The American College of Preventive Medicine (ACPM) maintains that primary care providers should screen all adults for depression and that all primary care providers should have systems in place, either within the primary care setting itself or through collaborations with mental health professionals, to ensure the accurate diagnosis and treatment of this condition. The earliest and best opportunities to identify depression are in the clinics of primary care providers. Thus, the ACPM supports the recommendations of the US Preventive Services Task Force (USPSTF), and further suggests that all primary care practices should have such systems of care in place.
Why a position statement? The rationale
Primary care physicians have already been urged by the USPSTF and other authorities to consider screening adults for depression an essential aspect of care.1-5 So why is the ACPM issuing a new position statement on the subject? Because, the College believes, controversy over how to apply this mandate in the primary care setting is ongoing. Primary care providers—whether they practice family medicine, internal medicine, obstetrics/gynecology, or are in general practice—need to know what role they should play in screening adults for depression and ensuring adequate diagnosis and treatment.
The USPSTF recommendation
In May 2002, the USPSTF made a category B recommendation (high certainty of moderate net benefit) that adults should be screened for depression in “clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up” of depression1 (emphasis added). The less-than-clear aspect of this recommendation is italicized: Just what constitutes the “system” that primary care providers, the first and often the only point of contact adults have with the health care system, are told to have “in place”? And how can they go about providing such systems? That’s what the College has set out to elucidate.
The toll depression takes
Depression is a potentially life-threatening disorder that affects up to 6.7% of the population 18 years of age and older, or approximately 14.8 million Americans, in a given year.6 Many people younger than age 18 are also affected. The extensive STAR*D (Sequenced Treatment Alternatives to Relieve Depression) study of outpatients with depression found that nearly 40% of respondents had their first depressive episode before the age of 18.7,8
The ripple effects
Depression is the leading cause of disability in the United States for individuals between the ages of 15 and 44 years.9 But the burden of this illness is not borne only by those diagnosed with the disorder; depression has a serious impact on the patient’s family, caregivers, colleagues, and society at large.
Medical costs. Depression contributes to a higher morbidity and mortality of other medical conditions. For example, people who have a myocardial infarction (MI) with comorbid depression have worse outcomes than those having an MI without depression. However, if the depressive episode is treated successfully, medical and surgical outcomes improve.10 Furthermore, studies documenting increased cardiovascular morbidity and mortality in patients with depressive symptoms or major depression suggest that depression is an independent risk factor in the pathophysiologic progression of cardiovascular disease, not just a secondary emotional response to the illness.11
Economic costs. Depression is a leading contributor to lost productivity, not only from worker absenteeism, but also from what is known as “presenteeism”—being physically at work but not fully engaged. Thus, depression may be a leading cause of poor organizational performance. Further, employees diagnosed with depression have a higher incidence and longer duration of both work-related and nonwork-related disabilities.
Screening: Easier than you think
Screening instruments with acceptable sensitivity and specificity are available. These brief, paper-and-pencil instruments can be quickly completed by patients in your waiting room. Some of the most commonly used self-administered measures are the Beck Depression Inventory (BDI), the Center for Epidemiologic Studies Depression Scale, Revised (CES-DR), the Zung Self-Rating Depression Scale, and the Patient Health Questionnaire (PHQ-9).12-16 These tools take approximately 5 to 10 minutes for patients to complete and do not interfere with clinical practice. You can choose the tests that are appropriate for screening your patient population, and you can also use the same instruments for ongoing monitoring of patients receiving treatment for depression.
Two questions. For an even briefer screen, ask your patients these 2 questions:
- Over the past month, have you felt down, depressed, or hopeless?
- Over the past month, have you felt little interest or pleasure in doing things?
Patients who answer Yes may need more in-depth screening and clinical assessment.