Is one question enough to screen for depression and anxiety

Psychological factors, such as depression and anxiety, are significant contributors in the transition from acute to chronic pain. A person suffering from acute low back pain with additional symptoms of anxiety and/or depression has a higher risk of becoming a chronic pain patient than a person without these additional symptoms. Furthermore, suffering from low back pain for a long time can, in and of itself, result in depression and anxiety, which again worsens the prognosis for the patient if these symptoms are not handled adequately. It is therefore important to identify easy and efficient ways to identify pain patients who have depression and anxiety. Several screening measures exist, but most of them are too long and time-consuming to be used routinely in clinical care. There is a need for shorter instruments. We investigated if two single-item questions would be enough to screen for anxiety and depression in a large group of patients with chronic low back pain.

We studied 564 patients who were on sick leave due to low back pain.[1] We compared a single-item screening question with two longer screening measures for anxiety and depression. As the “gold standard” we used a clinical diagnostic interview (The Mini-International Neuropsychiatric Interview, MINI). According to the diagnostic interview, 4% of the patients had a depressive disorder while 12% had an anxiety disorder. The results showed that the single-item screening questions were equal to or better than the two longer questionnaires in identifying depression and anxiety. The results were particularly good for depression, showing a sensitivity of 95%. That means that almost all of the patients who suffered from depression were identified with this single question. The sensitivity for anxiety was lower, at 68%, but that was still equal to or better than the longer questionnaires. The specificity of the screening questions – that is, the proportion of patients without depression/anxiety that the screening questions correctly identified – was 56% for depression and 85% for anxiety.

The findings of this study could be very helpful in clinical settings where short screening measures are needed. In most clinical settings, it should be possible to ask one question, even though time is limited. Because the specificity of the questions means that there will be some false positives – patients may screen positive without being clinically depressed/anxious – there will be a need for further evaluation of those who screen positive. We therefore suggest a 2-step process, where the single-item screening questions are used to identify potential individuals with depression/anxiety, and where those who screen positive then undergo a more detailed test with greater specificity to confirm the problem and decide on the need for treatment.

The single-item screening questions could also be very useful in research where they could replace longer screening measures to identify potentially depressed patients, particularly in cases where questionnaire length is a concern. Since both questions performed equal to or better than the longer questionnaires, they could, in fact, replace these questionnaires in epidemiological studies where time is limited.

However, before the two questions can be recommended and implemented in clinical settings, these results must be replicated in other populations. Additionally, more work is needed to improve the sensitivity of the anxiety question to obtain a sensitivity that matches that of the depression question. Nevertheless, the findings do represent a promising step towards the use of ultra-short screening instruments in clinical settings for pain patients, and that could lead to proper treatment for those patients who suffer from depression or anxiety in addition to their pain. Such treatments might involve cognitive–behavioral strategies to address unhelpful pain beliefs, strengthen coping resources, and provide instruction in pain self-management.

About Silje Reme

Silje RemeA native of Norway, Dr. Reme completed her educational studies at the University of Bergen, earning her doctorate in psychology as well as her clinical psychology and undergraduate degrees. She did a 2-year postdoctoral fellowship at Harvard School of Public Health, where she worked with the Harvard Center for Work, Health and Wellbeing. She now works as a senior researcher at Uni Research in Bergen, Norway, where she is currently co-heading the research group Stress, Health and Rehabilitation. Additionally, she works as a clinical psychologist and research fellow at The Department of Pain Management and Research at Oslo University Hospital. 

Reference

[1] Reme SE, Lie SA, & Eriksen HR (2014). Are 2 questions enough to screen for depression and anxiety in patients with chronic low back pain? Spine, 39 (7) PMID: 24480946