Primary care is an untapped resource for depression screening

September 10, 2018, University of California, San Francisco
Credit: CC0 Public Domain

Hazardous alcohol use and depression often go hand-in-hand. Yet when a patient is screened by their doctor for hazardous alcohol use, rarely are they also screened for depression.

A new study has identified at-risk populations for whom depression combined with hazardous use screening could detect that might otherwise go untreated. These populations include non-White and more medically ill patients, and men in general, for whom screening rates are particularly low.

"Our study provides evidence that, with a simple questionnaire, doctors have a big opportunity to better spot depressive symptoms in at-risk patients and help improve their lives through treatment," said Matthew Hirschtritt, MD, MPH, a forensic psychiatry fellow at UC San Francisco and first author of the new study.

Hirschtritt conducted the study in collaboration with the paper's senior author Stacy Sterling, DrPH, of the Division of Research of Kaiser Permanente Northern California (KPNC). Their findings were published September 10, 2018, in the Journal of the American Board of Family Medicine.

Depression Is Common, Screening Is not

The negative health effects of excessive alcohol consumption are now well-recognized, and screening for hazardous drinking is becoming more standard in primary care, but it wasn't always. KPNC boosted the practice within its own healthcare system through the "Alcohol as a Vital Sign" initiative, which provided data for the current study. Their slogan is "We ask everyone," meaning every adult primary care patient can expect to be screened about alcohol use.

Screening for depression is not as common, however, despite its common comorbidity with hazardous drinking. The U.S. Preventive Services Task Force recommends that primary care practitioners screen for depressive symptoms using an instrument known as the Patient Health Questionnaire 9. The questionnaire is effective, when it's used. But clinicians must prioritize which recommendations to act upon in a given appointment, or a simple check-up would be hours long. As a result, depression screening is part of only about 1.4 percent of adult ambulatory care visits nationwide.

But given the prevalence of depressive symptoms in the U.S., the authors argue that forgoing screening means missing an opportunity to help patients.

"Depressive symptoms are extremely common, but we know many people don't make it to specialty psychiatric treatment," said Sterling. "Many people do already have a strong relationship with their primary care provider, so it may actually be the perfect environment for behavioral health intervention."

Surprising Discrepancies in Screening

The study utilized data from more than 2,800,000 KPNC primary care patients who had been screened for hazardous alcohol use. Per national guidelines, patients were asked how many days they typically drank per week, and how many drinks they consumed on those days. Hazardous use was defined as more than 14 drinks a week for men 65 and younger, and more than 7 drinks a week for women and men 66 and over.

In addition to participants' drinking habits, the researchers analyzed electronic health records to determine whether they were screened for depression with the recommended health questionnaire. They found that among patients screened for hazardous alcohol use, 2.4 percent were also screened for depression within the next 30 days, which is consistent with estimates from national surveys. The depression screening rate was lower for non-Whites, men, and those who were more medically ill.

"The finding that I found most concerning is that individuals who self-identified as White were more likely to receive screening than were historically marginalized ethnic groups," said Hirschtritt. Though the study potentially underestimates absolute rates of depression screening, because doctors could screen patients for depression using methods other than the recommended questionnaire, but the observed discrepancy in screening rates was still a red flag, Hirschtritt said.

Although non-White patients, including Black, Hispanic, Asian, and those categorized as "other/unknown" were less likely to be screened for depression than White patients, these patients were more likely to report clinically significant depressive symptoms. Similarly, although less medically sick patients were less likely to be screened than healthier patients, they were more likely to report clinically significant depressive symptoms.

Discrepancies in screening and rates of depressive symptoms by ethnicity and medical illness are concerning, the authors said, given that some groups are more vulnerable to depression than others.

"It's unclear why non-White individuals weren't screened at a higher rate," Hirschtritt said. "These may face multiple stressors that put them at a higher risk for depression, in addition to hazardous alcohol use."

Boosting the Numbers

When surveyed, approximately 8.1 percent of U.S. adults have exhibited significant depressive symptoms in the past two weeks, while 21.6 percent have had some depressive symptoms at some point. Primary care settings are an "untapped resource" to treat this prevalent condition, Hirschtritt said.

He said that innovative healthcare models, such as integrative and collaborative care, are being adopted and serve to empower primary care practitioners to address mental health in the clinic. Physicians can also seek consults from psychiatrists, with mental health professionals as their in-house liaisons.

The Alcohol as a Vital Sign initiative equipped practitioners with clear protocols for screening, training for brief intervention and handy tools built into the electronic health records—and both Hirschtritt and Sterling suggested these strategies could applied to as well.

"The Alcohol as a Vital Sign initiative has resulted in extremely high screening and brief intervention rates," said Sterling. "It could make a difference if we established a similar protocol for ."

Explore further: Depression screening rates in primary care remain low

Related Stories

Depression screening rates in primary care remain low

February 20, 2017
Despite federal recommendations for depression screening, a new Rutgers study found that less than 5 percent of adults were screened for depression in primary care settings. The low screening rate suggests missed opportunities ...

Depression screening rates among adults increased slightly in recent years, but remain low

July 9, 2018
Rates of routine screening of U.S. adults for depression have increased slightly in recent years, but remain very low. Adults were screened in about 3 percent of office visits in 2015, up from a low of less than 1 percent ...

Many Americans not being assessed for depression

August 15, 2018
(HealthDay)—Many Americans aged 35 and older are not being assessed for depression, according to a study recently published in the Journal of the American Board of Family Medicine.

One in three hospitalized patients experience symptoms of depression, study shows

June 2, 2017
About one in three hospitalized patients shows symptoms of depression, potentially affecting their clinical outcomes, a new Cedars-Sinai study has found.

Mental health screening in primary care helps veterans

August 13, 2014
Veterans who receive mental health screening during primary care visits are generally getting adequate follow-up treatment, but the process for acquiring care could be improved, finds a new study in General Hospital Psychiatry. ...

Collaborative care cuts depression with diabetes

November 6, 2014
(HealthDay)—Using a nurse case-manager-based collaborative primary care team can cut depressive symptoms in patients with type 2 diabetes, according to a study published online Oct. 14 in Diabetes Care.

Recommended for you

Why the brain struggles to get off the sofa

September 18, 2018
About 30% of adults and 80% of teenagers today do not meet the minimum levels of daily physical activity for staying healthy, as recommended by the World Health Organisation (WHO). Previous studies have already demonstrated ...

New brain research suggests that schizophrenia is an extreme version of a common personality type

September 18, 2018
Researchers have found that the signals in people's brains differ depending on a particular aspect of an individual's personality, termed Schizotypy, a discovery that could improve the way schizophrenia is characterised and ...

Do we trust people who speak with an accent?

September 18, 2018
You are in a strange neighbourhood, your cell phone's dead, and you desperately need to find the closest garage. A couple of people on the street chime in, each sending you in opposite directions. One person sounds like a ...

New era in virtual reality therapy for common phobias

September 18, 2018
Dick Tracey didn't have to visit a tall building to get over his fear of heights. He put on a virtual reality headset.

We are predisposed to forgive, new research suggests

September 17, 2018
When assessing the moral character of others, people cling to good impressions but readily adjust their opinions about those who have behaved badly, according to new research.

Being forgotten by acquaintances can affect self-esteem in the same way as being rejected

September 17, 2018
Psychologists at The University of Aberdeen looking into the experience of being forgotten have discovered that memory lapses can damage relationships.


Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.