Depression Screening Is Not Enough

• Depression
• Mass screening
• Outcome and process assessment (health care)
• Cost-benefit analysis
• Primary health care

Not enough” does not mean “not at all.” The individual and societal burden of depression is enormous in terms of economic costs (over $40 billion annually in the United States alone); disability days; and pervasive effects on physical, mental, and social well-being (1-3). This burden, coupled with the eminent treatability of depression, compels us to action (4, 5). The first action must be recognition of the depressed patient, without which amelioration is impossible. The second action is treating the patient in whom depression has been identified. Although screening can enhance both recognition and initiation of treatment (6), improvement in depression outcomes requires a third step: careful follow-up and monitoring of treatment effectiveness.

These steps are no different from those taken in any other chronic disease. Imagine a system in which providers screened for hypertension and started medical treatment, only to neglect follow-up blood pressure checks and adjustment of therapy. Is the patient taking his or her antihypertensive medication? Is it working? Are there side effects? Does the dose of medication need to be increased, or should an alternative agent be used? The same principles apply to diabetes, high cholesterol, asthma, congestive heart failure, and many other conditions requiring patient education, ongoing treatment, outcome monitoring, and vigilance for episodic exacerbations.

A systematic review of depression case-finding instruments illustrates why routine screening may be inefficient (7). Synthesizing data from 18 studies of nine different instruments, Mulrow and colleagues found an overall sensitivity of 84% and specificity of 72%, and no instrument was superior to another. Given a 5% prevalence of major …