Depression Screening Yields Benefits Despite Inadequate Tools

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The question of routinely screening adult patients in primary or specialist care for depression remains fraught.
The question of routinely screening adult patients in primary or specialist care for depression remains fraught.

To screen or not to screen: the question of routinely screening adult patients in primary or specialist care for depression remains fraught, despite official recommendations from the US Preventive Services Task Force. The task force recommends screening in the general adult population based on grade B evidence that harms of screening are few to none and that net benefit favors screening.

Yet research earlier this year determined that less than 5% of all outpatient visits for adults have screens. As pointed out in a new study looking at the effects of screening on mood disorder diagnosis and treatment, critics of screening argue against its cost-effectiveness because of high false-positive rates. Depression screening advocates counter that depression detection and treatment remain low despite high prevalence. The study itself found at least 1 significant reduction of harm from screening: fewer unneeded prescriptions.

"While depression screening is still controversial due to its high false-positive rate, depression screening seems still useful to prevent doctors from prescribing potentially inappropriate antidepressants in ambulatory care visits made by older adults," lead author Greg Rhee, PhD, MSW, told Psychiatry Advisor. Dr Rhee is an adjunct assistant professor at the University of Minnesota College of Pharmacy in Minneapolis.

His study investigated how depression screening, conducted in adults age 65 and older in outpatient primary care, affected mood disorder diagnoses, overall antidepressant prescriptions, and potentially inappropriate antidepressant prescriptions.

"[C]onsidering that the rate of antidepressant prescriptions has dramatically increased in the past decade, there are increasing concerns about potentially inappropriate antidepressant use," the authors wrote. They pointed to a study last year estimating that 30.9% of older adults receive possibly inappropriate medications, increasing healthcare costs, hospitalization rates, adverse effects, and mortality.

Screening Reduces Inappropriate Antidepressant Prescriptions

Researchers in this study relied on data from the 2010-2012 National Ambulatory Medical Care Survey from the Centers for Disease Control and Prevention. The analysis accounted for patient characteristics that included age, sex, race/ethnicity, census region, primary source of payment, reason for visit, number of visits within the previous year, number of chronic conditions, and number of medications and use of nonpharmacologic psychiatric services. The analysis also included adjustments for the type of medical practice, population density of the area, and time the patient spent with the physician.

Among 9313 adults, 209, or 2.2%, were screened. All clinical characteristics differed significantly between screened and unscreened populations. Adults with at least 2 chronic conditions or taking at least 3 medications, for example, were more likely to be screened. In addition, "health education related to injury prevention and stress management [was] more commonly provided in screened visits than those in non-screen visits," the authors reported.

Unsurprisingly, screened adults were about 5 times more likely to receive both a mood disorder diagnosis and antidepressant prescription than those not screened. In more than a quarter (26.3%) of all visits with screens, patients received either a mood disorder diagnosis or an antidepressants prescription, which is double the rate seen in visits without screening.

However, after accounting for all confounding variables, an association between depression screening and prescriptions of antidepressants and/or mood disorder diagnoses lost significance. Depression screening did, in contrast, show a negative association with antidepressant prescriptions that were potentially inappropriate.

"This is good news, as depressing screening is a tool to reduce risks of adverse drug events -- death, hospitalization, and morbidity -- for older adults," Dr. Rhee told Psychiatry Advisor. "There is a list of potentially inappropriate antidepressants where risks outweigh potential benefits."

The finding of no link (after adjustment) between screening and mood disorder diagnosis or antidepressant prescriptions differed from results of past randomized controlled trials, however. The authors suggested that tools in randomized controlled trials are used more systematically and represent efficacy only under ideal conditions.

"In the real world, no specific depression screening tool has been specifically recommended for this population of interest," they wrote. "If primary care physicians and other healthcare providers are not well-informed about depression screening tools and their utilities, they may not likely diagnose and treat depression and other mood disorders."

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