Doctors called on to screen all adults for depression

All adults should be screened for depression, and primary care physicians should do the screening, according to a position statement issued in October by the American College of Preventive Medicine.

With 6.7% of American adults -- about 15 million people -- experiencing depression in any given year, the prevalence of the disabling and potentially deadly condition makes it imperative that primary care doctors regularly screen their patients, the college's statement said. The college consists of 2,000 physicians who specialize in preventive medicine practice or research.

Primary care physicians are the principal health care contacts for most patients with mental illnesses, according to the paper, published in the October Journal of Family Practice. More than a third of primary care patients experience some form of depression, and 10% of patients have major depression. But, the college's position statement said, most depressed patients seeing primary care doctors go undiagnosed.

"We're not trying to place any blame on primary care providers, because we realize the complexities of their practices," said Michael T. Compton, MD, MPH, who co-authored the statement. "Depression is highly treatable, either in primary care or in specialty mental health care, and we feel that screening is important for all primary care providers."

The guideline builds upon a 2002 recommendation by the U.S. Preventive Services Task Force, a part of the Dept. of Health and Human Services' Agency for Healthcare Research and Quality. The USPSTF recommended depression screening "in clinical practices that have systems in place to assure accurate diagnosis, effective treatment and follow up."

But the college's Prevention Practice Committee said that recommendation was not strong enough, and every primary care practice should be able to screen for depression and refer patients for appropriate diagnosis and treatment.

"We wanted to sort of equate the screening and treatment of depression with the screening and treatment of high blood pressure," said Dr. Compton, assistant professor in the Dept. of Psychiatry and Behavioral Sciences and the Dept. of Family and Preventive Medicine at Emory University School of Medicine in Atlanta. "Primary care practices don't just screen for high blood pressure if they feel they can manage it. They screen for it regardless, and it is incumbent upon them to figure out how to manage it. We felt we want to make a bolder statement."

The authors acknowledged that primary care doctors already have a full plate. Pay is declining, the administrative burden is increasing and patient visit times are shrinking. The USPSTF recommends nearly 100 different preventive medications, immunizations, screenings and counseling services.

"It doesn't even have to take five or 10 minutes to ask the [depression screening] questions," said V. James Guillory, DO, MPH, chair of the college's Prevention Practice Committee and associate professor of preventive medicine and public health at the Kansas City University of Medicine and Biosciences in Missouri. "The majority of the time, it is not going to lead you in the direction that will take an overwhelming amount of time. It may very well lead you in the direction where you say, 'Those questions need additional discussion, so how about we reschedule to talk more about that problem at a time that's more convenient for you?' "

But Dr. Guillory said he knows it is not always so simple. "The problem [physicians] all have is once the question is asked, you open that can of worms. Then it's not five or 10 minutes, it's often 30 minutes or an hour, or 'Oh, my God, this patient is suicidal.' "

Psychiatrists welcomed the new guideline.

"Many people with depression will mainly be seeing their primary care physicians, so we need to figure out how to make this an important vital sign that all clinicians are aware of and help them think about ways to screen and then diagnose and treat," said Michelle Riba, MD, associate director of the University of Michigan Comprehensive Depression Center and a past president of the American Psychiatric Assn.

"We've learned that if physicians ask about tobacco, about substance abuse, about guns in the house, about obesity and weight management, that we can make a tremendous impact on overall health and prevention," Dr. Riba said. "But it takes time. It takes clinicians time to think about how they put this into their practice. This is a mandate, and a lot of doctors don't like mandates. This says, 'You should screen.' It's not a suggestion -- it's really saying this should be part of regular care."

In March, the USPSTF added another item to the mix, recommending that doctors also conduct depression screening for adolescents age 12 to 18.

Joseph W. Stubbs, MD, president of the American College of Physicians, said the flurry of preventive-care guidelines poses a challenge for harried doctors.

"There's just not enough time, literally, in the day" to address acute issues, chronic conditions and cover every preventive service, Dr. Stubbs said. "We need more help on how to manage patients on a team basis so that it doesn't all fall on the responsibility of the physician to do that. Can other people in the practice be used to screen for depression or other things? But how we do that is a bit of a puzzle because really the only person who's reimbursed for their time is the physician, when he gets face-to-face time with the patient."