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Facts
of Life
Facts of Life:
Issue Briefings for Health Reporters
Vol. 10, No. 12
December 2005
Editor's
note: This Facts of Life was amended on 1/10/2006.
Screening for
Depression
The Issue
The Facts
Is Screening Hazardous to Mental Health?
Expert Sources
References
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:
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.
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
http://www.cfah.org
© Copyright 2005, Center
for the Advancement of Health
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