The use of brief depression symptom measures may lead to overdiagnosis of the disorder ― and to the overprescribing of antidepressants, new research suggests.
Dr. Anthony Jerant
An observational study of almost 600 adult participants deemed to be at low risk for depression at baseline showed that 11% received a diagnosis for the disorder after completing a primary care office visit and that 4% were prescribed an antidepressant.
However, among the 50 participants who completed a brief symptom measure during the visit, 20% received a diagnosis of depression, and 12% were prescribed an antidepressant. These findings were largely due to use of the 9-item Patient Health Questionnaire (PHQ-9).
"We were a little surprised at the strength of the associations," lead author Anthony Jerant, MD, professor in the Department of Family and Community Medicine at the University of California, Davis, told Medscape Medical News.
Dr. Jerant noted that the study does not suggest the PHQ-9 is a bad measure per se. Although the brief measures could be contributing to the problem, it could also be that clinicians are just not using them correctly.
"I don't think the findings mean we shouldn't use the measures. But if we're going to use them, providers need to be very sure they understand the likelihood of depression at different score cutoffs and to follow up with further questioning," he said.
The study was published in the September-October issue of the Journal of the American Board of Family Medicine.
Overdiagnosis?
"Use of brief depression symptom measures for identifying or screening cases may help to address depression undertreatment," write the investigators.
"But whether it also leads to diagnosis and treatment of patients with few or no symptoms ― a group unlikely to have major depression or benefit from antidepressants ― is unknown."
They note that in contrast with the US Preventive Services Task Force, the Canadian Task Force on Preventive Health Care has recommended not using brief depression symptom measures because of concerns about overtreatment with antidepressants.
"We've talked about this being a problem of mismatching treatment to need. We want to maximize directing the treatment to the people who are going to benefit and not subject people who are not going to benefit to potential harms and to the hassles of taking the medicine," said Dr. Jerant.
"Nobody has really looked at the overtreatment side that could be associated with using these tools to either screen or case-find depression. And that's why we wanted to look at it," he explained.
The study included 595 participants between the ages of 25 and 70 years (mean age, 52.5 years; 55% women) who were from California and who scored a 9 or less on the PHQ-9, which was administered by computer 20 minutes before visits to a primary care physician. These results were not given to the provider.
The researchers then reviewed the physicians' notes and chart data for 3 main points of interest:
Whether a brief symptom measure was administered by the practice
Whether the provider diagnosed depression
Whether the provider recommended and/or prescribed an antidepressant
Brief symptom measures administered in the office setting included the PHQ-9 and the 2-item Patient Health Questionnaire (PHQ-2).
Balancing Risk/Benefit Ratio
Results showed that 57 of the 545 participants (10.5%) who did not undertake a brief, practice-administered measure received a diagnosis of depression during their visit. Of these, 21 received an antidepressant prescription, and 9 received a recommendation for this type of prescription.
A total of 50 individuals filled out a brief measure during their office visit, with 26 completing the PHQ-2 and 23 completing the PHQ-9. Of the 50 total, 10 were diagnosed with depression (20%), and 6 were prescribed an antidepressant (12%).
After adjusting for multiple variables, use of a brief symptom measure was significantly associated with a diagnosis of depression (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.1 - 9.2; P = .02) and a recommendation and/or prescription for an antidepressant (OR, 3.8; 95% CI, 1.0 - 13.9; P = .04).
Use of these measures was also significantly associated with antidepressant prescription alone (AOR, 4.1; 95% CI, 1.1 - 16.2; P = .04).
"Analyses by practice-administered measure (PHQ-9 vs PHQ-2) indicated the study findings were largely associated with PHQ-9 use," report the investigators.
The adjusted OR of increased antidepressant recommendation and/or prescription for office administration of the PHQ-9 was 10.0 (95% CI, 1.8 - 55.4) vs 1.1 for the PHQ-2 (95% CI, 0.3 - 4.0). The likelihood of a depression diagnosis was also significantly increased (AOR, 5.3 vs 1.7, respectively).
"Caution is required when interpreting our findings, given their preliminary nature and the limitations of the study design," write the investigators.
However, "if these findings are confirmed, researchers should investigate the balance of benefits and risks...associated with use of a brief symptom measure," they add.
Better Guidance Needed
Dr. Jerant noted that although treating depression is important, so is making sure the patients receiving treatment actually need it ― especially because there are significant adverse effects associated with antidepressants.
He added that common depression symptoms such as insomnia, fatigue, and trouble concentrating are also associated with other health conditions.
"We need to give providers good guidance on how to use brief symptom measures in evaluating patients and making treatment decisions," he said.
"If a doctor sees that a patient has just 1 or 2 positive answers, even though that doesn't technically increase the odds of depression, it may lead him down that path. So this could be a problem with the physician not interpreting it correctly or overinterpreting it."
He noted that, overall, there needs to be something better than just a simple screening that does not give feedback to the patient about what the responses could mean.
"Depression is such an important topic for family physicians that we continue to get excellent manuscripts exploring important intricacies of depression care," the editors of the Journal of the American Board of Family Medicine, led by Marjorie A. Bowman, MD, write in the journal's foreword.
"Jerant et al provide data that strongly suggest we consider the possibility of negative outcomes from depression screening in family physician offices," they add.
The study authors have reported no financial relationships.
J Am Board Fam Med. 2014;27:611-620. Full article
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Cite this: Brief Scale Linked to Antidepressant Overprescribing - Medscape - Sep 10, 2014.
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