by Brett D Thombs, Roy C ZiegelsteinBritish Medical Journal. 2014 348:g1253.Major depression is present in 5-10% of patients in primary care, including 10-20% of patients with chronic medical conditions. Based on the prevalence and burden of depression, the availability of screening tools, and access to potentially effective treatments, routine depression screening has been proposed as a way to improve depression care. Depression screening involves the use of self administered questionnaires or small sets of questions to identify patients who may have depression but who are not already diagnosed or being treated for depression. Clinical practice guidelines do not agree on whether health professionals should screen for depression in primary care. The US Preventive Services Task Force [USPSTF] recommends screening for depression when enhanced, staff assisted, depression care programmes are in place to ensure accurate diagnosis and effective treatment and follow-up. The Canadian Task Force on Preventive Health Care previously endorsed a similar recommendation, but in 2013 recommended against depression screening in primary care, citing a lack of evidence of benefit from randomised controlled trials and concern that a high proportion of positive screens would be false positives.
In the UK, the National Screening Committee has determined that there is no evidence of benefit from depression screening to justify costs and potential harms and has recommended against it. A 2010 guideline from the National Institute for Health and Care Excellence [NICE] did not recommend routine depression screening, but suggested that clinicians be alert to possible depression, particularly among patients with a history of depression or with a chronic medical condition… In contrast to these recommendations, between 2006 and 2013, the UK Quality and Outcomes Framework [QOF] financially rewarded routine depression screening of patients with coronary heart disease and diabetes in primary care. By 2007, 90% of eligible Scottish primary care patients had been screened, but outcomes were disappointing: 976 patients had to be screened for each new diagnosis of depression, and 687 for each new antidepressant prescription. The 2013-14 QOF no longer included depression screening as a quality indicator.
Thus, screening for depression is sometimes encouraged in primary care guidelines and is often encouraged via other mechanisms, such as expert opinion articles in the medical literature. It is not clear, however, that screening would benefit patients…
What is the evidence of uncertainty? A depression screening programme can be successful only if patients not already known to have depression agree to be screened, if a substantial number of new cases are identified with relatively few false positive screens, and if newly identified patients engage in treatment with successful outcomes. An assessment of the effect of a screening programme on depression outcomes must separate the effect of screening from the effect of providing additional depression treatment resources not otherwise available, such as staffing for collaborative depression care. Thus, randomised controlled trials of depression screening must fulfil at least three key criteria: [1] determining eligibility and randomising patients before screening; [2] excluding patients already known to have depression or already being treated for depression; and [3] providing similar depression care options to patients in both trial arms, whether they are identified as depressed by screening or via other methods, such as self report or unaided clinician diagnosis.
We searched Embase, PubMed, PsycINFO, Scopus, and the Cochrane Library for systematic reviews on the effect of depression screening on depression outcomes and for randomised controlled trials conducted in primary care settings that fulfilled the three criteria we have described for tests of depression screening. This search was partly based on that for our own systematic review.
We identified three systematic reviews. A systematic review done in conjunction with the recent Canadian guideline did not identify any randomised controlled trials of depression screening. A 2008 Cochrane systematic review, on the other hand, assessed five randomised controlled trials and reported that depression screening did not reduce depressive symptoms [standardised mean difference −0.02 (95% confidence interval −0.25 to 0.20)]. In contrast to this, a systematic review done in conjunction with the 2009 USPSTF depression screening guideline included nine randomised controlled trials and concluded that depression screening benefitted patients when done in the context of staff assisted collaborative care but not in the context of usual care without these services…
Overall, no trials in the Cochrane review or USPSTF review fulfilled all three criteria for a test of depression screening…
We did not identify any randomised controlled trial that tested whether screening with collaborative depression care would be more effective than collaborative care without screening…
We did not find any studies that reported the degree to which administering depression symptom questionnaires improved diagnostic accuracy for depression among patients suspected by healthcare providers of having depression.
Is ongoing research likely to provide relevant evidence? We searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform for ongoing trials intended to evaluate the effects of depression screening, but did not find any studies that fulfilled the criteria for tests of depression screening…
What should we do in the light of the uncertainty? The absence of evidence that routine screening of all primary care patients or even screening of only high risk patients improves depression outcomes does not take away from the importance of depression as a condition that negatively affects quality of life and may respond to treatment. It only means that there is insufficient evidence to recommend screening as a strategy to identify the condition…
At the risk of being preachy, being attuned to the emotional state of a patient is no different than noticing that they’re covered with a rash, or jaundiced, or gasping for breath, or have a knife sticking out of the middle of their forehead. To my mind, the results of a depression screening test are just something else to put on the ubiquitous computer screens that medical personnel look at rather than their patients [that’s a preachy part]. They finally took the computer out of my office because I didn’t use it, even for prescriptions [even though I’m something of a computer guy]. The point is that no matter what the tenets of modern psychiatry or medicine teach, emotional discomfort is best evaluated in inter·subjective space. If we’re missing a lot of emotional illness, it says something about us, not our tools. We’re not properly inhabiting the offices where we meet our patients [preaching again].
I fully agree with your statement “If we’re missing a lot of emotional illness, it says something about us, not our tools.” I don’t think it sounds preachy at all.
When someone is truly Depressed, it’s quite obvious without requiring that much effort from the clinician, and it’s very different from just being sad. That doctors may not recognize true depression tells me they are under too much pressure to spend less time with patients and more time looking at computer screens.
And if the purpose of these screening tools is so that primary doctors won’t have to spend as much time actually talking to patients, then I think it’s pretty tragic. It’s akin to having some kind of lab test that doctors reflexively order instead of taking a good history, which actually reveals the diagnosis a good majority of the time.
Check out this TEDx talk by Dr. Leana Wen, who is trying to educate patients about the importance of getting their doctors to listen to them, instead of just running around ordering tests.
Dr. Wen is quite good, but I felt sad listening to her talk. When you get older, you become the one that goes to the doctor, and what she says is not a caricature but the truth. I had an EKG, a stress test, an echocardiogram, and a chest CAT SCAN before the first person listened with a stethoscope. They were all normal and had little to do with why I went. I think that experience has something to do with why I wrote this post…
This post is right on, doctors need to go back to doctoring, and move away from assembly line work. I have also been run through the gauntlet only to find nothing wrong other than my insurance would pay for a repeat.
My fear is that someday I will walk into a doctor’s office and be presented with a touch screen to check in and then fill in questionnaires about my health that will become part of an EMR that will tag me forever with something that generates income for the practice, but does nothing for my health.
Steve Lucas
It was with relief and heartbreak that I read your writing today. I rarely comment here because I understand it is not about subjective experience on this blog, And, that is fine. However, it is the way I relate to the world and it does get me to where I need to be.
To explain I’ll start with the heartbreaking part. You wrote “But fortune shone through the clouds…” You may think it was fortune that led you to these studies, yet I have known at least about the Canadian Study for some time. It wasn’t fortune, except that someone decided to do the studies, but rather because I went looking for the studies in the first place.
Ultimately, I think you also went looking for them too and that is the refreshing part. Perhaps you are seeing that experiences, rather than being an enemy that makes you stick to faulty conclusions, can be the very thing that leads you to feel in “your gut” that something is wrong. And, when that happens you start to question things. But, it doesn’t end there. Questioning things and “all authority” is actually quite harmful. No, what gets you where you need to be is when your questions prompt you to seek the truth.
I’ll give you a tad bit of my philosophy here and then go. The drug trial lies, cover-ups and conclusions are wrong because of the harm they cause. But, they are also wrong on a fundamental level, simply because they are not the truth. I wouldn’t need to see any of the collateral damage to know this.
The whole world runs after love, and why not, it is a beautiful thing. I, on the other hand, have always pursued truth. I find it generally comes at a high cost and it is usually not pleasant. But, when you sit with the truth for awhile you find that love is always there with it…and I have absolutely no idea how that works. It makes zero sense.
Anyway, I hope you continue to search for the truth and share what you learn here.
Arby
Personally, I find multiple-choice questionnaires about my emotional state to be intrusive, insulting, and belittling.
me too…
DSM-5 spawns new indications for antidepressant treatment http://mag.newsweek.com/2014/02/07/pill-ill.html
“….Cymbalta, which is prescribed for major depressive disorder and generalized anxiety disorder, earned its blockbuster title almost five times over in 2012, bringing in nearly $5 billion to developer Eli Lilly. Lilly’s patent on Cymbalta expired in December 2013, and the developer should soon begin to lose revenue to generics.
But thanks to the changes made by the APA to the DSM, the money will likely keep rolling in.
In past editions of the DSM, a so-called bereavement exclusion from major depressive disorder recommended that actively grieving individuals not be diagnosed with depression. In the DSM-5, this recommendation has been erased, giving rise to “bereavement-related depression” – a subset of major depressive disorder that is treatable by all the standard methods (and drugs) that ease depression. But if you didn’t need to treat the loss of a loved one with medication in 2000, is it really necessary in 2014?
Companies like Lilly certainly want it to be – and they may just get their way. Public records regarding clinical investigations show that Lilly’s expired patent on Cymbalta will in all likelihood be renewed, as it is currently the focus of a new trial for the pharmacological treatment of bereavement-related depression. In other words, it’s going to end up being the drug of choice for treating what was merely called “grief” at the time of Lilly’s original patent filing…..”
Totally agree Alto and Mickey about the AD questionnaires. If a doctor gave me one, I would refuse to participate.
After feeling like I was given a similar type one several years ago by a neuropsychologist under false pretenses which led to what I felt were big time BS comments, I vowed that would never happen to me again.
So when a situation occurred that led to an attempt to give me this test again when I thought I was going to be tested for something else, I refused.
Alto-
Thanks for the link to that Newsweek article and the Krinsky study. That is a big deal and I may write more. To get a patent extension for Cymbalta for grief induced depression is wrong on so many levels.
Dr. Steingard,
Isn’t that still under the MDD umbrella? It wouldn’t qualify for patent extension would it?
Thanks, Sandy. Commercial exploitation of the DSM-5’s redefinition of grief demands a big public outcry.
Annonymous-
Mickey is writing about it now. According to this article and the study, it would extend the patent. As I noted, this makes no sense. It is absurd. The point of eliminating the exclusion was that that they argued there was no distinction based on the cause of the symptoms and, therefore, treatments would be the same.They were concerned about people not getting adequate treatment. (Mind you, this is not MY argument but the APA’s.) If they are successful, this will confirm all of the critics worries about eliminating the exclusion. No doubt, DTC advertising will follow. It will be as scurrilous as the notion of Cymbalta treating the “pain of depression.” Ironically, this was a drug initially developed for incontinence. David Healy has written about this. It was packaged and marketed to treat pain and depression because they found out there was an unmet need.
A couple of months ago my wife called me very distressed after told by her parents that they both have Depression. They were vacationing in Florida in my house for 3 months. They look wonderful besides the normal aging problem and some chronic diseases treated chronically with medications to lower “numbers” that their Doctors in Florida are obsessively treating (you know cholesterol 215 with no hx of cardiac disease, Osteopenia, marginal HTN, Back pain…The Doctor wanted to start antidepressants on both immediately.
They both became quite depressed after being told about the news based on a test done by the office manager. I called the MD to discuss these findings and identified myself as a psychiatrist. He was very apologetic and not happy about the new mandate to evaluate the Medicare patients and initiate treatment. I was enraged and strongly advised him to stop doing it or to go for training in psychiatry if he likes to prescribe psychotropics.
Montesdeoca,
Great response to the doctor!
“not happy about the new mandate to evaluate the Medicare patients and initiate treatment”
Mandate? Yikes!