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Depression is a multifaceted disease that affects the physical, mental, and emotional health of more 300 million people worldwide and is the leading cause of global disability.1 Individuals of all ages are affected by depression, and it is associated with higher rates of chronic disease, substance use, and suicide.2,3
In approximately 65% of cases, individuals with depression first present for evaluation in the primary care setting.3 However, a meta-analysis found that primary care providers (PCPs) failed to diagnose depression in nearly 50% of individuals who met the criteria for major depressive disorder (MDD).4
Barriers to Diagnosis
Identification of depression in the primary care setting can be challenging due to a number of barriers, including time constraints of providers, a lack of established screening and diagnostic protocols, increased patient acuity and comorbidities, and variation in the presenting features of depression.3
The United States Preventive Services Task Force (USPSTF) recommends annual screening to identify depression in primary care settings. However, screening alone has not been shown to improve outcomes. Screening must occur in a clinical setting in which providers can confirm the diagnosis through a clinical interview, treat and/or refer for treatment, and provide adequate follow-up care.2,4
Busy clinicians care for increasingly complex patients in brief appointment slots. Time-intensive charting associated with best practices, meaningful use, and Medicare Core Quality Measures, and progress notes can be overwhelming for providers and support staff.
Change in Workflow
One possible solution to overcome time constraints that prevent screening for depression is to change workflow. In a randomized controlled trial, Mertens et al showed that workflow redesign improved provider adherence to screening and treatment protocols.5 Screening rates improved when medical assistants (MAs) were tasked with baseline screenings and PCPs addressed positive screens with a follow-up diagnostic interview and treatment, if indicated. MAs screened more patients (50.9%) than PCPs (9.2%), and only 3.5% of patients in the control group, with no established screening protocol, were screened.
Providing printed copies of a brief depression screening tool, such as the 2-item Patient Health Questionnaire (PHQ-2), to patients in the waiting area facilitates self-administration of depression screening, further reducing time required by staff for administration. MAs can enter the PHQ-2 (and PHQ-9, if indicated) score into the electronic medical record while with the patient.5
Establish Screening Protocols
Use of a depression screening and treatment protocol in primary care practices has been shown to increase screening and evidence-based treatment of depression and improve patient outcomes by decreasing time to remission.6 Gallo et al examined the effects of implementing an evidence-based depression care protocol on depression scores and mortality rates among chronically ill patients in 20 primary care practices.6 Patients with comorbid depression were treated “per protocol” or “per usual care.” Patients treated per protocol had a greater rate of remission at 2 years than did patients treated per usual care. Patients’ risk for mortality rose over time in the usual care group (odds ratio [OR], 3.02; 95% CI, 1.32-8.72) and declined in the treatment group (OR, 1.73; 95% CI, 0.86-3.96).
Variation in the symptoms of depression throughout the lifespan may complicate recognition and treatment of depression.3 Adolescents are more likely to present with chronic somatic complaints (headache, stomachache, and general pain symptoms), which may explain why approximately 50% of adolescents with depression are not diagnosed until adulthood, when they typically present with complaints of mood alteration.7 Likewise, elderly patients present with somatic symptoms more often than mood alteration or anhedonia.8 Strategies for identification of depression in individuals presenting with chronic somatic symptoms include administering valid and reliable depression screening tools and allowing time for effective provider-patient communication.7,8
Recognizing At-Risk Groups
An additional barrier to effective depression screening practices is the lack of knowledge about at-risk groups. Understanding which populations are most at risk for depression helps providers identify individuals in need of evaluation that is more frequent than the minimum recommendation for annual screening in individuals aged 12 years and older.7 Some groups, such as postpartum women, adolescents, adults experiencing high levels of stress, individuals who struggle with substance abuse, or individuals with serious or multiple comorbidities, are at high risk of developing depression and should be evaluated at each primary care visit (Table 1).3,6-9
The American College of Obstetrics and Gynecology (ACOG) recommends screening women for depression at least once during the perinatal period.10 Women should be screened frequently for depression during the postpartum period; 10% to 20% of mothers will develop postpartum depression during the first 12 months after childbirth.9 The USPSTF and ACOG recommend screening for postpartum depression during the postpartum visit and the American Academy of Pediatrics (AAP) recommends frequent screening the first year after childbirth.11 Since a new mother has only 1 to 2 postpartum visits with an obstetrician, the AAP recommends that pediatric or family medicine providers screen women for postpartum depression during newborn, first-week, 1-month, 2-month, 4-month, and 6-month visits.12
As providers learn to recognize individuals at high risk for depression, vulnerable groups will receive appropriate screening and treatment to reduce morbidity and mortality.