Panel says all adults should be screened for depression

Jan. 27--All American adults should be screened for depression, including women who are pregnant and new mothers, an influential panel of medical experts has suggested.

The U.S. Preventive Services Task Force made the universal recommendation, its most sweeping on the subject, in a report released Tuesday. The group also urges doctors to have follow-up assistance in place for those diagnosed with depression.

Task force recommendations are taken seriously by health care providers, including the federal government, which funds it and appoints its 16 members. Medicare and Medicaid pay for depression screening under the task force's previous guidelines, which were last updated in 2009.

The report puts the onus on health care providers to ensure that appropriate treatment for depression is routinely provided. The goal is to end the separation of mental health services from treatment of physical ailments. Published in the Journal of the American Medical Association, it's available at j.mp/depression16.

The 2009 report recommended providers screen adults for depression only if they could also provide adequate follow-up care. It recommended against screening if such follow-up care was not available, as little benefit would be provided. That report, and the new one, do not cover children below the age of 18, who are addressed in separate reports.

The task force graded its updated recommendation as a B, the second-highest level of confidence under its A to D rating system. That means there's a high certainty of a moderate benefit, or a moderate certainty of a moderate to substantial benefit. That rating, the same as the 2009 report, should provide coverage for the depression screenings under the Affordable Care Act.

Depression is a leading cause of disability among adults, the report said, and degrades the quality of life among patients and their family members. It can not only lead to suicide, but impair handling other health issues. In 2011, an estimated $23 billion in lost productivity in the United States was attributed to depression. In 2014, an estimated 15.7 million American adults, or 6.7 percent, had at least one major depressive episode in the past year, according to the National Institute of Mental Health.

Making care available at the place of screening is important to ensure that depressed people don't later fall through the cracks, said Dr. David Folsom, director of the Division of Clinical Psychiatry at UC San Diego Health. And since the last report, he said, evidence has accumulated that comprehensive screening is effective in identifying those who would otherwise be missed.

Finding those in need

"Physicians miss certain people who are quietly depressed, not obviously depressed, and so that could be part of the reason they're emphasizing screening of the general population," said Folsom, who wasn't involved in preparing the report. And the combination of universal screening with easy access to depression care, through psychotherapy, antidepressant drugs or both, can be a powerful combination.

The task force left some issues unresolved, such as how often to screen for depression. There is little evidence to go on to determine timing, the report stated.

"A pragmatic approach in the absence of data might include screening all adults who have not been screened previously and using clinical judgment in consideration of risk factors, comorbid conditions, and life events to determine if additional screening of high-risk patients is warranted," the report stated.

Patients with depression face a discouraging hurdle from the common practice of referring patients with mental health issues to another location, with another set of procedures to go through, Folsom said. It's better to give depressed patients their care at the same location as their physical care.

Folsom said he oversaw such comprehensive care as medical director of St. Vincent de Paul Village Family Health Center, which provides health care for the homeless in San Diego.

"Depression was extremely common, and there were a huge number of people who had been depressed for many years and never gotten any treatment," he said. "We were able to offer some wonderful integrative care I wish everyone could get. When we can combine people's medical care and their mental health care, we tend to get better outcomes than when those two treatments are separated."

But a lot of work needs to be done to bring that example to the general population, he said.

Bringing it together

"Most health care practices are not set up to do that easily," Folsom said. "This report encourages, as much as possible, a system where you can have mental health treatment co-located on site, working collaboratively between primary care doctors and mental health clinicians. That's becoming more common, but it's far from universal. One of the challenges is it can be difficult to pay for with insurance."

On the positive side, the burden of providing such co-located care could be lighter than it appears at first glance, stated a JAMA editorial accompanying the report.

Universal screening and treatment can be as effectively provided by regular clinical practices as specialist practices, said the editorial, by Dr. Michael E. Thase. He cited a 2008 study that found patients treated in primary care with a moderate level of support, "had the same chances for response and remission as patients treated in psychiatric practices."

A bigger challenge can be finding a specialist to whom primary care doctors can refer their more seriously affected patients, said Dr. Michael Klinkman of the University of Michigan, who also wasn't involved with the task force.

"Either the capacity is not there, or the wait times are so long that a patient who is referred is in limbo for weeks and weeks while they might be fairly sick," said Klinkman, a family physician who works with rural primary care providers to develop needed support systems.

Wire services contributed to this story

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