Prevalence of depressive symptoms in the general population with a fully structured interview with skips vs. unconditional sequential assessment: implications for clinical and psychiatric epidemiology studies

Diagnostic methods in psychiatry often rely on categorical approaches, such as the skip-out procedure, which conditionally assesses symptoms based on prior responses. This study evaluates how assessment methods influence the prevalence of depressive symptoms and Major Depressive Episode (MDE), comparing the skip-out approach with a sequential assessment that evaluates all symptoms independently. It also examines how assessment method affects symptom associations and explores the relationship between self-perceived mental health and symptom count. We conducted a cross-sectional analysis of 2005 Spanish adults using a self-administered online version of the WHO Composite International Diagnostic Interview (CIDI) 3.0. MDE prevalence, symptom frequencies, and associations were compared between skip-out and sequential assessments. Odds ratios with 95 % confidence intervals analyzed symptom associations with MDE, while intercorrelations and self-perceived mental health ratings were evaluated by symptom count. The skip-out method identified only 25 % of the cases detected by the sequential assessment (102 vs. 407), indicating a 75 % reduction in the detected MDE cases. Core symptoms like sadness and anhedonia were more strongly associated with MDE under skip-out, whereas non-core symptoms were better captured by sequential assessment. Sadness and concentration difficulties showed the strongest links to impairment. Over half of individuals reporting five or more symptoms rated their mental health as good or excellent. These results suggest that clinical and epidemiological assessments should consider the use of skip-out logic, as it may substantially underestimate depression prevalence and diversity. Improving assessment strategies may enhance early detection, reduce underdiagnosis, and support more tailored public health interventions.