Screening for depression in hospitalized medical patients
Depression among hospitalized patients is often unrecognized, undiagnosed, and therefore untreated. Little is known about the feasibility of screening for depression during hospitalization, or whether depression is associated with poorer outcomes, longer hospital stays, and higher readmission rates. We searched PubMed and PsycINFO for published, peer-reviewed articles in English (1990-2016) using search terms designed to capture studies that tested the performance of depression screening tools in inpatient settings and studies that examined associations between depression detected during hospitalization and clinical or utilization outcomes. Two investigators reviewed each full-text article and extracted data. The prevalence of depression ranged from 5% to 60%, with a median of 33%, among hospitalized patients. Several screening tools identified showed high sensitivity and specificity, even when self-administered by patients or when abbreviated versions were administered by individuals without formal training. With regard to outcomes, studies from several individual hospitals found depression to be associated with poorer functional outcomes, worse physical health, and returns to the hospital after discharge. These findings suggest that depression screening may be feasible in the inpatient setting, and that more research is warranted to determine whether screening for and treating depression during hospitalization can improve patient outcomes. Journal of Hospital Medicine 2017;12:118-125. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
In our current healthcare system, pressure to provide cost- and time-efficient care is immense. Inpatient care often focuses on assessing the patient’s presenting illness or injury and treating that condition in a manner that gets the patient on their feet and out of the hospital quickly. Because depression is not an indication for hospitalization so long as active suicidality is absent, inpatient physicians may view it as a problem best managed in the outpatient setting. Yet both psychosocial and physical factors associated with depression put patients at risk for rehospitalization.1 Furthermore, hospitalization represents an unrecognized opportunity to optimize both mental and physical health outcomes.2
Indeed, poor physical and mental health often occur together. Depressed inpatients have poorer outcomes, increased length of stay, and greater vulnerability to hospital readmission.3,4 Among elderly hospitalized patients, depression is particularly common, especially in those with poor physical health, alcoholism,5 hip fracture, and stroke.6 Yet little is known about how often depression goes unrecognized, undiagnosed, and, therefore, untreated.
The US Preventive Services Task Force (USPSTF) recommends screening for depression in the general adult population, including pregnant and postpartum women, and further suggests that screening should be implemented “with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.”2 The USPSTF guidelines do not distinguish between inpatient and outpatient settings. However, the preponderance of evidence for screening comes from outpatient care settings, and little is known about screening among inpatient populations.7
This study had 2 objectives. First, we sought to examine the performance of depression screening tools in inpatient settings. If depression screening were to become routine in hospital settings, screening tools would need to be sensitive and specific as well as brief and suitable for self-administration by patients or for administration by nurses, resident physicians, or hospitalists. It is also important to consider administration by mental health professionals, who may be best trained to administer such tests. We, therefore, examined 3 types of studies: (1) studies that tested a self-administered screening instrument, (2) studies that tested screening by individuals without formal training, and (3) studies that compared screening tools administered by mental health professionals. Second, we sought to describe associations between depression and clinical or utilization outcomes among hospitalized patients.
METHODS
We adhered to recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement,8,9 including designing the analysis before performing the review. However, we did not post a protocol in an online registry, formally assess study quality, or perform a meta-analysis.
Data Sources and Searches
We searched PsycINFO and PubMed databases for articles published between 1990 and 2016 (as of July 31, 2016). In PubMed, 2 search term strings were used to capture studies of depression screening tools in inpatient settings. The first used the advanced search option to exclude studies related to primary care settings or children and adolescents, and the second used MeSH terms to ensure that a wide variety of studies were included. Specific search terms are included in the Appendix. A similar search was conducted in the PsycINFO database and these search terms are also included in the Appendix.
