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Biases in the Laboratory Diagnosis of Depression in Medical Practice

Biases in the Laboratory Diagnosis of Depression in Medical Practice Abstract • Several studies, conducted in psychiatric settings, have reported that the dexamethasone suppression test (ST) is useful in the diagnosis of endogenous depression. To determine whether the test has clinical utility in internal medicine practice, data were reviewed and reanalyzed from all studies that evaluated the dexamethasone ST in the diagnosis of depression. In these 11 studies, the mean positive predictive value reported for the test was 84%, reflecting high prevalence of disease (50%), sensitivity (43%), and specificity (92%) in those specialized populations studied. When estimates of the prevalence and severity of conditions associated with depressed mood seen in internal medicine were used, the sensitivity dropped to 30%, and the specificity to 85%. Assuming a prevalence of 20%, a figure based on available epidemiologic data, the predictive value for a positive test would be 33%, too low to have value in most clinical settings. Data from studies currently available do not support the use of dexamethasone ST in internal medicine practice. More generally, before any test is adopted in a general medical setting, it should be studied in that setting, or available data should be reanalyzed to correct for biases affecting prevalence, sensitivity, and specificity that may inflate the test's value. (Arch Intern Med 1983;143:2085-2088) References 1. Carroll BJ, Curtin GC: Neuroendocrine identification of depressed patients. Aust NZ J Psychiatry 1976;10:12-20.Crossref 2. Carroll BJ: Neuroendocrine procedures for the diagnosis of depression , in Garattini S (ed): Depressive Disorders . Stuttgart, Germany, Friedrich-Karl Schattaur Verlag, 1978, pp 231-236. 3. Kalin NH, Risch SC, Janowsky DS, et al: Use of the dexamethasone suppression test in clinical psychiatry. J Clin Psychopharmacol 1981;1:64-69.Crossref 4. Carroll BJ, Feinberg M, Steiner M, et al: Diagnostic application of the dexamethasone suppression test in depressed outpatients. Adv Biol Psychiatry 1980;5:107-116. 5. Asnis BM, Sachar EJ, Halbreich U, et al: Cortisol secretion and dexamethasone response in depression. Am J Psychiatry 1981;138:1218-1221. 6. Carroll BJ: Implications of biological research for the diagnosis of depression , in Mendlewicz J (ed): New Advances in Diagnosis and Treatment of Depressive Illness . Amsterdam, Excerpta Medica 1980, pp 85-107. 7. Carroll MB, Curtis GC, Mendels J: Neuroendocrine regulation on depression. Arch Gen Psychiatry 1976;33:1051-1058.Crossref 8. Schlesser MA, Winokur G, Sherman B: Genetic subtypes of unipolar primary depressive illness distinguished by hypothalamic-pituitary-adrenal axis activity. Lancet 1979;1:739-741.Crossref 9. Brown WA, Johnston R, Mayfield D: The 24-hour dexamethasone suppression test in a clinical setting: Relationship to diagnosis, symptoms, and response to treatment. Am J Psychiatry 1979;136:543-547. 10. Nuller JL, Ostroumova MN: Resistance to inhibiting effect of dexamethasone in patients with endogenous depression. Acta Psychiatr Scand 1980;61:169-177.Crossref 11. Carroll BJ, Feinberg M, Greden JF, et al: Diagnosis of endogenous depression. J Affective Disord 1980;2:177-194.Crossref 12. Schlesser MA, Winokur G, Sherman BM: Hypothalamic-pituitary-adrenal axis activity in depressive illness. Arch Gen Psychiatry 1980;37: 737-743.Crossref 13. Brown WA, Shuey I: Response to dexamethasone and subtype of depression. Arch Gen Psychiatry 1980;37:737-743.Crossref 14. Carroll BJ, Feinberg M, Greden JF, et al: A specific laboratory test for the diagnosis of melancholia. Arch Gen Psychiatry 1981;38:15-22.Crossref 15. Amsterdam JD, Winokur A, Caroff S: Effect of tricyclic antidepressants on the dexamethasone suppression test. Am J Psychiatry 1980;138: 1245-1246. 16. Amsterdam JD, Winokur A, Caroff S, et al: The dexamethasone suppression test in outpatients with primary affective disorder and healthy control subjects. Am J Psychiatry 1982;139:287-291. 17. Carroll B: The dexamethasone suppression test for melancholia. Br J Psychiatry 1982;140:292-304.Crossref 18. Davis K, Hollister L, Mathe AA, et al: Neuroendocrine and neurochemical measurements in depression. Am J Psychiatry 1979;136:1328-1329. 19. Meltzer HY, Fang VS, Tricou BJ, et al: Effect of dexamethasone on plasma prolactin and cortisol levels in psychiatric patients. Am J Psychiatry 1982;139:763-768. 20. Targum S, Sullivan A, Byrnes S: Neuroendocrine interrelationships in major depressive disorder. Am J Psychiatry 1982;139:262-266. 21. Papakostis Y, Fink M, Lee J, et al: Neuroendocrine measures in psychiatric patients: Course and outcome with ECT. Psychiatry Res 1981;4:55-64.Crossref 22. Holsboer F, Bender W, Benkert O, et al: Diagnostic value of the dexamethasone suppression test in depression. Lancet 1980;2:706.Crossref 23. McNeil BJ, Keeler E, Adelstein SJ: Primer on certain elements of medical decision making. N Engl J Med 1975;293:211-215.Crossref 24. Feinstein AR: Clinical Biostatistics . St Louis, CV Mosby Co, 1977, pp 214-226. 25. Ransohoff DF, Feinstein AR: Problems of spectrum and bias in evaluating the efficacy of diagnostic tests. N Engl J Med 1978;299:926-930.Crossref 26. Griner PF, Mayewski RJ, Mushlin AI, et al: Selection and interpretation of diagnostic tests and procedures. Ann Intern Med 1981;94:557-600. 27. Shapiro MF, Schwabe AD: Gastric enzyme analyses and dyspepsia. Lancet 1981;2:423-427.Crossref 28. Goodman MJ, Kirsner JB, Riddell RH: Usefulness of rectal biopsy in inflammatory bowel disease. Gastroenterology 1977;72:952-955. 29. Go VYW: Carcinoembryonic antigen. Cancer 1976;37:563-566.Crossref 30. Silverman D: The epidemiology of depression: A review. Am J Psychiatry 1968;124:883-891. 31. Winokur G, Pitts RN Jr: Affective disorder: VI. A family-history study of prevalences, sex differences, and possible genetic factors. J Psychiatr Res 1965;3:113-123.Crossref 32. Weissman MM, Myers JK: Affective disorders in a US urban community: The use of research diagnostic criteria in an epidemiological study. Arch Gen Psychiatry 1978;35:1304-1311.Crossref 33. Dohrenwend BP, Crandall DL: Psychiatric symptoms in community clinic, and mental hospital groups. Am J Psychiatry 1970;126:1611-1621. 34. Lee SH, Gainturco DT, Eisdorfer C: Community mental health center accessibility: A survey of the rural poor. Arch Gen Psychiatry 1974;31: 335-339.Crossref 35. Kellner R, Sheffield BF: The one-week prevalence of symptoms in neurotic patients and normals. Am J Psychiatry 1973;130:102-105. 36. Craig TJ, Van Natta PA: Presence and persistence of depressive symptoms in patient and community populations. Am J Psychiatry 1976; 133:1426-1429. 37. Regier DA, Goldberg ID, Taube CA: The de facto US mental health services system: A public health perspective. Arch Gen Psychiatry 1978;35: 685-693.Crossref 38. Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine: II. Clinical aspects. Psychosom Med 1967;29:201-224.Crossref 39. Stoeckle JD, Zola IK, Davidson GE: The quantity and significance of psychological distress in medical patients: Some preliminary observations about the decisions to seek medical aid. J Chronic Dis 1964;17:959-970.Crossref 40. Houpt JL, Orleans CS, George LK, et al: The Importance of Mental Health Sciences to General Health Care . Cambridge, Mass, Ballinger Publishing Co, 1979. 41. Neilson AC, Williams TA: Depression in ambulatory patients. Arch Gen Psychiatry 1980;37:999-1004.Crossref 42. Carroll BJ, Greden JF, Feinberg M, et al: Neuroendocrine evaluation of depression in borderline patients. Psychiatr Clin North Am 1981;4:89-99. 43. Gerner RH, Gwirtsman HE: Abnormalities of the dexamethasone suppression test and urinary MHPG in anorexia nervosa. Am J Psychiatry 1981;138:650-653. 44. Spar JE, Gerner R: Does the dexamethasone suppression test distinguish dementia from depression? Am J Psychiatry 1982;139:238-250. 45. Insel TR, Kalin NH, Guttmacher LB, et al: The dexamethasone suppression test in patients with primary obsessive-compulsive disorder. Primary Res 1982;6:153-160. 46. Curtis GC, Cameron OG, Nesse RM: The dexamethasone suppression test in panic disorder and agoraphobia. Am J Psychiatry 1982;139: 1043-1046. 47. Raskind M, Peskind E, Rivard M, et al: Dexamethasone suppression test and cortisol circadian rhythm in primary degenerative dementia. Am J Psychiatry 1982;139:1468-1471. 48. Swartz CN, Dunner FJ: Dexamethasone suppression testing of alcoholics. Arch Gen Psychiatry 1982;39:1309-1312.Crossref 49. Hwu HG, Rodorfer MV, Clayton PJ: Dexamethasone suppression test and subtypes of depression. Arch Gen Psychiatry 1981;38:363-364.Crossref 50. Goldberg IK: Dexamethasone suppression test as an indicator of safe withdrawal of antidepressant therapy. Lancet 1980;1:376.Crossref 51. Greden JF, Albala AA, Haskett RF, et al: Normalization of dexamethasone suppression test: A laboratory index of recovery from endogenous depression. Biol Psychiatry 1980;15;449-458. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Biases in the Laboratory Diagnosis of Depression in Medical Practice

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Publisher
American Medical Association
Copyright
Copyright © 1983 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1983.00350110063017
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Abstract

Abstract • Several studies, conducted in psychiatric settings, have reported that the dexamethasone suppression test (ST) is useful in the diagnosis of endogenous depression. To determine whether the test has clinical utility in internal medicine practice, data were reviewed and reanalyzed from all studies that evaluated the dexamethasone ST in the diagnosis of depression. In these 11 studies, the mean positive predictive value reported for the test was 84%, reflecting high prevalence of disease (50%), sensitivity (43%), and specificity (92%) in those specialized populations studied. When estimates of the prevalence and severity of conditions associated with depressed mood seen in internal medicine were used, the sensitivity dropped to 30%, and the specificity to 85%. Assuming a prevalence of 20%, a figure based on available epidemiologic data, the predictive value for a positive test would be 33%, too low to have value in most clinical settings. Data from studies currently available do not support the use of dexamethasone ST in internal medicine practice. More generally, before any test is adopted in a general medical setting, it should be studied in that setting, or available data should be reanalyzed to correct for biases affecting prevalence, sensitivity, and specificity that may inflate the test's value. (Arch Intern Med 1983;143:2085-2088) References 1. Carroll BJ, Curtin GC: Neuroendocrine identification of depressed patients. Aust NZ J Psychiatry 1976;10:12-20.Crossref 2. Carroll BJ: Neuroendocrine procedures for the diagnosis of depression , in Garattini S (ed): Depressive Disorders . Stuttgart, Germany, Friedrich-Karl Schattaur Verlag, 1978, pp 231-236. 3. Kalin NH, Risch SC, Janowsky DS, et al: Use of the dexamethasone suppression test in clinical psychiatry. J Clin Psychopharmacol 1981;1:64-69.Crossref 4. Carroll BJ, Feinberg M, Steiner M, et al: Diagnostic application of the dexamethasone suppression test in depressed outpatients. Adv Biol Psychiatry 1980;5:107-116. 5. Asnis BM, Sachar EJ, Halbreich U, et al: Cortisol secretion and dexamethasone response in depression. Am J Psychiatry 1981;138:1218-1221. 6. Carroll BJ: Implications of biological research for the diagnosis of depression , in Mendlewicz J (ed): New Advances in Diagnosis and Treatment of Depressive Illness . Amsterdam, Excerpta Medica 1980, pp 85-107. 7. Carroll MB, Curtis GC, Mendels J: Neuroendocrine regulation on depression. Arch Gen Psychiatry 1976;33:1051-1058.Crossref 8. Schlesser MA, Winokur G, Sherman B: Genetic subtypes of unipolar primary depressive illness distinguished by hypothalamic-pituitary-adrenal axis activity. Lancet 1979;1:739-741.Crossref 9. Brown WA, Johnston R, Mayfield D: The 24-hour dexamethasone suppression test in a clinical setting: Relationship to diagnosis, symptoms, and response to treatment. Am J Psychiatry 1979;136:543-547. 10. Nuller JL, Ostroumova MN: Resistance to inhibiting effect of dexamethasone in patients with endogenous depression. Acta Psychiatr Scand 1980;61:169-177.Crossref 11. Carroll BJ, Feinberg M, Greden JF, et al: Diagnosis of endogenous depression. J Affective Disord 1980;2:177-194.Crossref 12. Schlesser MA, Winokur G, Sherman BM: Hypothalamic-pituitary-adrenal axis activity in depressive illness. Arch Gen Psychiatry 1980;37: 737-743.Crossref 13. Brown WA, Shuey I: Response to dexamethasone and subtype of depression. Arch Gen Psychiatry 1980;37:737-743.Crossref 14. Carroll BJ, Feinberg M, Greden JF, et al: A specific laboratory test for the diagnosis of melancholia. Arch Gen Psychiatry 1981;38:15-22.Crossref 15. Amsterdam JD, Winokur A, Caroff S: Effect of tricyclic antidepressants on the dexamethasone suppression test. Am J Psychiatry 1980;138: 1245-1246. 16. Amsterdam JD, Winokur A, Caroff S, et al: The dexamethasone suppression test in outpatients with primary affective disorder and healthy control subjects. Am J Psychiatry 1982;139:287-291. 17. Carroll B: The dexamethasone suppression test for melancholia. Br J Psychiatry 1982;140:292-304.Crossref 18. Davis K, Hollister L, Mathe AA, et al: Neuroendocrine and neurochemical measurements in depression. Am J Psychiatry 1979;136:1328-1329. 19. Meltzer HY, Fang VS, Tricou BJ, et al: Effect of dexamethasone on plasma prolactin and cortisol levels in psychiatric patients. Am J Psychiatry 1982;139:763-768. 20. Targum S, Sullivan A, Byrnes S: Neuroendocrine interrelationships in major depressive disorder. Am J Psychiatry 1982;139:262-266. 21. Papakostis Y, Fink M, Lee J, et al: Neuroendocrine measures in psychiatric patients: Course and outcome with ECT. Psychiatry Res 1981;4:55-64.Crossref 22. Holsboer F, Bender W, Benkert O, et al: Diagnostic value of the dexamethasone suppression test in depression. Lancet 1980;2:706.Crossref 23. McNeil BJ, Keeler E, Adelstein SJ: Primer on certain elements of medical decision making. N Engl J Med 1975;293:211-215.Crossref 24. Feinstein AR: Clinical Biostatistics . St Louis, CV Mosby Co, 1977, pp 214-226. 25. Ransohoff DF, Feinstein AR: Problems of spectrum and bias in evaluating the efficacy of diagnostic tests. N Engl J Med 1978;299:926-930.Crossref 26. Griner PF, Mayewski RJ, Mushlin AI, et al: Selection and interpretation of diagnostic tests and procedures. Ann Intern Med 1981;94:557-600. 27. Shapiro MF, Schwabe AD: Gastric enzyme analyses and dyspepsia. Lancet 1981;2:423-427.Crossref 28. Goodman MJ, Kirsner JB, Riddell RH: Usefulness of rectal biopsy in inflammatory bowel disease. Gastroenterology 1977;72:952-955. 29. Go VYW: Carcinoembryonic antigen. Cancer 1976;37:563-566.Crossref 30. Silverman D: The epidemiology of depression: A review. Am J Psychiatry 1968;124:883-891. 31. Winokur G, Pitts RN Jr: Affective disorder: VI. A family-history study of prevalences, sex differences, and possible genetic factors. J Psychiatr Res 1965;3:113-123.Crossref 32. Weissman MM, Myers JK: Affective disorders in a US urban community: The use of research diagnostic criteria in an epidemiological study. Arch Gen Psychiatry 1978;35:1304-1311.Crossref 33. Dohrenwend BP, Crandall DL: Psychiatric symptoms in community clinic, and mental hospital groups. Am J Psychiatry 1970;126:1611-1621. 34. Lee SH, Gainturco DT, Eisdorfer C: Community mental health center accessibility: A survey of the rural poor. Arch Gen Psychiatry 1974;31: 335-339.Crossref 35. Kellner R, Sheffield BF: The one-week prevalence of symptoms in neurotic patients and normals. Am J Psychiatry 1973;130:102-105. 36. Craig TJ, Van Natta PA: Presence and persistence of depressive symptoms in patient and community populations. Am J Psychiatry 1976; 133:1426-1429. 37. Regier DA, Goldberg ID, Taube CA: The de facto US mental health services system: A public health perspective. Arch Gen Psychiatry 1978;35: 685-693.Crossref 38. Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine: II. Clinical aspects. Psychosom Med 1967;29:201-224.Crossref 39. Stoeckle JD, Zola IK, Davidson GE: The quantity and significance of psychological distress in medical patients: Some preliminary observations about the decisions to seek medical aid. J Chronic Dis 1964;17:959-970.Crossref 40. Houpt JL, Orleans CS, George LK, et al: The Importance of Mental Health Sciences to General Health Care . Cambridge, Mass, Ballinger Publishing Co, 1979. 41. Neilson AC, Williams TA: Depression in ambulatory patients. Arch Gen Psychiatry 1980;37:999-1004.Crossref 42. Carroll BJ, Greden JF, Feinberg M, et al: Neuroendocrine evaluation of depression in borderline patients. Psychiatr Clin North Am 1981;4:89-99. 43. Gerner RH, Gwirtsman HE: Abnormalities of the dexamethasone suppression test and urinary MHPG in anorexia nervosa. Am J Psychiatry 1981;138:650-653. 44. Spar JE, Gerner R: Does the dexamethasone suppression test distinguish dementia from depression? Am J Psychiatry 1982;139:238-250. 45. Insel TR, Kalin NH, Guttmacher LB, et al: The dexamethasone suppression test in patients with primary obsessive-compulsive disorder. Primary Res 1982;6:153-160. 46. Curtis GC, Cameron OG, Nesse RM: The dexamethasone suppression test in panic disorder and agoraphobia. Am J Psychiatry 1982;139: 1043-1046. 47. Raskind M, Peskind E, Rivard M, et al: Dexamethasone suppression test and cortisol circadian rhythm in primary degenerative dementia. Am J Psychiatry 1982;139:1468-1471. 48. Swartz CN, Dunner FJ: Dexamethasone suppression testing of alcoholics. Arch Gen Psychiatry 1982;39:1309-1312.Crossref 49. Hwu HG, Rodorfer MV, Clayton PJ: Dexamethasone suppression test and subtypes of depression. Arch Gen Psychiatry 1981;38:363-364.Crossref 50. Goldberg IK: Dexamethasone suppression test as an indicator of safe withdrawal of antidepressant therapy. Lancet 1980;1:376.Crossref 51. Greden JF, Albala AA, Haskett RF, et al: Normalization of dexamethasone suppression test: A laboratory index of recovery from endogenous depression. Biol Psychiatry 1980;15;449-458.

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Nov 1, 1983

References