December 18, 2013

Should PCPs Screen All Patients for Depression?

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Larry Culpepper, MD, MPH

Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts


In June 2013, the Canadian Task Force on Preventive Health Care reversed their prior recommendation and now recommend against screening for major depression in patients who are not at increased risk. One of the task force’s arguments against screening is that false positives lead to improper labeling of patients and overtreatment. The United States Preventive Services Task Force’s (USPSTF) standing recommendation (originally in 2002, updated in 2009) is to screen only if practice resources are available to diagnose and actively manage those who screen positive. Rather than wade into the debate about whether routine screening for major depression is warranted in primary care, I suggest that perhaps instead it is time to reframe the question.

A bit of history is in order. In a 1994 review of the then-available 6 relevant studies, Higgins had established that introducing screening for depression into usual primary care practice did not lead to improved patient outcomes and thus was not warranted. This publication heralded the start of a number of high-quality, practice-based trials that demonstrated that, with the right practice supports, screening indeed did lead to improved outcomes. These practice supports include using care management strategies such as maintaining a practice registry of patients who screen positive and continuing to engage them, providing guideline-based care, and having access to psychiatric expertise—which are now all now components of the patient-centered medical home.

In 2002, when the USPSTF first made their positive recommendation, it was in the context of the growing use of SSRIs, a treatment that primary care physicians could use due to their greater safety margin than older antidepressants. A number of other realities were at play in 2002. Mental health care for the majority of insured Americans was a “carve out,” and primary care physicians were not paid for visits to care for depression or other psychiatric diseases. And, if you weren’t insured, well, while you were several times more likely to have major depression, access to care was minimal. So, not only was identifying depression not a top priority, it wasn’t even on the list of priorities for most in primary care, who have a long list of urgent concerns. We had much less appreciation of the marked interaction between depression and chronic medical disease—both the doubling in rates of onset of cardiovascular, diabetic, and many other chronic conditions in those with mental illness and the much worse outcomes when depression was comorbid with chronic medical illness. The fee-for-service world, in which such chronic conditions were the primary care physicians’ bread and butter, did not incentivize our including depression care as part of good care of chronic medical illness.

So, in the early 2000s, advancing depression care through advocating routine screening of all adults for major depression was a bold step forward. The USPSTF recommendation brought into focus the schism between mental health care and primary care, and it proposed a limited action that was fairly simple to introduce into practice. Adopting this recommendation had the benefit of demonstrating the unmet need and patient suffering that had been virtually invisible within the walls of many primary care practices whose physicians were not attuned to depressive illness.

But the realities of 2013 and 2014 are much different. With the arrival of the Affordable Care Act, expanded insurance coverage, and mental health parity, the financial incentives for diagnosing and treating depression are improving. We also now understand that effective care of depression is critical not only to improving comorbid medical conditions but to returning the patient to full functioning and productivity, including at work. With the latest recession, patients are at heightened risk of major depression. We now have a primary care workforce that is much more educated and experienced in the care of at least depression if not all mental disorders. We also have an American population in which depression is no longer a major source of stigma (in part through the national emphasis on its recognition and treatment) and in which concern about the occasional association of mental illness with violent events encourages treatment-seeking.

So, the issue of screening for major depression is so, well, 20th century. The question no longer is, Should we screen everyone for major depression? Check back for my next blog entry to consider the question, How can we better coordinate mental and medical health care?

Financial disclosure:Dr Culpepper is a consultant for Forest, Lundbeck, Merck, Sunovion, and Takeda.

Category: Depression , Medical Conditions
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2 thoughts on “Should PCPs Screen All Patients for Depression?

  1. This question-to screen? is best answered empirically! Research shows that without screening instruments Primary Care Physicians only catch about 10% of mental illnesses and do a poor job of linkage with specialists and appropriate treatment when they do. This costs the patient, healthcare resources, and future generations. Still, empirically, if the local facility “catch rate” for mental illness is compared to research established incidence rates in similar facilities and prevalence rate in the population you could get a “batting average” or “quality of identification” (read as physician skill) rate to evaluate whether more formal screening and protocols for mandatory specialist referral and more comprehensive diagnostic evaluation.
  2. There is research indicating that as many as 66% of all visits to PCP’s are for something the PCP can not “fix.” They are things like loneliness, depression, low back pain, poor sleep,
    uncomplicated obesity, substance abuse, etc. Depression is probably at the root of many of these complaints. There is little disagreement that depression is probably under diagnosed, under treated, and likely to become chronic when this happens, leading to loss of productivity, family unhappiness and even disintegration, and decreased quality of life.
    Even when diagnosed, there is about a 50% likelihood that the right medication will be given in the right dose. And if it is, there are still 50% of patients who will never fill the prescription. Of those that fill it, only about half will continue taking it long enough to actually judge its effectiveness for them. Of that small percentage, far fewer will take the medication regularly and as prescribed for six months or more. No wonder only about 6% of patients who go to their PCP with clear symptoms of depression are treated to “cure” –with cure defined as remission of all depression-associated symptoms for a period of one year or more.
    What that suggests is that not only do we lack skills and tools in diagnosis of this common problem, but we also lack treatment protocols or referral strategies that are effective enough to keep patients in treatment until a cure is provided for them. Treating depression to “cure” is yet another thorny issue. Currently, we treat to about 50% reduction in symptoms and call it a success, leaving the patient with some symptoms, such as anhedonia, sexual anesthesia, poor sleep, irritability, slowed cognitive functions such as poor recall, substance abuse, and pain of various kinds. Patients with residual symptoms have been shown to be prone to relapse. And the problem goes on, and on, becoming ever more resistant to treatment. We need to take this costly disease more seriously, find better treatments ad use the ones we have more effectively.

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