A new and expanded recommendation for depression screening has been issued by the U.S. Preventive Services Task Force (USPSTF), an independent expert panel that issues preventive medicine recommendations.
The USPSTF first recommended regular depression screening for adults in 2002. In a July update, they recommend that physicians regularly screen patients for depression by asking two questions that provide a quick evaluation of a person’s mood:
- Over the past two weeks, have you felt down, depressed or hopeless?
- Over the past two weeks, have you felt little interest or pleasure in doing things?
Simple screening questions may perform as well as instruments that are more complex, according to the National Institutes of Health. They also include expanded options for screening tools for clinicians such as the Patient Health Questionnaire (PHQ-9) download here. PHQ-9 is a list of 10 questions that patients can complete quickly while waiting to see the doctor. It asks about energy levels, sleep, appetite, interest in activities and ability to concentrate.
The USPSTF emphasized that screening tools like PHQ-9 cannot diagnose depression, but a high score means the patient needs a follow-up or referral to a mental health professional. They also cautioned that clinicians who perform depression screening should follow up by referring the patient to a mental health professional for a full standard diagnostic interview.
The USPSTF’s Grade B recommendation is to “screen when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment and follow-up.” Citing limited evidence, they suggest that depression screening in the absence of staff-assisted depression treatment does not improve depression outcomes. Their Grade C recommendation: “Do not routinely screen when staff-assisted depression care supports are not in place.”
Although the USPSTF urged clinicians not to try to diagnose and treat depression themselves, currently, primary care physicians treat more than half of patients with mental disorders. Non-psychiatrists prescribe about 70 percent of antidepressants in the United States.
Why screen for depression?
- Fully half of people with depression have not been diagnosed. About 7 percent of American adults currently suffer with depression. The average age of onset is 32 years old. Additionally, 3.3% of 13 to 18 year olds have experienced a seriously debilitating depressive disorder.
- Only about 35 percent of people with severe depression seek professional help for their depression. However, the majority of people with depression see a physician regularly and describe symptoms that could be diagnosed as depression.
- Depression itself can cause poor health and is linked to several chronic conditions. Mood disorders such as depression are the third most common cause of hospitalization for adults 18-45, according to the National Association on Mental Illness (NAMI).
- Depression lowers productivity because of missed work and not functioning as fully or productively as possible.
- The life span of seriously mentally ill people is 25 years shorter, on average.
- Mental illness is the chief cause of disability in the United States.
- Unmet mental health needs can ultimately be very expensive. About half of chronic mental health conditions start by age 14. In most cases, many years pass before care is provided and, compared to early intervention, delayed care is more expensive. Depression costs the United States an estimated $210 billion annually in direct and indirect costs. Only 40 percent of that amount is associated with depression itself. For every dollar spent treating depression, an additional $1.90 is spent in reduced workplace productivity and economic costs associated with suicide; another $4.70 is spent on direct and indirect costs of related illness, according to the Journal of Clinical Psychiatry.
Persons at risk for depression remain at risk throughout their lifetime. Those most at risk have:
- Other psychiatric disorders
- Substance misuse
- Family history of depression
- Chronic disease (s)
- Low income or are unemployed
- Female gender – women are 70 percent more likely than men to experience depression during their lifetimeThe USPSTF did not indicate when to screen or what the best interval is for screening. They suggested that recurrent screening would be productive for patients with a history of depression, sleep problems, substance abuse, chronic pain or other psychological conditions. For older patients, significant depressive symptoms are associated with common life events such as illness or bereavement, as well as when there is cognitive decline or institutional placement in a nursing home or other inpatient setting.
Scarcity of mental health resources
Eleven million Americans need mental health care that is not available to them. There is a scarcity of mental health professionals, especially for the Medicaid-eligible population and particularly in rural areas. However, it’s also a problem in major cities, regardless of having insurance or the ability to pay. More than 20 percent of psychiatrists are not accepting new patients. Wait times often exceed one month. Two-thirds of primary care physicians say they cannot get outpatient mental health services for their patients.
Another obstacle to finding mental health care is the fact that psychiatrists are reimbursed less than other doctors. Insurance companies are more likely to pay for medication and far less likely to pay for spending time counseling patients.
There is also a scarcity of treatment programs for the intermediate, outpatient level of care. Supportive programs, such as transitional and supportive housing, home therapy visits and case management for daily living needs, can allow the patient to live successfully in the community.