Special issue on depression and mental disorders and diabetes, renal disease and obesity and nutritional disordersScreening for depression in medical care: Pitfalls, alternatives, and revised priorities☆
Introduction
The arguments in favor of routine screening for depression among general medical patients are straightforward and appear compelling, based on the prevalence of depression, its associated personal and social costs, and the large proportion of depressed persons remaining untreated despite the availability of efficacious treatments. Depression is common among medical patients, approaching the prevalence of hypertension in primary care [1], [2], [3], [4]. Depression comorbid with physical health problems takes on added importance because persons prone to depression have more severe episodes in the context of a comorbid medical condition [5], [6], [7]. There is evidence across a variety of medical conditions that depression decreases quality of life and adherence to treatment [8], [9], [10], [11], [12]. Among cardiac patients, depression predicts mortality independent of the biomedical and functional parameters of their condition [13], raising the possibility that improvement in depression will translate into increased survival [14], [15]. Depression negatively affects psychological, occupational, and social role functioning [7], [16], [17], and may have a greater impact on functioning than health conditions such as diabetes, hypertension, arthritis, and back pain [7], [18].
A range of treatments has been shown to be efficacious for depression, including various antidepressants and brief psychotherapy [19], [20], giving rise to empirically based treatment guidelines. Yet, many depressed persons in the community remain untreated [21]. Although unlikely to visit specialty mental health settings, depressed persons in the community are likely to seek care in general or specialty medical settings, making these visits particularly important opportunities to detect and initiate treatment of depression.
Increasingly, the goal of care for depression is being defined not merely as clinical improvement in those patients receiving treatment, but as a reduction in morbidity and the impairment associated with depression on a population basis [22], [23]. This much more ambitious goal of demonstrating a public health benefit is supplanting the already challenging goal of demonstrating efficacy in clinical trials and effectiveness in the application of treatments in the community. An emphasis on increased case-finding in general medical care would seem to be an obvious solution to the problem of community-residing depressed persons who are not receiving adequate treatment, and brief, easily administered instruments would appear to be important tools in this effort. Routine screening was a prominent component of the “detect–treat–improve” paradigm for addressing undetected depression in primary care in the mid-1990s [24], [25], and calls for routine screening have now been extended to specialty medical settings. For example, screening has been advocated in settings focused on cancer [26], [27], [28], cardiovascular disease [2], [29], diabetes [2], emergency medicine [30], and postnatal care [31], [32].
Sentiment in favor of screening in medical settings is so strong that expressions of skepticism must assume a high burden of proof. Yet, seldom are data presented demonstrating that screening for depression improves functional status and mental or physical health, or that screening is cost effective. Evidence that routine screening may not be efficacious or cost effective [25], [33], [34] tends to be dismissed because such findings defy clinical wisdom or practice guidelines that may themselves have been advocated without the benefit of data [26], [35], [36].
This paper briefly reviews some of the evidence calling into question the assumption that routine screening is an efficient and dependable means of improving patient outcomes, and outlines some of the difficulties and unintended consequences of such screening. Although there are ample data regarding the effects of screening in primary care settings, screening in specialty medical settings has not been so systematically evaluated. We propose that lessons learned from evaluations of screening in primary care settings provide a basis for questioning whether screening by itself leads to improvement in the outcome of depression (e.g., [25], [37]), and suggest that if there are compelling institutional reasons for implementing routine screening, it should be undertaken with an appreciation of the difficulties and potential disappointments that will likely be faced. We also offer the recommendation that if screening instruments are to be introduced into medical settings, they would be most efficient as a means of monitoring patients already identified as either currently depressed or having a history of depression, rather than identifying new patients.
Section snippets
Reviews of the effectiveness of screening
Recently, the U.S. Preventative Services Task Force (USPSTF; [38]) adopted recommendations to screen for depression in primary care settings “that have systems in place to assure accurate diagnosis, effective treatment, and follow-up” (p. 760). This is a change from both prior USPSTF recommendations [39] and those of the Canadian Task Force [40]. The USPSTF classified its recommendation as “grade B,” signifying that there was “fair evidence” that screening improves outcomes and that the
Lessons learned from large-scale demonstration projects
Concern about MDD and other treatable mental disorders remaining undetected among medical patients has combined with enthusiasm for routine screening to yield a number of industry-sponsored initiatives aimed at demonstrating the cost effectiveness and benefit of screening. The most high profile and ambitious of these involved use of the Primary Care Evaluation of Mental Disorders (PRIME-MD), which produced a package consisting of a self-report questionnaire to screen for multiple psychiatric
Does screening improve outcomes?
Although some research has demonstrated that screening and physician feedback results in increased recognition and treatment of MDD (e.g., [24], [69], [70]), sufficient evidence has accumulated to conclude that under conditions of routine care, screening generally does not improve outcome [25], [34], [49]. This becomes understandable in the context of a lack of studies demonstrating that routine treatment of depression in general medical care is guideline congruent [71] and an accumulation of
The changing context of screening for depression in medical settings
Substantial documentation had been gathered by the mid-1990s that much of the MDD in general medical care goes undetected and presumably untreated. Yet, by the end of that decade, there was a marked increase in rates of prescription of antidepressants such that the proportion of individuals receiving antidepressants approximated or exceeded the expected prevalence of depression. For instance, in 1997, 11.5% of the elderly population and 17.2% of women in the oldest age groups in Toronto [84],
Unintended consequences of routine screening for depression
Routine screening during medical visits may not be cost effective, even after optimistic assumptions about the prevalence of depression, follow-up of positive screens, clinician accuracy in evaluating patients, rates of treatment initiation, and the adequacy of patient adherence and follow-up are made [50]. There have yet to be systematic studies of the acceptability of screening to key stakeholders such as patients, physicians, and support staff. Their resistance, however, may be indicated
Alternatives to routine screening and revised priorities
We believe it would be a mistake to increase the flow of patients into treatment for depression without assuring that they will receive accurate diagnosis and the effective, guideline-congruent treatments that have consistently been found lacking in the context of general medical care. Barring substantial improvements in care for depression in medical settings, the most appropriate use of screening instruments may be to monitor patients already identified as depressed and receiving treatment.
References (99)
- et al.
The prevalence, nature and co-morbidity of depressive disorders in primary care
Gen Hosp Psychiatry
(1994) - et al.
Epidemiology of depression in primary care
Gen Hosp Psychiatry
(1992) - et al.
Gender differences in depression in primary-care
Am J Obstet Gynecol
(1995) - et al.
Psychoneuroimmunology and cancer: fact or fiction
Eur J Cancer
(1999) - et al.
Even minimal symptoms of depression increase mortality risk after acute myocardial infarction
Am J Cardiol
(2001) - et al.
An open-label preliminary trial of sertraline for treatment of major depression after acute myocardial infarction (the SADHAT Trial)
Am Heart J
(1999) - et al.
Should we screen for depression? Caveats and potential pitfalls
Appl Prev Psychol
(2000) - et al.
The use of the Hospital and Anxiety Scale (HADS) and the EORTC QLQ-C30 questionnaires to screen for treatable unmet needs in patients attending routinely for radiotherapy
Cancer Treat Rev
(1996) - et al.
We should screen for major depression
Appl Prev Psychol
(2000) - et al.
Case-finding for depression in primary care: a randomized trial
Am J Med
(1999)
Nondetection of depression by primary care physicians reconsidered
Gen Hosp Psychiatry
Treatment of minor depression
Am J Geriatr Psychiatry
Ventricular tachycardia and psychiatric depression in patients with coronary artery disease
Am J Med
Toward a resolution of contradictions: utility of feedback from the GHQ
Gen Hosp Psychiatry
Short-term outcomes of detected and undetected depressed primary care patients and depressed psychiatric outpatients
Gen Hosp Psychiatry
Outcomes of recognized and unrecognized depression in an international primary care study
Gen Hosp Psychiatry
A randomized controlled trial of CQI teams and academic detailing: can they alter compliance with guidelines?
J Qual Improv
Persistently poor outcomes of undetected major depression in primary care: implications for intervention
Gen Hosp Psychiatry
Major depressive disorder: a prospective study of residual subthreshold depressive symptoms as predictor of rapid relapse
J Affect Disord
Physical and psychiatric comorbidity in general practice
Br J Psychiatry
The effect of physical ill health on the course of psychiatric disorder in general practice
Br J Psychiatry
Psychiatric disorder and limitations in physical functioning in a sample of the Los Angeles general population
Am J Psychiatry
Fatigue in multiple sclerosis and its relationship to depression and neurologic disability
Mult Scler
Depression and chronic medical illness
J Clin Psychiatry
Depression after myocardial infarction
Cardiol Rev
The impact of negative emotions on prognosis following myocardial infarction: is it more than depression?
Health Psychol
Enhancing Recovery in Coronary Heart Disease (ENRICHD) study intervention: rationale and design
Psychosom Med
Marital quality, coping with conflict, marital complaints, and affection in couples with a depressed wife
J Fam Psychol
Medical comorbidity of major depressive disorder in a primary medical practice
Arch Intern Med
The functioning and well-being of depressed patients: results from the medical outcomes study
JAMA
Treatment of depression collaborative research program: general effectiveness of treatments
Arch Gen Psychiatry
Acute therapy of depression
J Clin Psychiatry
The epidemiology of the psychiatric disorders and the de facto mental health care system
Annu Rev Med
Editorial: the public health model for mental health care for the elderly
JAMA
Effectiveness of a nurse-based outreach program for identifying and treating psychiatric illness in the elderly
JAMA
Improving treatment of late life depression in primary care: a randomized clinical trial
J Am Geriatr Soc
Preliminary guidelines for the treatment of distress
Oncology
Prevalence, predictive factors, and screening for psychological distress in patients with newly diagnosed head and neck cancer
Cancer
Psychometric assessment of cardiac transplantation candidates
J Clin Psychol Med
Psychiatric screening of admissions to an accident and emergency ward
Br J Psychiatry
Routine screening for postpartum depression
J Fam Pract
Improving the detection of postnatal depression
Prof Nurse
Distress and psychiatric morbidity among women from high-risk breast and ovarian cancer families
J Consult Clin Psychol
Routinely administered questionnaires for depression and anxiety: systematic review
BMJ
Screening and treatment of distress
J Consult Clin Psychol
Primary care—managing depression in medical outpatients
N Engl J Med
Screening for depression: recommendations and rationale
Ann Intern Med
Guide to preventive services
Cited by (108)
Emergency health services use and medically-treated suicidal behaviors following depression screening among adolescents: A longitudinal cohort study
2022, Preventive MedicineCitation Excerpt :Our study builds on the findings of this review by examining depression screening specifically, and supports a similar conclusion about the disconnect between mental health interventions received outside of emergency settings and subsequent emergency health services use. Some investigators have postulated that depression screening may increase the detection of individuals with milder and less distressing cases of depression (Mojtabai, 2017; Palmer and Coyne, 2003). These less severe cases of depression may be more likely to resolve over time without intervention, and may not be expected to result in crises that require emergency care.
Effects of depression screening on diagnosing and treating mood disorders among older adults in office-based primary care outpatient settings: An instrumental variable analysis
2017, Preventive MedicineCitation Excerpt :Since the mid-1990s, depression screening has been a “prominent component of the “detect—treat—improve” paradigm for undetected depression” in primary care settings (Palmer and Coyne, 2003, p. 280).
A randomised controlled trial of the effectiveness of a program for early detection and treatment of depression in primary care
2016, Journal of Affective DisordersScreening for anxiety disorders with the GAD-7 and GAD-2: A systematic review and diagnostic metaanalysis
2016, General Hospital PsychiatryCitation Excerpt :However, there is considerable uncertainty about the value of screening for mental health problems [11,12] and the lack of evidence for screening and case finding for anxiety disorders has been noted [13]. Critics of screening suggest that too little attention has been paid to the harms of screening to those who are incorrectly diagnosed as having a mental health problem (false positives) [14,15]. Harms include the stigma of being diagnosed with a mental health problem and unnecessary (and costly) interventions such as drug or psychological treatment.
Patient-reported depression measures in cancer: A meta-review
2015, The Lancet Psychiatry
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Proceedings of a conference on Depression and Mental Disorders in Patients with Diabetes, Renal Disease and Obesity/Eating Disorders cosponsored by the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institute of Mental Health, and the National Institutes of Health Office of Behavioral and Social Sciences Research, Bethesda, MD, January 2001.