Special issue on depression and mental disorders and diabetes, renal disease and obesity and nutritional disorders
Screening for depression in medical care: Pitfalls, alternatives, and revised priorities

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Abstract

Depression is a disorder seen commonly in general and specialty medical settings. Screening has been advocated as a means of ensuring that depressed patients are identified and receive appropriate treatment. Yet, recommendations for routine screening are frequently made without reference to empirical data demonstrating that it will have its intended effect. We examine the literature regarding screening in medical settings and suggest that screening in itself is unlikely to improve patient outcomes. Further, we identify costs to screening that are not readily apparent and that may negatively affect both patient outcomes and health-care delivery systems. We offer suggestions for how screening instruments might be used to improve the outcomes of depressed persons while minimizing negative effects on health care.

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.

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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.

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