Screening for Depression

Depression is the most common mental health condition in the general population. 1 in every 10 patients seen in primary care have and meet the criteria for major depression.  Although symptoms of depression are common among primary care patients, two-thirds of the patients present with pain symptoms such as headache, back problems, or chronic pain and because few patients discuss their symptoms directly with their doctor, making detection of depression more difficult.

In the absence of screening, it is estimated that only 50 percent of patients with major depression are identified. Unless directly asked about their mood, patients omit information about depressive symptoms for a variety of reasons, including fear of judgment, belief that depression does not fall under the realm of primary care, belief that depression isn’t a “real” illness, concerns about medical record confidentiality, and concerns about being prescribed antidepressant medication or being referred to a psychiatrist.

Untreated depression is associated with decreased quality of life, increased risk of suicide, and poor physiological outcomes when depression co-occurs with chronic medical conditions. Routine depression screening has been proposed as a way to improve depression care.  It is critical that, once a patient has been diagnosed with depression, the condition be treated into remission.  The importance of achieving remission of depression is twofold:

1) If the patient doesn’t get the depression into remission, damage to the brain and life continues, and

2) if the patient can get it into remission, it looks like the damage to the brain that occurs as a result of depression can be limited or even reversed. Beyond that, getting disorder into sustained remission allows for people to start to get their lives back.

If depression is not treated into remission, it becomes harder to treat and more difficult to get it into remission.  Every time the patient has an episode of depression, theres a high probability that the patient will have to live with depression for the rest of their life.  Compared to non-depressed persons, patients with depression have an increased risk of mortality. Each year lived with depression has been calculated to detract approximately 20% to 40% from a quality adjusted life year. Depression can be devastating to family relationships, friendships, and the ability to work or go to school. Many people still believe that the emotional symptoms caused by depression are “not real,” and that they should be able to shake off the symptoms. Because of these misconceptions, people with depression either may not recognize that they have a treatable condition or may be discouraged from seeking help. For these reasons, early screening and detection carries the potential for substantial benefit.

Effectiveness of Screening

Patients with depression may present with physical, emotional and cognitive symptoms. The challenge with diagnosing depression is that most patients present with symptoms that cannot be seen unless the patients disclose them or their doctor ask; which is why screening is crucial.

Effective treatments for depression include medication and talk therapy. Chronic depression is associated with poorer treatment response. Depression screening improves diagnosis rates, but clinical outcomes are only improved if screening is part of an enhanced care approach in which staff are available to participate in patient management. The effectiveness of screening, in general,  depends upon multiple factors:

  • Whether a condition is sufficiently common in the general population to merit screening
  • Whether there is an asymptomatic or early phase of the condition that can be detected by screening and for which treatment is more effective than if started at a later and more symptomatic time.
  • Whether there is a screening test with acceptable performance characteristics (high sensitivity and relatively high specificity).
  • Whether the screening test is easily administered, inexpensive, and well tolerated by the patient.
  • Whether outcomes of screening result in clinically meaningful benefits that outweigh potential harms to the patient.

In considering screening for depression in primary care, there is good evidence that depression is both a common condition and frequently undetected in the absence of screening, due to the fact that it is considered an invisible illness and its symptoms may be not be apparent. There is evidence that response rates to treatment are better if treatment is initiated earlier in the course of depression. Screening instruments are available that are relatively easy to administer and have been validated for use in primary care, such as a PHQ9. The PHQ-9 is the nine item depression scale of the Patient Health Questionnaire. It can be a powerful tool to assist clinicians with diagnosing depression and monitoring treatment response.  It is scored 0 to 27, with scores ≥ 5 indicating a possible depressive disorder. It also includes a question to assess whether depressive symptoms are impairing function, a key criteria to establish a diagnosis. The PHQ-9 can be used to monitor treatment response and helps in the screening of patients during routine visits to then further evaluate those who score above a specified threshold.

Here at Bandera Family Health Care, our specialty is the patient; and as such, we are taking preventative steps towards early detection and treatment of depression with all of our patients. For more information or to schedule an appointment, visit one of our facilities or call 210-695-1900.