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Less than half of adults assessed for depression
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Only 48% of American adults in the general population were assessed for depression, whether through screening or as part of treatment for depression, and despite the U.S. Preventive Services Task Force recommendations encouraging clinicians do so, according to findings recently published in the Journal of the American Board of Family Medicine.
“Making sure that health care encompasses both physical and mental health has always been important to me in both my professional and personal work,” Amanda Borsky, DrPH, MPP, of the Agency for Healthcare Research and Quality, told Healio Family Medicine. “My father started out as a social worker and I remember hearing stories about the heartbreaking effects of what happens when people’s mental health needs are not assessed and treated adequately. Now, as a health services researcher by training, I have tried to examine how best to improve mental and behavioral health services.”
“There is still a lot of work to be done to improve the delivery of mental and behavioral health care, and looking at whether Americans are being properly assessed for depression is one step in this direction,” she continued.
Borsky and colleagues evaluated 1,852 responses from the Agency for Healthcare Research and Quality Medical Expenditure Panel Survey to determine if adults 35 years and older were being assessed for depression by their health care providers. The adults’ age, chronic conditions, education, insurance, perceived health and poverty status, race, sex and where they resided was also noted.
Researchers found that 48.6% (95% CI, 45.5-51.6) of respondents were assessed for depression. Specifically, men were less likely to be assessed vs. women (OR = 0.58; 95% CI, 0.46-0.72), adults older than 75 years of age vs. those 50 to 64 years old (OR = 0.47; 95% CI, 0.32-0.69), adults without recognized depressive symptoms vs. those with recognized symptoms (OR = 0.39; 95% CI, 0.24-0.63) and uninsured vs. private insurance holders (OR = 0.3; 95% CI, 0.18-0.51). In addition, Asians (OR = 0.35; 95% CI, 0.19-0.67), African Americans (OR = 0.42; 95% CI, 0.27-0.67) and Hispanics (OR = 0.47; 95% CI, 0.29-0.75), were less likely to be assessed vs. non-Hispanic whites.
“Somewhat surprisingly, we found some of the populations that were less likely to have been assessed for depression included: adults who believe they are in good health, do not have symptoms of depression and have fewer chronic conditions. This suggests that, contrary to concerns that depression will be overlooked in patients with multiple comorbidities, it is patients without chronic health issues, and who are less likely to go to the doctor, that do not have the opportunity to be assessed,” Borsky said in the interview.
"Prior research has shown that minorities, the elderly, and those with less education and access to health care are more likely to suffer from depression, and our study’s results show they are also less likely to have their depression needs assessed. Much remains to be done to achieve universal screening for depression,” she continued.
Borsky added that the studies that led to the USPSTF recommendations indicated PCPs can improve their patient’s depressive symptoms by screening and then, if appropriate, prescribe treatment such as antidepressants and/or psychotherapy either themselves or by referring the patient to a qualified professional. - by Janel Miller
Disclosure: The authors declare no relevant financial disclosures.
Perspective
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John Kern, MD
Efforts to improve the identification and treatment of depression have been in place for a number of years, as exemplified by the U.S. Preventive Services Task Force recommendations for major depressive disorders in the general adult population. In this paper, Kato, et al revisit the execution in the United States of this recommendation, using data from the Agency for Healthcare Research and Quality's Medical Expenditure Panel Survey from 2014 and 2015, 5 and 6 years after the original recommendation in 2009 for universal depression screening.
They found that about 50% of adults in the U.S. are screened. Their definition of "screened" includes people receiving treatment as well as those just self-reporting screening. Given an incidence of major depressive episode of 6.7%, and a U.S. population of 327 million people, this suggests approximately 10 million Americans with active major depression are not being screened — a significant missed opportunity, as the title of the article points out.
The impact of this missed opportunity reaches beyond the suffering of untreated individuals and their families. The medical cost of individuals with active mental disorder is two to three times that of the general population, and the number of days out of role at the societal level associated with active major depressive disorder is the highest of any physical or mental disorder.
The universal screening process is part of the process that underlies the success of the collaborative care model of depression care in the primary care setting, which has been shown to be effective, as well has highly acceptable to both patients and primary care providers in more than 80 randomized controlled trials since 2002.
Screening can be manageably made part of a routine primary care workflow, as has been shown in the experience of federally qualified health centers, where universal depression screening is an expected practice.
The perceived inability of a PCP to either find adequate psychiatric referral or to respond effectively on site to a positive screen can create a disincentive to screen at all. Implementation of a collaborative care process in the primary care setting can provide an efficient and effective response to positive depression screens.
There is little controversy about the importance of identification and treatment of depression. The problems with access to traditional psychiatric treatment that exist in the U.S. and everywhere are beyond question as well.
I believe that effective primary care-based depression care interventions, exemplified by the collaborative care model, can continue to incentivize medical providers to improve the process of screening, and begin to take advantage of opportunities to identify and treat successfully more people.
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