Franklin James Cook

Primary Care Depression Screening Would Save Lives

In Mental Illness, Opinion, Prevention on February 8, 2010 at 2:46 pm

By Franklin Cook, SPNAC Editor

In a Huffington Post item today, titled “Let’s Not Get Too Depressed about Depression,” Dr. Lloyd Sederer, a psychiatrist and public health advocate, argues for a mandate that would do as much to prevent suicide as any other single action might accomplish:

One hundred percent of primary care practices .. should be screening for depression and using standardized treatment guidelines.

Dr. Sederer has a fairly straightforward plan to accomplish the nationwide screening he recommends.

Mental health has been losing in the competition for fair time and proper management without a numerical measure of a disease. How about starting with its poster child disease — depression — to remedy that?

The good news is that there is a simple, nine-item questionnaire called the PHQ-9 that someone can fill out in the waiting room, before seeing the doctor or nurse, that provides a highly reliable number that tells the doctor the likelihood (almost 90 percent sensitive) that you have a depression.

Of course, screening every visitor to a doctor’s office and then further assessing and effectively treating those who have depressive illness is a vast undertaking that would not be simple nor easy nor without cost. [Editor’s note: Please see Dr. DeQuincy Lezine’s comprehensive and insightful comment on this point.]

But we know that about 33,000 people a year die by suicide in the United States and that about half of them have a mood disorder (which implicates some type of depression in 16,000 suicides annually). So if depression is mental health’s “poster child disease” and it plays a role in 16,000 deaths every year, might not universal screening for depression in primary care be, as Dr. Sederer argues, a good starting place for prevention?

There are several models already available to move such an initiative forward. Here are two examples:

(1) The Three Component Model developed by the Macarthur Initiative on Depression and Primary Care is “a systematic approach” involving the “primary care clinician and practice, care management, and collaborating mental health specialist.”

The three components include elements shown to improve depression outcomes in recent randomized controlled trials. Telephone support for the depressed patient from a care manager is one central element as is periodic quantitative feedback about the patient’s response to treatment from the care manager to the clinician. The feedback is provided through depression severity scores based on PHQ-9. Another element is closer relationships between the primary care clinician and mental health specialists …

(2) The Suicide Prevention Toolkit for Rural Primary Care is an Internet-based resource containing “information and tools to implement state-of-the-art suicide prevention practices and overcome the significant hurdles this life-saving work faces in primary care practices.”

The Toolkit offers the support necessary to establish the primary care provider as one member of a team, fully equipped to reduce suicide risk among their patients. For instance, the tools will help you engage your patients and those around them in managing their own suicide risk. You’ll find tools for developing partnerships with mental health providers — regardless of how far away they may be — and a guide to developing telemental health services, a promising solution for many rural areas. There are also posters for display in your office, schools, and churches, and wallet cards listing warning signs for suicide and the number of the national crisis line.

[The abridged URL for this post is http://tinyurl.com/DepressionScreening .]

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  1. It is definitely feasible for a brief screening, like the PHQ-9, to be completed at a primary care clinic. Getting 100% of primary care clinics to adopt a depression screening would be a significant accomplishment!

    However… it seems important to follow through on the logic that would enable such an intervention to actually save lives.

    1. The depression screening must be valid and reliable (PHQ-9 qualifies here).
    2. The physician, assistant, or nurse must read/review the results.
    3. The health practioner must understand the results.
    4. The practioner must select an appropriate referral.
    5. The practioner must convince the person to follow-through on the referral.
    6. The person must actually go to the referral (once scheduled).
    7. The mental health practioner must provide effective treatment.
    8. The person must respond to the treatment, or be willing to try an alternative.
    9. The symptoms of depression that resolve must have been the primary cause of the suicidal urge.

    If the process breaks down at any of those points, then the result is, at best, not optimal. For example, if the primary care doctor is in a rural location with no mental health facilities. Or, as in many cases, if the person receives a referral but does not follow-through.

    One may argue that the primary care clinic could provide the care themselves. However, that requires at least some specialty training. Otherwise, the physician may mis-diagnose secondary depression, bipolar disorder, depression with psychotic features, schizoaffective disorder, or other variants of depression as being a “regular” depressive episode – and the results of mistreatment may actually make the person get worse.

    Of course, this is somewhat playing devil’s advocate and looking at the potential downside to such an approach.

    It would be a magnificent accomplishment if we could get all primary care clinics to adopt depression screening. We just can’t stop there…

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