Screening for Depression in Primary Care

Jay M. Pomerantz, MD

Disclosures

Depressive disorders are common, costly, and treatable, but they often go unrecognized. A 2001 World Health Organization report projected that by 2020, depression will account for more lost disability-adjusted life-years than all other conditions, except for ischemic heart disease.[1] Currently, nearly half of lost productivity in the United States can be attributed to major depression, at an estimated cost of $44 billion annually.[2]

In 2002, the US Preventive Services Task Force endorsed screening for depression in primary care settings, particularly when screening is coupled with system changes that help ensure adequate treatment and follow-up.[3] The focus on screening for depression in primary care makes sense, since almost two thirds of patients with depression receive care in that setting.[4]

In outpatient primary care settings, the incidence of depression by type breaks down as the following: major depression, 4.8% to 8.6% of patients seen; dysthymia, 2.1% to 3.7% of patients; and minor depression, 8.4% to 9.7%. Thus, the total for all types of depression comes to 15.3% to 22% of all patients seen in primary care offices.[5] These numbers are supported by findings of site studies, in which investigators administered depression self-rating scales, combined with structured psychiatric interviews, to all primary care patients during office visits for any reason.[6]

Despite the frequency of depression, diagnosis by nonspecialist practitioners is often haphazard. Studies show that primary care physicians who provide usual care fail to recognize depressive symptoms in 30% to 50% of patients with depression.[7] What is being missed is not a small problem here and there, but a range of disorders, some of which—such as major depression—occur frequently and can be quite severe. For example, of persons who committed suicide, 40% had visited their primary care physician in the month before their death.[8,9] During these visits, the question of suicide was seldom raised.

Physicians and patients may sometimes enter into an unspoken agreement that physical symptoms are the only legitimate ticket of admission to a doctor's office.[10] Patients may find their story cut short by the physician's asking where the pain is and whether it is sharp or dull, rather than asking about the circumstances, personal and social, under which the pain occurs;[11] it may not be just time pressure. Many physicians may also have a somatic mindset that prevents them from exploring psychological variables.

Even when depression is recognized, the dosage and duration of antidepressant therapy is often inadequate. A number of issues may be responsible for this, but one likely culprit is the lack of proper follow-up. The National Committee for Quality Assurance/Health Plan Employer Data and Information Set standards for adequate follow-up care for depression require at least 3 visits over 90 days, but most large health care systems meet this standard less than 25% of the time.[12] Lack of follow-up contributes to poor antidepressant adherence rates. Almost 50% of patients stop taking their medication as early as 3 months after starting antidepressant treatment,[13] and more than 70% discontinue medication before 6 months.[14] This early discontinuation is at odds with clinical guidelines, which show little utility for antidepressants in the short term but much evidence for efficacy of 6 months or more of treatment.[15]

Management of depression is also quite cost-effective. A recent systematic review of cost-utility studies of depression management concluded that costs per quality-adjusted life-year for screening, pharmacologic treatment, nonpharmacologic treatment (eg, psychotherapy), and care management for depression are well within the acceptable range for screening or care for other medical conditions, such as coronary artery disease, hypertension, diabetes, and colon cancer.[16]

Two relatively new screening tools may make screening and follow-up for depression easier. The first screening tool consists of 2 questions:

  1. During the past month, have you often been bothered by feeling down, depressed, or hopeless?

  2. During the past month, have you often been bothered by little interest or pleasure in doing things?

The use of these 2 screening questions alone showed a sensitivity and specificity of 97% and 67%, respectively, when tested in a primary care setting on patients not receiving psychotropic drugs.[17] In practice, even one positive answer should expand the inquiry and, possibly, bring into play a second new tool for diagnosing depression.

The second screening tool is a 9-question Patient Health Questionnaire (PHQ-9), which not only shows great validity but also measures severity and can be used at follow-up visits to evaluate the effectiveness of treatment.[18] It includes a specific question on suicidality. The PHQ-9 is available at: www.pfizer.com/phq-9.

Primary care physicians now have simple, easy-to-administer tools to screen for and quantify the severity of depression in their patients. Lack of time and discomfort with emotional issues are no longer reasonable excuses for the failure of practitioners to look for and treat depressive symptoms in their patients. Along with weight, pulse, and blood pressure, a patient's mental state also deserves routine measurement and monitoring; primary care physicians should particularly be on the lookout for depression.

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