Perspectives The epidemic in and strategies of depression screening for its prevention Mutsuhiro Nakao a & Takeaki Takeuchi a,b

Introduction fication of high-risk persons to prevent Simple screening methods suicide) and post-intervention (social Suicide is among the most tragic outcc to detect depression support for bereaved family and friends). comes of all mental disorders. WHO They also published two guidelines for The most commonly used standard for estimates that, worldwide, there are managing depression: one for health-care the diagnosis of major depressive disoc approximately one million deaths from order (MDD) is a structured interview suicide each year, and 20 times this numbc professionals and one for public servants. The guidelines recommend a screening by a specialist, such as a psychiatrist, ber of people attempt suicide. Although according to the DSM-IV-TR criteria. the Japanese population leads the world test for depression in the workplace and the community, using a method based Essential MDD symptoms are depressc in longevity, it has a high rate of suicide sive mood and a loss of interest lasting at that is globally ranked ninth. From 1995 on the full criteria of the Statistical manuu ual of mental disorders, 4th edition, text least two weeks; diagnosis also requires to 2004, the incidence of reported suicc three additional concurrent symptoms cides rose dramatically from 17.5 to 25.1 revision (DSM-IV-TR), including eight or nine items for assessment. A simpler (e.g. appetite loss, fatigue and insomnia). per 100 000. Some studies have reported With the possible exceptions of psychiatc method is required to promote screening that this increase is closely related to trists and psychological specialists, diagnc for depression nationwide. Fulfilment the economic depression that occurred nosing depression is not an easy task: of the national goal within the next five in Japan over the same period. While a interviews are somewhat complex and years will require identification of target reduction in suicide rates may depend are time consuming. Although some reliac groups and extensive intervention for on an economic recovery, public health able questionnaires exist and are used in high-risk persons in these groups. practitioners must try to help potentially clinical screening, such as the Profile of suicidal individuals, regardless of outside Mood States, the Self-rating Depression influences such as the economy. Identification of target Scale and the Center for Epidemiologic Depression plays an important role groups Studies–Depression questionnaire, the in the etiology of suicide. Over 60% length of such questionnaires (consisti Depression is one of the most rapidly c of the individuals who commit suicide ing of more than 10 questions) can be spreading mental disorders in Western were identified as depressive. Reducing burdensome and they can be expensive countries and in Japan. According to the the number of suicide attempts requires, (US$ 7.00 per person for a professional National Survey in Japan, the number therefore, an initial identification of evaluation in Japan). It is important, of individuals diagnosed with depressc people with potential depression. When therefore, to find screening methods sion increased from 83.1 to 340.0 per the University of Iowa’s psychiatric decp that are less costly in terms of both time partment hosted clinics on the National 100 000 during the period 1984–98. and money. Depression Screening Day in the USA Although depression is generally more Previous studies have examined the in 1996, 65% of the 927 participants common in women than in men, the possibility of reducing the number of required further evaluation, of whom most dramatic increase has involved questions in depression screening questc 83% subsequently received treatment for middle-aged men (40–60 years); this tionnaires. American researchers found depression.1 Efforts made in the USA tendency also applies to the percentage that using two items (“depressed mood” indicate that tactics instituted to identify of the population who commit suicide. and “no feeling of pleasure”) from the depression can work well to reduce suicc In Japan, most middle-aged men funcct Primary Care Evaluation of Mental Disoc cide rates at the national level. tion as the family breadwinner and may orders questionnaire resulted in 96% In 2000, the Japanese Government be too busy with work to visit a clinic, sensitivity and 57% specificity for MDD declared its goal to reduce the annual even when they feel mental distress. detection.2 European researchers found incidence of suicide by 30% until 2010. Because it is mandatory for all workers in that two items (“depressive mood” and The National Committee published Japan to undergo health check-ups every “not active”) from the WHO-5 Wellbeing proposals for in year at the expense of their employers, Index were sufficient to screen for pcde 2002, emphasizing the importance of targeting middle-aged men in the workpc pression.3 Although these studies were pre-intervention (assessment of factors place is a good strategy for identifying limited, in that they examined only partc affecting suicide), intervention (identifc potentially depressive persons. ticipants who visited clinics in the USA

a Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi, Tokyo 173-8605, Japan. Correspondence to this author (email: [email protected]). b Harvard Graduate School of Public Health, Boston, MA 02115, USA. Ref. No. 06-031476

492 Bulletin of the World Health Organization | June 2006, 84 (6) Perspectives Mutsuhiro Nakao & Takeaki Takeuchi Depression screening for suicide prevention in Japan or Europe, they provide practical possibc number of somatic symptoms for detc these annual health check-ups: the total bilities for depression screening in Japan. tecting MDD.4 More specifically, lower annual cost borne by Japanese industry Results from our recent studies indicc back pain and dizziness at baseline were for the check-ups is estimated to be cate that including one or two screening independent risk factors of major depressc several billion dollars. The addition of questions in annual medical check-ups sion in the year following the check-up.5 one or two questions would not increase can be an effective way to screen for Studies in clinical settings have also expenditure except for copying costs, MDD in Japanese workers. Items selected found that the number of somatic symptc and the answers could offer a very pracct for inclusion are not necessarily limited toms can predict the severity of major tical way for finding depressive persons 6 to psychological discomfort; any commc depression and . among workers. Once a person is identc mon somatic symptom can also be usefc This screening plan may be limited tified as suffering from depression, the ful. For example, our study concerning because of possible over-diagnosis. When treatment is covered by health insurance. annual health check-ups involved using one or two questions with high sensitivic While compulsory annual health check- DSM-IV-TR interviews with 991 male ity are selected, they simply elicit core ups may be specific to Japan, elements of requirement symptoms for diagnosis. A workers, 24 (2.4%) of whom were diagnc the approach may be useful for settings 4 definite diagnosis of depression requires nosed with MDD. Based on our previoc in other countries. more symptoms, which may result in ous studies and Western studies involvic A systematic reduction of the incc ing primary care patients, the following situations of unsatisfied false-positives cidence of will first 12 common major somatic symptoms (individuals who were initially diagnc require finding potentially depressive were simultaneously assessed: fatigue, nosed as positive but were subsequently persons because most individuals who headache, insomnia, back pain, abdominc found to be without the disorder). This nal pain, joint or limb pain, dizziness, screening plan, however, is proposed as commit suicide are depressive. In Japan, chest pain, constipation, palpitation, a first and convenient test to identify government health-care policy recogcn nausea, and shortness of breath. Somatic real depression. High sensitivity is much nizes mental health as a top-priority symptoms were defined as positive when more important than low specificity, issue, and in 2005 the Ministry of experienced one or more times a week. so as not to leave a depressive person Health, Labour and Welfare organized Surprisingly, no cases of MDD were identc undetected, and marginal tests could the Strategic Research Group on Managic tified among the 665 (67.1%) subjects improve specificity during the successive ing Suicide Related to Depression. The who exhibited no somatic symptoms. screening process. strategy proposed here could promote MDD prevalence was positively associca understanding of the need to screen for ated (P<0.001) with the total number of Depression screening as depression in the working population, somatic symptoms, and an area of 0.92 an approach to suicide with less dependence on psychological appeared under the receiver operator specialists. O characteristic (ROC) curve, indicating prevention the sensitivity and specificity of the total Financially, employers cover the cost of Competing interests: none declared.

References 1. Greenfield SF, Reizes JM, Muenz LR, Kopans B, Kozloff RC, Jacobs DG. 4. Nakao M, Yano E. Reporting of somatic symptoms as a screening marker for Treatment for depression following the 1996 National Depression Screening detecting major depression in a population of Japanese white-collar workers. Day. Am J Psychiatry 2000;157:1867-9. J Clin Epidemiol 2003;56:1021-6. 2. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for 5. Nakao M, Yano E. Prediction of major depression in Japanese adults: somatic depression: two questions are as good as many. J Gen Intern Med 1997; manifestation of depression in annual health examinations. J Affect Disord 12:439-45. 2006;90:29-35. 3. Henkel V, Mergl R, Coyne JC, Kohnen R, Moller HJ, Hegerl U. Screening for 6. Nakao M, Yamanaka G, Kuboki T. Major depression and somatic symptoms in depression in primary care: will one or two items suffice?Eur Arch Psychiatry a mind/body medicine clinic. Psychopathology 2001;34:230-5. Clin Neurosci 2004;254:215-23.

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