in comparison to the DSM-5 depression screening tool.

Implications

Self-report methods are common for various depression symptoms. Some of them are good for initial diagnosis, for instance, the PHQ-2 screening tool, while others are good in the measurement of severity of depression like the GDS-15 screen tool. For older adults, the findings indicate that the PHQ-2 had more success in the diagnosis of depression. The figures indicated a prevalence of depression in older adults aged above 60 years old. The strength of this study is that it considers fairly large participation and therefore offers conclusive and objective results that represent the

Analysis of Strengths and Weaknesses

Generally, the study was well conducted and provided crucial information in the identification, comprehension, and assessment of common depression diagnosis screening tools. The methods applied have scientific merits, and the findings understandable and sensible. However, the findings could have been more accurate and efficient should have the following considerations be put in place.

1. Some studies on the online databases did not include a tally of their population samples and diagnosis findings, leaving such information to the deduction of the audience. For instance, in the tally to identify how many people were diagnosed with depression, percentages were given, which this study had to calculate backward. Similarly, several studies did not account for the inconclusive tests, and the tally for this study could not establish from the total participants how many tests were not considered.
2. In the search for the studies that analyze the PHQ-2 and GDS-15 tools, most of the studies were locked, and findings are hidden. Such studies were not considered for this study. Others were unavailable in English, and the Google Translation to English was not very accurate. Such studies were also not considered for this literature review.
3. Full information was not extracted from the studies, and instead, only the summary of the findings was considered—specifically the data involving the two tools, GDS-15 and PHQ-2.
4. The five studies did not consider participants from all the regions in the world. For instance, there was no data from the continent of Africa and Australia. Only data from Asia, Europe, and America was considered. This a crucial point owing to the key contribution of culture to a depression diagnosis. For instance, in most African countries, rather than putting the elderly at home, they are assimilated to their younger families, and that could create a huge variation in the outcome of the diagnosis. Similarly, the elderly population in Africa is extremely low, and the population is majorly comprised of young people, also a factor that could have contributed to the final outcomes of the studies.
5. Lastly, the studies did not account for a prior diagnosis of participants for other illnesses. For instance, depression differs in patients with dementia, where the causative factors cannot be covered by the PHQ-2 test. Such patients are expected to have different symptoms of depression. The same case applies to Parkinson’s disease, coronary heart disease, and cancer. These prior diagnoses could have altered the outcome of this literature review.

Conclusion

This study has applied the PICOT formatted clinical project questions to perform an analysis of research that addresses diagnosis. The ultimate conclusion indicates that screening for depression should rely on highly specific screening tools such as GDS-15 and PHQ-2 rather than using clinical judgment and other tools like Beck Depression Inventory, Patient Health Questionnaire-9, Centre for Epidemiological Depression Scale-20, Hamilton Rating Scale for depression and the one question screen to determine depressive symptoms among the elderly.

References

Balsamo, M., Cataldi, F., Carlucci, L., Padulo, C., & Fairfield, B. (2018). Assessment of late-life depression via self-report measures: a review. Clinical interventions in aging, 13, 2021.

Chen, I. P., Liu, S. I., Huang, H. C., Sun, F. J., Huang, C. R., Sung, M. R., & Huang, Y. P. (2016). Validation of the Patient Health Questionnaire for depression screening among elderly patients in Taiwan. International Journal of Gerontology, 10(4), 193-197.

Durmaz, B., Soysal, P., Ellidokuz, H., & Isik, A. T. (2018). Validity and reliability of geriatric depression scale-15 (short form) in Turkish older adults. Northern Clinics of Istanbul, 5(3), 216.

Manea, L., Gilbody, S., Hewitt, C., North, A., Plummer, F., Richardson, R., … & McMillan, D. (2016). Identifying depression with the PHQ-2: A diagnostic meta-analysis. Journal of Affective Disorders, 203, 382-395.

Tsoi, K. K., Chan, J. Y., Hirai, H. W., & Wong, S. Y. (2017). Comparison of diagnostic performance of Two-Question Screen and 15 depression screening instruments for older adults: systematic review and meta-analysis. The British Journal of Psychiatry, 210(4), 255-260.