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Which Version of the Geriatric Depression Scale is Most Useful in Medical Settings and Nursing Homes? Diagnostic Validity Meta-Analysis

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Background

The Geriatric Depression Scale (GDS) has been evaluated in individual studies, but its validity and added value in medical settings and nursing homes is uncertain. Therefore, the authors conducted a meta-analysis, analyzing the diagnostic accuracy of long, short, and ultrashort versions of the GDS and stratified this into those with and without cognitive impairment.

Methods

A comprehensive search identified 69 studies that measured the diagnostic validity of the GDS against a semistructured psychiatric interview, and of these, 43 analyses (in 36 publications) took place in medical settings. Twenty-one studies examined the GDS30, 12 studies examined the GDS15, and 3 examined the GDS4/5. For comparison, the authors also summarized studies examining unassisted clinical judgment. Heterogeneity was moderate to high; therefore, random effects meta-analysis was used.

Results

Across all studies, the prevalence of late-life depression was 29.2% (95% confidence interval [CI] = 24.7%–33.9%), with no difference between inpatients, outpatients, and nursing homes. Diagnostic accuracy of the GDS30 after meta-analytic weighting was given by a sensitivity of 81.9% (95% CI = 76.4%–86.9%) and a specificity of 77.7% (95% CI = 73.0%–82.1%). For the GDS15, sensitivity was 84.3% (95% CI = 79.7%–88.4%) and specificity was 73.8% (95% CI = 68.0%–79.2%). For the GDS4/5, the sensitivity and specificity were 92.5% (95% CI = 85.5%–97.4%) and 77.2% (95% CI = 66.6%–86.3%), respectively. Results were not significantly influenced by the presence of dementia. Concerning added value, when identification using the GDS was compared with routine clinicians' ability to diagnose late-life depressions, at a prevalence of 30%, of every 100 attendees, the GDS30 would help correctly identify an additional 22 people as depressed but at a cost of 13 additional false positives. The GDS15 performed the same as GDS30 but with 15 false positives. The ultrashort form would help identify an additional 25 true positives with only 10 false positives. Thus, the best option when choosing between versions of the GDS seems to be the GDS4/5.

Conclusion

All versions of the GDS yield potential added value in medical settings, but the GDS4/5 is the most efficient. In nursing homes, given an absence of data on the GDS4/5, the GDS15 may be preferred until more studies are reported.

Section snippets

Inclusion/Exclusion Criteria

The principle inclusion criteria were studies that examined the diagnostic validity of the GDS in the detection of depression in older people defined by semistructured psychiatric interview. We defined late-life depression as any depression occurring at a mean age of 65 years or older. We examined three medical settings: a) medical inpatients, b) medical outpatients, and c) nursing homes. We included nursing homes because of the high prevalence of depression and comorbid physical disease that

Accuracy

To examine diagnostic accuracy, we examined the discriminatory value of the GDS at an optimal cutoff (if receiver operator curve data reported) or otherwise using the cutoff supplied by the primary authors. Overall, accuracy was calculated as the proportion of all cases who were either true positives or true negatives, known as the fraction correct (FC) or efficiency of a test.39 An FC >60% can be considered “adequate” and >80% can be considered “good.” FC also allows comparison of statistical

Study Description and Methods

From 1,080 initial hits, we identified 69 studies pertaining to the diagnostic accuracy or validity of the GDS against a robust semistructured interview of which 43 analyses (in 36 publications) took place in medical settings (Table 1). Twenty-one studies examined the GDS30, 12 studies examined the GDS15, and 3 examined the GDS4/GDS5. For comparison purposes, we located six studies examining hospital specialists' ability to detect late-life depression.22,44, 45, 46, 47, 48 Of these, only two

DISCUSSION

This is the first meta-analysis to synthesize the validity of the GDS in hospital and nursing home settings. We included nursing homes because the prevalence of depression and medical comorbidity is more similar to hospital settings than primary care.5 Indeed, in our sample of almost 5,000, when defined by semistructured psychiatric interviews, we found the prevalence of late-life depression to be 29.2% (95% CI = 24.7%–33.9%), with no difference between nursing homes, inpatients, or

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    Copyright © 2010 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.