Screening for depression in primary care: recommendation statement from the Canadian Task Force on Preventive Health Care

Clinical implications: What should primary health care providers do?

A number of screening tools exist for use in primary care settings. Asking 2 simple questions regarding mood and anhedonia — “Over the past 2 weeks, have you felt down, depressed, or hopeless?” and “Over the past 2 weeks, have you felt little interest or pleasure in doing things?” — may be as effective as longer instruments.12^,13 The authors of the systematic review for the US task force calculated that 11 patients with depression would need to be identified through screening to produce 1 additional remission at 6 months. Assuming a 10% prevalence of treatment-responsive depression in primary care, 110 patients would need to be screened to produce this additional clinical remission.2 Although the optimal interval for screening is unknown, the US task force recently stated that “recurrent screening may be most productive in patients with past history of depression, unexplained somatic symptoms, comorbid psychological conditions (such as panic disorder or generalized anxiety), substance abuse, or chronic pain.” 12 A positive screen must be followed by accurate diagnosis, effective treatment and follow-up to ensure that the benefits of screening are realized.

“Integrated programs” as defined in the US and Canadian task force reviews went beyond feedback and included interventions such as education of patients or health care providers or both, access to case management or mental health care and telephone follow-up.12 In deciding whether an integrated program of care for screening and treating depression exists in a community, clinicians need to examine the step-by-step process by which patients go from screening to receiving effective treatment. Given the heterogeneity of the models used in the studies reviewed, it is not possible to recommend a specific primary care-based screening and treatment program for depression. However, the following questions, with examples, may assist clinicians in determining whether integrated care exists in their community:

• Is there a mechanism to ensure that the screening results are reported to the clinician, who can then provide appropriate treatment for depression? What is the process by which the patient proceeds from screening positive to having the diagnosis confirmed to receiving treatment for depression? In the study by Katzelnick and colleagues,5 results of telephone screening were provided to physicians, who saw the patients at an evaluation visit and then for prescheduled follow-up sessions. Providers in the study by Wells and colleagues7 were asked to schedule a visit with patients 2 weeks after the initial screening.

• Is there a clinician trained in the use of antidepressants who will follow up with patients who screen positive? Is there access to psychotherapists trained in approaches effective for the treatment of depression? Evidence-based training in the management and treatment of depression was implemented in the integrated programs reviewed. For example, the study by Wells and colleagues7 provided a 2-day training workshop to clinical leaders (local primary care experts and nurse specialists) as well as educational materials for clinicians and patients. Furthermore, the clinical leaders provided educational sessions, including lectures and ongoing feedback, to clinicians based on medical record audits. Those in the psychotherapy intervention group of this trial had access to therapists who received specific training in cognitive behavioural therapy. In the study by Rost and colleagues,6 both primary care physicians and nurses received brief training in the management of depression that was aimed at enhancing the proportion of patients who completed a course of psychopharmacotherapy or psychotherapy. In each of these studies, there was strong coordination in place and a systematic process that integrated screening with treatment of depression.

Authors of the US task force review suggested that, for increased rates of screening to be translated into improved outcomes, special focus on the course of therapy may be required, “perhaps in the form of a quality improvement effort or other programs systematically designed to provide appropriate care” (page 66).3

The Canadian task force recognizes that such services may not yet be available in all settings. However, on the basis of the evidence, and the burden of this disease, physicians are encouraged to advocate for the implementation of systems to provide linked screening for depression and treatment services in primary care settings.