Few patients screened for alcohol use also screened for depression

Less than 3% of all patients screened for hazardous alcohol use were also administered the Patient Health Questionnaire-9 within 30 days of their first alcohol-use screening, according to findings recently published in the Journal of the American Board of Family Medicine.

Perspective from Mark H. Duncan, MD

Significant depressive episodes and hazardous alcohol use are commonly witnessed by primary care physicians, Matthew E. Hirschtritt, MD, MPH, a clinical fellow at the department of psychiatry at the Weill Institute for Neurosciences at the University of California San Francisco, and colleagues wrote.

“Despite the strong association between depressive symptoms and hazardous alcohol use, there are no data of which we are aware regarding rates of depression screening by alcohol use severity and demographic characteristics in primary care settings. This information would inform systematic efforts to detect and design tailored treatments for patients with significant depressive symptoms and hazardous alcohol use,” they added.

Researchers investigated the rate of depression screening by alcohol use severity among primary care patients screened for hazardous alcohol use. Among those assessed for depression, the researchers examined patterns of significant depressive symptoms.

Hirschtritt and colleagues found that among the 2,894,906 patients screened for alcohol use, only 2.4% also completed a Patient Health Questionnaire-9. These 68,686 patients were more likely to be younger, female, white, on Medicaid, and have a lower Charlson comorbidity score and nondepressive psychiatric diagnosis.

Additionally, nonwhite patients with higher Charlson comorbidity scores were more likely to endorse significant depressive symptoms and those considered moderate drinkers or abstainers were less likely than hazardous drinkers to complete the questionnaire or have significant depressive symptoms (score of 10 or greater).

“Our findings have important implications for the primary care setting. First, the low overall rate and relative rates of depression screening of certain groups (men, ethnic/racial minorities, more medically ill patients) highlight a specific area for system-wide improvement in primary care settings,” Hirschtritt and colleagues wrote. “Second, screening for and treating significant depression among primary care patients may improve the quality of medical care and decrease the burden of physical illnesses given the impact of depression on medical care.” – by Janel Miller

Disclosures: The authors report no relevant financial disclosures.

Perspective

Mark H. Duncan, MD

The question around depression screening rates and symptom severity according to alcohol use in primary care patients is a great one.

As Hirschtritt et al outline in their study, depression and hazardous alcohol use are common in primary care patients and are related to significant morbidity and mortality, so much so that the USPSTF recommends routine screening for both depression and hazardous alcohol use in adult primary care patients, with the provision that there is appropriate follow-up available. And, as these authors pointed out, these issues often go hand-in-hand, so it is essential to look for depression in patients who are drinking excessively and vice versa.

Though screening for depression was low, this could have been an underestimate based on the fact that depression screening was not part of the workflow and could have been captured in other ways that were not recorded by the investigators. To me, this illustrates the need for universal screening to occur within the context of a larger programmatic effort. Assuming screenings are just going to happen because they should is not enough within the context of a busy primary care practice with many other competing demands.

The authors also noticed a discrepancy between who got screened and who needed to be screened, with nonwhite and higher medical comorbidity patients, likely with more significant depressive symptoms, not getting screened as regularly. Again, this points to the need for a population-based approach as providers can miss things, misread patient symptoms, get distracted, not have enough time, and be unintentionally influenced by personal biases. So building it into workflows to promote universal screening is critical to not missing patients. It is not enough to have it embedded into the electronic health record.

In the end, the main message of this study is that universal screening for depression and alcohol use is the standard of care and should be done within systemic approach. There are many risk factors for depression, including alcohol misuse, but it is not the only risk factor to look for.

Mark H. Duncan, MD

board certified psychiatrist, University of Washington Medical Center Roosevelt Campus and University of Washington Neighborhood Northgate Clinic

assistant professor, departments of family medicine, psychiatry and behavioral science, University of Washington

Disclosures: Healio Family Medicine was unable to confirm Duncan's relevant financial disclosures prior to publication.

Sources/Disclosures

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Source:

Hirschtritt ME, et al. J Am Board Fam Med. 2018;doi:10.3122/jabfm.2018.05.180092.