Screening for Depression in Adults

6 May 2003 | Volume 138 Issue 9 | Pages 767-768

IN RESPONSE:

We agree with Coyne and colleagues that outcomes for depressed patients in primary care are better when screening is coupled with systematic efforts to improve initiation and continuation of effective therapy, as exemplified in the study by Wells and colleagues (1). The recommendation statement by the USPSTF (2) that accompanied our systematic review also explicitly noted that screening was more effective when coupled with systematic support. Rather than "distract[ing]" from efforts to promote greater access to such services, we believe our evidence review and the USPSTF recommendation will further encourage payers and health systems to make the changes necessary to provide high-quality care for patients with depression. Existing evidence suggests that such care includes systematic efforts to identify patients with depression ("screening" or "case finding").

The question of whether screening without systematic support for treatment and follow-up produces any benefit has generated a great deal of controversy (3). Critics often cite the number of "negative" studies as evidence of lack of efficacy, but many of the screening trials were too small to exclude important benefits of screening. Meta-analysis of the trials identified in our review, excluding the trials by Wells and Katzelnick and their colleagues (1, 4), shows that screening without such support produces an absolute reduction of 6 percentage points (95% CI, 0 to 12 percentage points) in the proportion of patients depressed at 6 months (Figure). This effect is smaller than the effect seen in the overall meta-analysis, which found a reduction of 9 percentage points (CI, 4 to 14 percentage points). These findings are consistent with our conclusion that screening without systematic support is probably more effective than usual care but that screening with systematic support is better than screening without it.

View larger version (21K): [in this window] [in a new window]   Figure. Meta-analysis of the effect of screening without systematic support. For the overall effect, P = 0.04. RD = risk difference.

 

Author and Article Information

Top Author & Article Info References

Research Triangle Institute–University of North Carolina Evidence-based Practice Center; Chapel Hill, NC 27514 (Pignone, Gaynes, Lohr)
University of Michigan; Ann Arbor, MI 48109 (Rushton)
University of Texas Health Science Center; San Antonio, TX 78284 (Mulrow)

References

Top Author & Article Info References

1. Wells KB, Sherbourne C, Schoenbaum M, Duan N, Meredith L, Unützer J, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial JAMA. 2000;283:212-20. [PMID: 10634337].[Abstract/Free Full Text]

2. Screening for depression: recommendations and rationale Ann Intern Med. 2002;136:760-4. [PMID: 12020145].[Abstract/Free Full Text]

3. Schwenk TL. Screening for depression in primary care. A disease in search of a test [Editorial] J Gen Intern Med. 1996;11:437-9. [PMID: 8842939].[Medline]

4. Katzelnick DJ, Simon GE, Pearson SD, Manning WG, Helstad CP, Henk HJ, et al. Randomized trial of a depression management program in high utilizers of medical care Arch Fam Med. 2000;9:345-51. [PMID: 10776363].[Abstract/Free Full Text]

5. Williams JW Jr, Mulrow CD, Kroenke K, Dhanda R, Badgett RG, Omori D, et al. Case-finding for depression in primary care: a randomized trial Am J Med. 1999;106:36-43. [PMID: 10320115].[Medline]

6. Whooley MA, Stone B, Soghikian K. Randomized trial of case-finding for depression in elderly primary care patients J Gen Intern Med. 2000;15:293-300. [PMID: 10840264].[Medline]

7. Callahan CM, Hendrie HC, Dittus RS, Brater DC, Hui SL, Tierney WM. Improving treatment of late life depression in primary care: a randomized clinical trial J Am Geriatr Soc. 1994;42:839-46. [PMID: 8046193].[Medline]

8. Callahan CM, Dittus RS, Tierney WM. Primary care physicians' medical decision making for late-life depression J Gen Intern Med. 1996;11:218-25. [PMID: 8744879].[Medline]

9. Zung WW, King RE. Identification and treatment of masked depression in a general medical practice J Clin Psychiatry. 1983;44:365-8. [PMID: 6643397].[Medline]

10. Lewis G, Sharp D, Bartholomew J, Pelosi AJ. Computerized assessment of common mental disorders in primary care: effect on clinical outcome Fam Pract. 1996;13:120-6. [PMID: 8732321].[Abstract/Free Full Text]

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