Depression Screening in Primary Care Still Rare

Nancy A. Melville

February 22, 2017

Amid ongoing debate over universal depression screening, new research shows that only a small fraction of primary care practitioners provide it.

Primary care practitioners are the frontline providers of mental health care, often seeing depressed patients who may not otherwise be receiving care, first author Ayse Akincigil, PhD, the School of Social Work, Rutgers University, New Brunswick, New Jersey, told Medscape Medical News.

"Primary care settings are an opportune location for early identification of depression, as many depressed patients' contact with the healthcare system is through primary care," she said.

Despite recommendations from the US Preventive Services Task Force (USPSTF) that all adults be screened for depression, previous research has shown rates of screening in primary care in the United States to be as low as 1% to 2%.

Recent regulatory and policy changes, such as rules set forth in the 2010 Affordable Care Act (ACA) requiring private insurers to cover recommended depression screening, as well as a similar reimbursement policy announced in 2011 for Medicare beneficiaries, may have improved screening.

In an effort to assess rates of depression screening, the investigators evaluated data from the National Ambulatory Medical Care Survey of 2012 and 2013 regarding 33,653 encounters between physicians and patients.

The investigators found that the overall rate of depression screening in primary care was 4.2%. Screening was half as likely among African Americans (adjusted odds ratio [aOR] = .48), and screening of elderly patients was half as likely as screening of middle-aged patients.

Although the overall rate represents an improvement of more than twofold in screening in the past decade, "4% suggests many missed opportunities for depression screening," Dr Akincigil said.

The study was published online February 15 in Psychiatric Services.

Differences by Patient Population

Nearly half (47%) of visits that included screening resulted in a new diagnosis of depression, a finding that suggests screening is likely prompted by a suspicion of depression, the authors note.

However, screening patients only when there is a suggestion of depression may miss a significant proportion of individuals who do not display or disclose symptoms or who may have lesser-known depressive symptoms, they add.

Evidence shows that the clinical presentation of depression may differ in African Americans and the elderly, which may explain lower screening rates in these populations.

Research indicates that rather than expressing mood-related symptoms, such as sadness, African Americans and the elderly display somatic symptoms, including headaches, lethargy, or body pain, the authors add.

"Therefore, recognizing depression requires providers to accurately differentiate somatic symptoms stemming from depression from those caused by general medical ailments that may be a result of the normal aging process or other medical conditions," they write.

In addition, symptoms in men can differ from those in women and may more commonly include aggression or risk-taking behaviors, as well as substance abuse.

Because symptoms may not be apparent, current guidelines call for screening of patients regardless of symptoms.

Although the study was not designed to investigate the reasons for a lack of depression screening, previous research has shown that deterrents include inadequate reimbursement and difficulty in adding screening to existing clinical routines.

In addition to the recent improvements in insurance coverage of screening, the adoption of electronic health records (EHRs) has placed simplified, time-saving depression screening tools at clinicians' fingertips.

The findings from the current study did show that providers with fully adopted EHRs were more likely to screen for depression than those using paper charts (aOR = 1.81).

In addition, the literature suggests that depression screening can be performed even in the waiting room. Studies have found that validated screening tools that include as few as two questions can be effective in detecting depression, Dr Akincigil said.

A point of contention in the recommendations regarding screening for depression lies not in the screening itself but with respect to what should be done if a patient screens positive for possible depression.

The USPSTF recommendation, detailed in JAMA, recommends that screening be implemented with "adequate systems in place" to appropriately diagnose and treat depression with evidence-based care or referral to a setting that can provide appropriate care.

The USPSTF notes that such systems can vary widely. They can range from simply having a designated nurse give advice when patients screen positive and then follow a protocol of referring to treatment, to full, multidisciplinary training of staff and clinicians with ongoing support for medication adherence and arranging a visit with a trained therapist for cognitive-behavioral therapy.

Some have argued that there is a lack of evidence supporting the USPSTF depression screening recommendations.

In an analysis published in BMC Medicine in 2014, researchers reported that the guideline was not supported by evidence from any randomized controlled trials showing benefits from the screening.

The authors pointed to studies suggesting problems with overdiagnosis and overtreatment of depression in the primary care setting.

Lack of Evidence?

Commenting on the findings for Medscape Medical News, Brett D. Thombs, PhD, a senior author of that analysis and professor and William Dawson Scholar in the Faculty of Medicine at McGill University, Montreal, Canada, said the new findings on low screening rates may reflect continued concerns about the evidence.

"It is somewhat surprising that the rate is as low as 4%, but it is not surprising that relatively few doctors do regular screening," he said.

"There is not any evidence from well-conducted randomized controlled trials to support the idea that screening in itself would improve mental health, and practicing physicians likely realize that the resources involved would be potentially staggering and would impede their ability to do many other important healthcare activities adequately."

Dr Thombs, who is currently chair-elect of the Canadian Task Force on Preventive Health Care, noted that the Canadian Task Force and the UK National Screening Committee recommend against universal depression screening.

He said that although research shows that well-integrated care benefits patients with depression, problems may arise when those systems are inadequate.

"If primary care providers screen patients without proper procedures to adequately follow up with appropriate assessment and management, many patients would be inappropriately diagnosed and prescribed medications that may not help them but would certainly cause unwanted side effects for many patients," he said.

Andres Barkil-Oteo, MD, Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, commented that collaborative care models have had some success in helping primary care practices better address mental health needs, but that more widespread approaches are needed.

"The solution isn't to motivate physicians with monetary incentives or simply having them check a box indicating that a patient was screened," he told Medscape Medical News. "A system needs to be in place.

"A physician may only be with a patient for 10 minutes and has to prioritize that time, but shifting the task to someone on the staff is a start. Clinicians may need to spend some resources to help follow those cases, but it is doable."

The study was supported in part by the Agency for Healthcare Research and Quality. The authors, Dr Thombs, and Dr Barkil-Oteo have disclosed no relevant financial relationships.

Psychiatr Serv. Published online February 15, 2017. Abstract


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