Facts of Life: Issue Briefings for Health Reporters - from the Center for the Advancement of Health
The Issue:
Considerable evidence exists that depression, particularly when untreated, poses a significant global health burden.1To reduce this burden, screening campaigns to identify people with depression are increasingly widespread. Many researchers, mental health advocates and health care professionals would like to see depression screening become as routine as screening tests for cancer and heart disease.
However, the first wave of evidence on the effectiveness of depression screening suggests that these tests may not be as helpful as hoped.
Screening Under Scrutiny
Depression screening is coming of age at a time when all medical screening is under scrutiny. Up until recently, PSA tests for prostate cancer and mammograms were considered good preventive medicine without question.
But new studies question the efficacy and potential side effects – from unnecessary stress and treatment to financial burdens of the health care system – of some of these tests as they are currently delivered.2-4 Depression screening is not immune to these potential pitfalls, researchers say.5,6
A Test for Everyone
Researchers are revamping standard depression screening tests and deploying those tests in as many different populations as possible to reach the greatest number of people.
School-age children, pregnant and postpartum women, older adults, post-surgery patients and people with chronic medical conditions are among the patient populations identified as special risks for depression and in greatest need of screening.
However, little evidence exists on whether special screening tests are necessary for special populations or if these groups can be reached by “one-size-fits-all” questionnaires.
The Facts:
A 2005 study of depression screening in cancer patients suggests that women are more likely than men to have screening test scores that indicated psychological distress.7
A 2002 evidence review by the U.S. Preventive Services Task Force found “limited evidence” for the accuracy and effectiveness of depression screening tests in children and adolescents.8
A recent study suggests that doctors and nurses who do not formally screen heart attack patients for depression but rely simply on informal observations may underestimate the prevalence of depression among their patients.9
Screening high-risk patients such as those with chronic diseases or unexplained symptoms, postnatal parents and older adults is an effective alternative to screening all primary care patients for depression, according to a 2002 review.10
A recent study of 298 physicians who screened new mothers for postpartum depression found that only 18 percent of the doctors used a screening tool specifically designed to identify postpartum depression.11
Written questionnaires given to mothers at their child’s pediatrician office were more successful than interviews at identifying mothers with depression and led to more referrals to mental health specialists, according to a 2005 study.15
In a 2005 study of veterans, mental health specialists who received patient referrals from primary care physicians agreed with the primary care doctor’s diagnosis of depression for more than two-thirds of the referrals.12
A recent review of survey tools to screen for depression found that the tools vary considerably in how easy the questions are for patients to comprehend.13
Asking patients if they have ever felt “down, depressed or hopeless” or have lost “interest or pleasure in doing things” in the past two weeks may be as effective a screen for depression as longer, more detailed questionnaires, according to the USPSTF’s 2002 report.8
Depression screening surveys that do a good job of identifying depression are also effective at gauging the severity of depression, according to a recent study of screening tools.14
A 2003 Veterans Affairs clinic study found that depression screening questions included in a larger health questionnaire given in a physician’s office were more effective than waiting room surveys or mail surveys for screening the largest number of primary care patients.16
Is Screening Hazardous to Mental Health?
The considerable health burden caused by depression has led the U.S. Preventive Services Task Force and others to recommend expanded screening for depression in primary care doctor’s offices and other settings.
National efforts such as Depression Screening Day, first promoted by Harvard psychiatrist Douglas Jacobs, M.D., support the idea of widespread screening for depression using a simple questionnaire that can be delivered by most health care professionals with little mental health training.
However, a new evidence review by the Cochrane Collaboration finds that these waiting room questionnaires have “minimal impact on the detection, management or outcome of depression by clinicians.”17
The Cochrane reviewers say that the use of routine depression screening in isolation “should be resisted.”
The Cochrane reviewers and other critics of routine screening say that one of the biggest pitfalls of the process is that many patients who show signs of depression on their screening tests do not get proper follow-up care.
For instance, physicians need to interview these patients more thoroughly to determine whether they are truly clinically depressed and would benefit from medication, says James Coyne, professor of psychiatry at the University of Pennsylvania.
“ There is real misery out there related to people’s circumstances in life, but we don’t always have effective therapy or medication to deal with that kind of problem,” Coyne says.
In a health care system where resources are already stretched thin and the average doctor spends only eight to 10 minutes with each patient, “there can quickly become a bottleneck of patients hanging out, waiting for someone to talk to them” about their screening test results, Coyne says.
Doctors or community organizations that provide screenings “have to have the mental health programs in place to do follow-up,” agrees Hazel Moran, director of youth and family outreach at the National Mental Health Association. “If these services are not in place it can really be a problem.”
Widespread screening without adequate follow-up care may be harmful, not just merely unhelpful, Coyne argues. He says patients who screen positive for depression on these tests may be prescribed unnecessary medications and put extra financial and work burdens on the health care system.
Coyne believes that doctors may be “too casual about putting people on meds after a positive screening,” assuming that the widely used drugs are safe and relatively inexpensive. “But the fact is that it can cost a lot and there can be side effects,” he says.
Doctors should focus their efforts on providing adequate treatment for patients already diagnosed with depression if they want to reduce the overall community burden of the disease, Coyne says. “Half the people who use [antidepressant] medicine are going to need attention if they are going to stay on it.”
Expert Sources:
Douglas Jacobs, M.D.
Harvard Medical School
(781) 239-0071
dgjacobs@tiac.net
James Coyne, Ph.D.
University of Pennsylvania
(215) 662-7035
jcoyne@mail.med.upenn.edu
Allen Dietrich, M.D.
Dartmouth Medical School
(603) 650-1766
Allen.J.Dietrich@Dartmouth.edu
Susan Czajkowski, Ph.D.
National Heart, Lung, and Blood Institute (NIH)
(301) 435-0406
susan.czajkowski@nih.hhs.gov
References
1. C.J.L. Murray and A.D. Lopez (eds.) (1996) The global burden of disease and injury series, volume 1: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Harvard University Press on behalf of the World Health Organization and the World Bank: Cambridge, MA:
2. M. Gurevich et al. (2004) Stress response syndromes in women undergoing mammography: a comparison of women with and without a history of breast cancer. Psychosomatic Medicine, 66, 104-112.
3. J.D. Voss and J.M. Schectman (2001) Prostate cancer screening practices and beliefs. Journal of General Internal Medicine, 16, 831-837.
4. A.S. Dunn et al. (2001) Physician-patient discussions of controversial cancer screening tests. American Journal of Preventive Medicine, 20, 130-134.
5. S.C. Palmer and J.C. Coyne (2003) Screening for depression in medical care: pitfalls, alternatives, and revised priorities. Journal of Psychosomatic Research, 54, 279–287.
6. M. Valenstein et al. (2001) The cost–utility of screening for depression in primary care Annals of Internal Medicine, 134, 345– 360.
7. P.B. Jacobsen et al. (2005) Screening for psychologic distress in ambulatory cancer patients. Cancer, 103, 1494-1502.
8. U.S. Preventive Services Task Force. (2002) Screening for depression: recommendations and rationale. Annals of Internal Medicine, 136, 760-764.
9. R.C. Ziegelstein et al. (2005) Can doctors and nurses recognize depression in patients hospitalized with an acute myocardial infarction in the absence of formal screening? Psychosomatic Medicine, 67, 393-397.
10. L.K. Sharp and M.S. Lipsky (2002) Screening for depression across the lifespan: a review of measures for use in primary care settings. American Family Physician, 66, 1001-1008.
11. D.A. Seehusen et al. (2005) Are family physicians appropriately screening for postpartum depression? Journal of the American Board of Family Practitioners, 18, 104-112.
12. M.J. Miller and S. McCrone (2005) Detection of depression in primary care. Military Medicine, 170, 158-163.
13. M. Shumway et al. (2005) Cognitive complexity of self-administered depression measures. Journal of Affective Disorders, 83, 191-198.
14. W.H. Rogers et al. (2005) Depression screening instruments made good severity measures in a cross-sectional analysis. Journal of Clinical Epidemiology, 58, 370-377.
15. A.L. Olson et al. (2005) Two approaches to maternal depression screening during well child visits. Journal of Developmental and Behavioral Pediatrics, 26, 169-176.
16. J.W. Kanter et al. (2003) Comparison of 3 depression screening methods and provider referral in a Veterans Affairs primary care clinic. Primary Care Companion: Journal of Clinical Psychiatry, 5, 245-250.
17. S. Gilbody et al. (2005) Screening and case finding instruments for depression (Review). The Cochrane Database of Systematic Reviews, Issue 4.
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© Copyright 2006, Center for the Advancement of Health
The Center for the Advancement of Health is an independent nonprofit organization that promotes greater recognition of how psychological, social, behavioral, economic and environmental factors influence health and illness. The Center advocates the highest quality research and communicates it to the medical community and the public. The fundamental aim of the Center is to translate into policy and practice the growing body of evidence that can lead to the improvement and maintenance of the health of individuals and the public. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.
For Information Contact:
Lisa Esposito, Editor, Health Behavior News Service
Center for the Advancement of Health
2000 Florida Ave., NW, Suite 210, Washington, DC 20009
p. 202.387.2829 / f. 202.387-2857 press@cfah.org
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Facts of Life: Issue Briefings for Health Reporters
The Center for the Advancement of Health
http://www.cfah.org/factsoflife/index.cfm