Is Universal Screening for Depression a Good Idea?
The drawbacks to this solution to high rates of untreated depression.
Posted December 2, 2018
With recent reports of suicide rates being on the rise in the U.S., we’ve been thinking a lot about what we can do to better detect, diagnose, and treat mental health issues in a wider portion of the population. One suggestion that has been emphasized in recent months is ensuring more screening for mental health issues in primary care. The argument tends to rest on the often-cited statistic that 64% of suicide attempts are associated with a healthcare visit within the previous month. This has led many to suggest that primary care providers could be doing more to prevent suicide, and universal screening for risk is thus often suggested.
There are many reasons to think this might be a good idea on an intuitive basis. But when we explore the literature, it quickly becomes clear that the evidence base on this practice is shaky at best. This led us to wonder about another screening practice at the intersection of primary care and psychiatry: universal screening for depression. How important is universal screening for depression in primary care? What are the benefits and limitations and what do we still need to find out?
Benefits of Screening
There are obvious benefits of universal screening for depression in adults. The burden of disease of depression in the U.S. (and globally) is significant. Treatments for depression, including antidepressant therapy and psychotherapy, are effective in many cases. At the same time, access to psychiatric care can be difficult due to stigma, psychiatric provider shortages, and lack of health insurance coverage, among other issues. Due to some evidence linking screening to better mental health outcomes, the U.S. Preventive Services Task Force (USPSTF) recommends this practice for all primary care providers. The hope is that increased detection will lead to increased treatment and lower overall disability burden due to depression throughout the country. And because a substantial number of people who attempt or complete suicide suffer with depression, the assumption can reasonably be made that better detection and treatment of depression would reduce suicide rates as well.
Limitations of Screening
While universal screening for depression has some obvious benefits and empirical support, it’s important to understand that there are also serious limitations, as with any kind of mass screening. For one thing, it’s important to understand that screening is not the same thing as a diagnosis. When primary care doctors screen patients for depression, they are usually only able to detect that someone may have a problem, but a definitive diagnosis often requires follow-up, usually with a psychiatrist or psychologist. Mass screening always increases the risk of coming up with false positives, and this case is no different. Unless the further step of a formal psychiatric evaluation is taken, false positives on a screening test can cause undue distress in patients and may even lead to unnecessary treatment. While treatment with antidepressant therapy is relatively low-risk, there are still side effects and costs associated with it, and as a result, it’s important to limit the use of medication only to patients who really need them.
In addition, mass screening for depression immediately opens up another major question: what should people do if they find out that they do, in fact, have depression? Mental healthcare is particularly difficult to access in the U.S. It is expensive and often not covered by insurance. Screening people for depression in primary care has the capacity to identify more people in need of extensive psychiatric care. But where should these people turn if there are no mental health specialists in their area or if their insurance doesn’t cover psychotherapy? Some general health practitioners prescribe psychiatric medication, but they are often not as deeply knowledgeable about psychopharmacology and are not qualified or able to provide psychotherapy. The USPSTF recommendations do not provide any guidance on what to do about this particularly thorny issue. So we may be getting ourselves into a situation in which more people are identified with no place to turn for treatment. In general, then, screening without a clear path to treatment when needed will do nothing to improve overall outcomes for individuals or populations.
Accomplishing Better Outcomes for Depression
Mass screening for depression in primary care is a component of accomplishing better outcomes for people with depression. But we have to remember that it’s just that: a component. It is not the full picture. It certainly needs to be coupled with a few other initiatives in order to result in lasting change for people with this debilitating mental illness.
For one thing, as alluded to above, we need to provide better access to care for depression. This is a no-brainer, but of course, it’s easier said than done. Despite the passing of mental health parity laws at the federal and state levels, there is a need for more airtight laws and improved enforcement of them so that people with depression can afford psychiatric treatment. Novel strategies for delivering mental health care, such as collaborative care and telepsychiatry, should be expanded.
In the meantime, we may be able to do more to build primary care providers’ capacity in mental health diagnosis and treatment. More thorough education in psychopharmacology can be part of the training for primary care providers. In addition, primary care providers can be obligated to complete specific continuing education courses in psychopharmacology and diagnosis and treatment of depression in order to ensure they are keeping up with the newest thinking and research. Primary care providers could also have some additional training in how best to communicate with patients who are depressed, as this is often extremely difficult, especially when patients don’t believe they are depressed or have no hope that treatment will make them feel better.
Finally, and perhaps most importantly, we have a long way to go in basic research to reach a much better understanding of depression in general. We could invest more in research on treatments for depression, in discovery of new and better drugs and evidence-based psychotherapies, and in reaching a much-enhanced understanding of suicide risk and suicidal behavior.
Until we commit to a more concerted effort to truly understand and better treat this often devastating illness, mass screening for depression can only do so much. We need to pay more attention to some of the underlying problems with our systems of care and our understanding of the illness itself in order to make mass screening for depression in primary care a truly effective practice.