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E-News from Washington May 21, 2002 Vol. 02-13
U.S. Preventive Services Task Force Recommendations for Depression Screening

By Shankar Vedantam
Washington Post Staff Writer
Tuesday, May 21, 2002; Page A01

A top independent advisory panel on Monday, May 20th, recommended that doctors begin routinely screening all patients for depression, saying that America's primary care doctors are missing and mistreating more than half  of all cases of the common mental disorder.

Asking all patients who walk into offices for tests, physicals and appointments two simple questions about whether they have experienced some of the warning signs of depression can swiftly begin to identify 90 percent of people who suffer from major depression, according to the U.S.  Preventive Services Task Force. The panel is a highly influential group of scientists that sets widely followed standards on topics ranging from prostate cancer screenings to mammograms.

The recommendation is the latest manifestation of the growing recognition that depression is one of the most common -- and most commonly undiagnosed and untreated -- chronic illnesses. About 19 million American adults suffer from depression, and estimates suggest that as many as two-thirds do not get treatment. The new recommendations could bring many of these people into treatment and add millions to the numbers who are taking antidepressants such as Prozac.

Two-thirds of patients with depression are treated in primary care settings. Primary care doctors also see most patients whose depression goes undiagnosed, as people come through clinics for routine outpatient care.

"Primary care doctors have done only a modestly good job in recognizing and treating depression," said Michael Pignone, a University of North Carolina researcher who analyzed the issue for the task force. "Only half of cases are recognized in primary settings, and less than that are properly treated."

The task force did not find sufficient evidence to recommend routine depression screening for children and adolescents.

Two questions ought to become part of the basic repertoire of every patient visit, the task force recommended in an announcement that coincided with the American Psychiatric Association's annual meeting here: "Over the past two weeks, have you felt down, depressed or hopeless?" and "Over the past two weeks, have you felt little interest or pleasure in doing things?"

If a patient answers yes to either question, the task force recommended that doctors offer patients written or oral questionnaires. These ask more specific questions and establish whether the problems are transient or persistent. If the problems have lasted throughout the previous two weeks, and have interfered with the patient's ability to perform day-to-day tasks, doctors may make a diagnosis of depression.

"Most patients who are depressed have some diminished function," said Alfred Berg, a professor at the University of Washington in Seattle and the chairman of the task force. "They don't take pleasure in activities, they are not productive, can't concentrate, are often sleep-deprived, don't eat well, have headaches or low back pain. If you go through a formal assessment, you find the depressed patients aren't doing as well."

But screening is only the first step in the task force's recommendation. "Asking, 'Are you depressed?' and having the patient say, 'Yes,' and then moving on doesn't cut it," Berg said. "You have to have access to the right therapy or medicines. Patients must have access to medicines. There should be follow-up if the patient doesn't show up two weeks later."

Berg and Pignone said medicines and psychotherapy are effective treatments, and some previous research has found the combination more effective than either alone. Both said it was important that the responsibility for implementing the new recommendation not be left to physicians alone, but to health systems and managed-care plans.

That is important because many plans do not offer coverage for psychotherapy, and some do not offer the same level of coverage for medicines compared with physical disorders. Perhaps more important, managed care is structured so that doctors are reimbursed for patient visits -- meaning that doctors have no financial incentive to follow up on their patients as regularly as is needed.

Under a health system that encourages patient follow-up care, a doctor or nurse would call a patient a couple of weeks after they are started on treatment to ask how they are doing, said Pignone, whose research is being published today in the Annals of Internal Medicine. If the patient is doing poorly, the doctor could recommend another visit. If the patient is doing better, the doctor can tell the patient not to miss work for an appointment.

The task force is widely considered to be more conservative and evidence-based than specialist organizations. Its government funding separates recommendations from personal and financial conflicts of  interest. Because its members do not come from any one medical specialty, they tend to have a practical approach, and the task force focuses on issues in which the scientific evidence conclusively shows a large difference.

© 2002 The Washington Post Company