Should Depression Screenings be a Part of Primary Care?
At the end of January and in early February, the U.S. Preventative Services Task Force released two recommendations that primary care doctors screen all adults and adolescents (12 years of age and older) for depression. In this recommendation, the federal task force urges primary care doctors to perform screenings whether or not they have mental health services readily available.
While this is not an obligation or requirement, only a suggestion to take into consideration, if doctors act on this recommendation, we could see some important changes in our healthcare system and possibly in American’s health outcomes.
A screening is a way to assess a person for early signs of illness or disease. Screenings are commonly performed on patients for high blood pressure, high cholesterol, diabetes and some cancers. Depression screenings are typically short ten-question surveys that can be incorporated into wellness exams. Primary care doctors are ideal professionals to screen for depression because they assess and treat patients for general needs. They look for respiratory, hearing, vision and cardiovascular issues, so shouldn’t mental health be one of them?
Mental health is often overlooked in primary care visits. I cannot remember a time when my primary care doctor initiated an in-depth discussion about my mental health. I was always the one to bring it up at my annual visits. Maybe he was reluctant to open up the topic because he had no rapid referral route to mental health professional if a patient needed psychotherapy. Maybe my primary care doctor, like many others, was too pressed for time to attend to a person who is depressed or suicidal.
People who are experiencing depression might not seek out help from a mental health professional and often trust their primary care doctors. Having primary care doctors regularly screen their patients for depression could eliminate many of these barriers and make recovery more attainable.
Here are some of the goals the recommendations seek to achieve:
Relieve Personal Distress
Many people will no longer struggle in silence. A screening provides the possibility of opening the door for people with undiagnosed depression. It lets people describe the feelings they have been having and allows them to find ways to get well. This means people hopefully won’t slip through the cracks untreated. Instead, they will get the attention and help they need earlier rather than later. Intervening early, with effective therapies and medications, can reduce the burden of depression and help people better manage their health.
Integrate Mental and Physical Health Care
Mental and physical health are tightly related. Untreated and unmanaged behavioral health problems can worsen and even lead to physical illness. It becomes hard to stay active, eat healthy meals and stay on top of taking medication to control physical ailments. Having a doctor who can integrate physical and mental health can benefit the individual.
Early identification of mental illness not only may increase the effectiveness of treatment, it also can reduce long-term personal costs and large-scale healthcare costs. Dealing with mental and physical health issues can get expensive.
Address the Mental Health Workforce Shortage
It has become harder and harder to find a mental health professional. The field is not growing quickly enough to meet increased demand and many available professionals are either not taking new patients or do not accept insurance. If primary care doctors are capable of assessing people for general needs, they are also capable of starting conversations about mental health needs. Primary care doctors are in a good position to help compensate for the national shortage of mental health care providers. In fact, they prescribe most of the antidepressants in the U.S. already.
Draw Attention to Mental Health Policy
Katy Kozhimannil, an associate professor of public health at the University of Minnesota, believes that policy makers will pay attention to the panel’s guidelines. “Increased screening and detection of depression is an enormous health need,” Kozhimannil said in a New York Times article that was published at the end of January.
The task force brings attention to needed policy changes. For one, federal and state mental health policies can establish ways to increase the mental health workforce shortage. They can fund the coordination and integration of behavioral health into primary care services, fund psychiatric telemedicine or tuition-reimbursement programs for students wanting to go into the mental health field. The screening guideline also draws attention to promoting early treatment intervention and covering the cost of mental health screenings for all.
In an article in USA Today that also appeared in January, Senior Policy Advisor at NAMI, Ron Honberg, said that screening for depression helps bring it “out of the shadows.” Making depression screenings a more regular occurrence in wellness exams, even if only one a year, may help reduce the stigma of mental illness. It increases awareness that depression is common. Coming face to face with the survey and talking about it with a doctor can bring mental illness out of hiding and into conversation, just as hypertension and diabetes are during routine wellness visits. And in the future, people may be more comfortable bringing up mental health concerns on their own.
Critics have brought up some negative consequences that could result from the task force’s published recommendation:
Allen Frances, M.D., and professor emeritus of psychiatry and behavioral sciences at Duke University School of Medicine, thinks that screening for depression could lead to over-diagnosis and over-treatment. The screening tool is a brief, generalized test that clumps all depression diagnoses together. It cannot judge clinical significance, so patients could be diagnosed as depressed who are not actually clinically depressed. Medication could be over-prescribed and patient costs would increase. “Routine screenings of all adults and adolescents would ramp up this already excessive treatment of the mildly ill and worried well,” Dr. Frances stated in STAT., a publication that focuses on health and medicine. He is also concerned that primary care depression screenings will take away precious time spent caring for patients and their already diagnosed illnesses.
Another risk is that people given antidepressants may have a risk of mania without the prescribers first receiving a thorough medical history of themselves and their family. A depression screening should also require training and resources to teach primary care doctors how to properly assess for that risk.
Additionally, even if more individuals are accurately diagnosed with depression, there is still the issue of getting that person to a therapist or other mental health care professional. Even with this screening in place, there will still be a workforce shortage of behavioral health specialists and a cost barrier for many.
Dr. Frances has made some valid points, but I feel we need to start somewhere, with the resources and professional workforce we have. Depression screenings should be viewed as a conversation starter, not the end of the road.
A depression screening given out in the primary care setting is a beginning effort at an organized, effective healthcare system that has a person’s wellbeing in mind. It is one step towards having a system that is thoroughly integrated and connects patients to the supports they need in the early stages of mental illness.
Elena Schatell is an intern at NAMI and has B.A. in neuroscience from Kenyon College.