Although psychiatrists and other mental health professionals are skilled at identifying and treating depression, people often seek treatment for depression from their primary care physicians (PCPs). Unfortunately many who visit their PCP for mental health issues go undiagnosed.
However, research suggests that guideline-based depression screening and tracking tools may improve early diagnosis and treatment for these patients, and can successfully be implemented in primary care settings.
The U.S. Preventive Services Task Force (USPSTF) currently recommends routine screening for depression when staff-assisted depression care supports are in place, which includes coordination, case management, and mental health treatment.
“Depression screening in primary care began in the 1980s and 90s, when we first had antidepressants that could be used in a primary care setting. Early studies did not support screening, but that began to change when practice guidelines were put in place,” said study author Larry Culpepper, MD, a professor of family medicine at Boston University School of Medicine.1
Depression Screening Tools
The most commonly used screening tool for depression is the Patient Health Questionnaire, PHQ-9. The nine-question document asks patients if they have been bothered by certain problems in the two weeks prior, and if so, how often.
“PHQ-9 is a good, safe, and effective screening tool. With the first two questions, you can eliminate depression in about half of your patients. If either of those questions gets a positive response, you go to the next seven,” explained Culpepper.
Simple screening questions perform as well as more complex screens, according to the USPSTF. If findings on a screening tool like PHQ-9 are positive, a full diagnostic interview should follow.
In addition, PCPs should be especially cognizant of patients at increased risk for depression. These include patients with other psychiatric disorders, a history substance abuse, a family history of depression, or chronic medical diseases, as well as those who are unemployed or of lower socioeconomic status.
“We know that as income goes down, depression goes up. Below middle income, depression rates are about 15%,” Culpepper said. “The Affordable Care Act and the Mental Health Parity Act are bringing many previously uncared for patients into primary care. Depression is a multiplier for other chronic conditions, increasing costs and lousy outcomes.”
The optimal frequency for depression screening is not clear, but thanks to new legislation many PCPs are making regular screening part of their routine.
“In Massachusetts, only 2% of our population is uninsured, and some form of screening is standard care. In states that have resisted expanding Medicaid, there may be no incentive for doctors to screen, and no access to care for people who need to be screened most,” said Culpepper.
Treatment and Tracking Tools
Although guidelines for treating and tracking depression are available, there also needs to be strong support staff to get good outcomes in primary care.
“You need a case manager to coordinate services, collaboration with mental health services (including psychiatry), and a guideline for care that you are comfortable using. My favorite is the guideline provided by the Institute for Clinical Systems Improvement [ICSI],” said Culpepper.
The ICIS guideline recommends screening along with using the DSM-5 criteria for diagnosing depression. It includes information on assessing for suicide risk, substance abuse, and secondary causes of depression.
Treatment may include psychotherapy, pharmacotherapy, or integrative medicine. Tracking includes evaluation of response and treatment.
Other Mental Health Disorders
“Screening for other mental health disorders usually starts with depression – 5% to 25% of patients who screen positive for depression will have bipolar depression. Up to 50% of patients with depression may also have anxiety disorder,” said Culpepper. “Substance abuse and [post–traumatic stress disorder] are also common. Researchers are working on simple screening tools that will screen for all these disorders.”
The Substance Abuse and Mental Health Services Administration provides resource links for mental health screening tools, including tools to identify depression, substance abuse, bipolar disorder, suicide risk, anxiety disorder, and trauma.
The American Psychiatric Association also provides treatment guidelines for substance abuse, bipolar disorder, PTSD, and other mental health disorders.
“The potential for guideline-based screening and treatment in primary care is evolving. You need the right support, the right financial incentives, and the right patient population to make it work,” said Culpepper. “We have only written the first chapter for mental health screening, treatment, and tracking in primary care. The rest of the book is a work in progress.”
Chris Iliades, MD, is a full-time freelance writer based in Cape Cod, Massachusetts.
This article was medically reviewed by Pat F. Bass III, MD, MS, MPH.