Screening for depression in medical settings: A 2015 Update

Public Health Research Centre Seminar

University of Hong Kong

9th December 2014

James C. Coyne, Ph.D.Department of Health Psychology

University of Groningen, University Medical Center Groningen (UMCG), Groningen, the

Netherlandsjcoynester@gmail.com

Screening for Depression

How do we evaluate a medical intervention?

How do we evaluate recommendations for a medial procedure?

How do we challenge recommendations?

I'm a skeptic.

Controversies are to be resolved by looking at the available evidence.

I’m skeptical about the quality of that evidence.

I believe that individuals and professional organizations are not skeptical enough, often have conflicts of interest that are worth attention.

I believe that you should be skeptical about me and what I say and demand evidence.

Recognized in 1990’s

Depression is a serious source of suffering, personal and social impairment.

Treatments such as psychotherapy and medication are effective.

Most people who were depressed were not getting treatment.

The solution?

Detect untreated depressed persons, diagnose them, and get them into appropriate treatment.

The model: detect –> diagnose –> initiate treatment –> watch the recovery.

How to accomplish this? Introduce routine screening for depression.

Defining Screening for Defining Screening for DepressionDepression

Screening for depressionScreening for depression

Involves using depression questionnaires or small sets of questions to identify patients who may be depressed, but who have not sought treatment and whose depression has not already been recognized by healthcare providers.

Patients identified as possible cases need to be further assessed and, if appropriate, offered treatment.

Screening for depressionScreening for depression

Screening is potentially useful only if it improves patient outcomes beyond any detection and treatment provided as part of existing standard care.

To be successful, a screening program must identify a significant number of depressed patients who are not already diagnosed with depression, engage those patients in treatment, and obtain sufficiently positive treatment results to justify costs and potential harms from screening.

Those who propose screening assume a burden to demonstrate that it improves patient outcomes more than simply allowing the patients and their healthcare providers access to the same resources without screening.

Who says so?Who says so?

A Digression: Screening for Thyroid Cancer in Korea

Screening patients without symptoms has led to 1500% increase in diagnosis since 1999.

No perceptible decrease in deaths due to thyroid cancer.

Surgery leaves 10% with problems metabolizing calcium, 2% vocal cord paralysis, .2% deaths.

Why withdrawn?

The World Health Organization recently withdraw its recommendation that primary-care physicians routinely screen women for domestic violence.

I was skeptical about screening for depression from the start, but didn't think I would find

many people to agree with me.

Community physicians missed over 2/3 of the depression in patients coming for a visit.

Most of the depression missed was mild and patients were highly functioning.

Most patients with missed depression had only the minimum number of symptoms needed for diagnoses or one more.

United States Preventive Services Task Force (USPSTF)

“An independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services.“

The task force is a panel of primary care physicians and epidemiologists. is funded, staffed, and appointed by the U.S. Department of Health and Human Services.”

2002 USPSTF Recommendation 2002 USPSTF Recommendation StatementStatement

Recommended in primary care settings ‘that have systems in place to assure accurate diagnosis, effective treatment, and follow-

up’’

Screening for depression in medical carePitfalls, alternatives, and revised prioritiesSteven C Palmer & James C Coyne

Change in recommendations based on 1 decisive collaborative care study (Wells et al)

Personnel to administer and score screening instruments, Training materials and academic detailing. Depression management specialists. Initiatives to ensure scheduling of follow up appointments, Consultations & training with mental health professionals.Ready access to antidepressants and psychotherapy.

Screening for depression in medical carePitfalls, alternatives, and revised prioritiesSteven C Palmer & James C Coyne

Accumulating evidence from diverse sources that recognition alone does not translate into improved outcome for depressed patients.

Difficulties sustaining screening programs in routine care.

Rising rates of persons receiving antidepressants

Antidepressant prescription rates Antidepressant prescription rates were already high and trending were already high and trending

upwardupward

Among adults 35 years of age and older in the United States, antidepressant use increased from 8.3% to 14.1% from 1996 to 2005 with a third to a half of prescriptions specifically for psychiatric problems.

In a 2005 study from Canada, 7% of a general population sample reported current antidepressant use, a figure higher than the estimated prevalence of major depression (4%).

One size fits some: the impact of patient treatment attitudes on the cost-effectiveness of a depression primary-care intervention

JEFFREY M. PYNE a1c1, KATHRYN M. ROST a2, FARAH FARAHATI a1, SHANTI P. TRIPATHI a1, JEFFREY SMITH a3, D. KEITH WILLIAMS a4, JOHN FORTNEY a1 and JAMES C. COYNE a5

Interpretation?

Detecting cases of depression and having a collaborative care system (care manager) are cost effective for the 50% of patients interested in a particular treatment, antidepressants.

Such a system of care is not cost-effective for the other half of patients who don't want an antidepressant.

ISBN 0195380193

Paperback, 416 pages

Nov 2009 USFeb 2010 UK

Screening for Depression in Clinical Screening for Depression in Clinical Practice An Evidence-Based GuidePractice An Evidence-Based Guide

Screening for Depression in Cardiovascular CareScreening for Depression in Cardiovascular CareJAMAJAMA

SummarySummary

“The high prevalence of depression in patients with CVD, the adverse health care outcomes associated with depression, and the availability of easy-to-use case-finding instruments make it tempting to endorse widespread depression screening in cardiovascular care. However, the adaptation of depression screening in cardiovascular care settings would likely be unduly resource intensive and would not be likely to benefit patients in the absence of significant changes in current models of care.”

American Heart Association American Heart Association Science AdvisoryScience Advisory

““Although there is currently no direct evidence that screening Although there is currently no direct evidence that screening for depression leads to improved outcomes in cardiovascular for depression leads to improved outcomes in cardiovascular populationspopulations, depression has been linked to increased morbidity , depression has been linked to increased morbidity and mortality, poorer risk factor modification, lower rates of and mortality, poorer risk factor modification, lower rates of cardiac rehabilitation, and reduced quality of life. Therefore, it cardiac rehabilitation, and reduced quality of life. Therefore, it is important to assess depression in cardiac patients with the is important to assess depression in cardiac patients with the goal of targeting those most in need of treatment and support goal of targeting those most in need of treatment and support services.”services.”

““In summary, the high prevalence of depression in patients with In summary, the high prevalence of depression in patients with CHD supports a strategy of increased awareness and CHD supports a strategy of increased awareness and screening for depression in patients with CHD.”screening for depression in patients with CHD.”

No systematic review of the evidence was conductedNo systematic review of the evidence was conducted..

American Heart Association American Heart Association Science AdvisoryScience Advisory

Circulation, 2008;118:1768-1775

Whoops!

How dare we disagree with the American Heart Association and the American Psychiatric Association?

There are rules for making policy recommendations and they didn't follow them.

Free Resource

http://tinyurl.com/3t9hj8

Guidelines for Screening for Depression Deficient in

Systematic review of the literature. Transparency. Composition of guidelines committee

including formal involvement of patients, frontline clinicians, and other key stakeholders.

Articulation of guidelines in terms of strength of evidence.

External review.

A difference

USPSTF guidelines have orderly process of gathering, grading, and integrating evidence.

Room for disagreement, but transparent enough so you could see process and challenge results.

Professional organizations consensus-based, room for bias.

What is the quality of routine care What is the quality of routine care into which screened patients would into which screened patients would be sent?be sent?

Only 20-30% of depressed persons being treated exclusively in general medical settings receive adequate care and follow up.

About 40% of all depressed patients are administered treatment with little benefit over what would be obtained by remaining on a wait list, representing 20% of the total cost of treating depression.

2009 USPSTF Recommendation 2009 USPSTF Recommendation

StatementStatement

Recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. (Grade B recommendation)

Recommends against routinely screening adults for depression when staff-assisted depression care supports are not in place.

Fair evidence that screening and feedback alone without staff-assisted care supports does not improve clinical outcomes in adults and older adults.

Evidence from meta-analysis of 11 trials in primary care settings supported recommendation.

Several of the trials found that screening increased identification or treatment of depression.

None found that screening reduced diagnoses of depression or improved depressive symptoms.

Overall effect estimate was virtually zero (standardized mean difference [SMD] = -0.02, 95% confidence interval [CI] -0.25 to 0.20).

2009 USPSTF Recommendation 2009 USPSTF Recommendation StatementStatement

2009 USPSTF Recommendation 2009 USPSTF Recommendation StatementStatement

Patients with depression in the intervention groups received a collaborative care intervention for depression, whereas depressed patients in the control groups received only standard primary care.

Whereas the results of the trials suggest that providing collaborative depression care is better than not providing such care to patients with depression, they do not address the issue of whether screening would benefit patients with previously unrecognized depression.

A closer look at the evidence cited for A closer look at the evidence cited for 2009 USPSTF Recommendation2009 USPSTF Recommendation

Among the 3 largest studies cited by the USPSTF (those with > 100 patients), in one, 44% of patients in the trial were treated for depression prior to trial enrollment.

In another, 44% were receiving appropriate depression care, defined as specialized counseling or antidepressant medication, prior to trial enrollment.

In the third, data on pre-trial treatment rates were not provided, but already treated patients were not excluded.

Collaborative Care for Depression

American studies consistently find moderate (.30) effect size of enhancements of depression care involving depression care manager.

Studies do not consistently replicate in Europe.

Reason?: Poorer routine care in US gives more room to show efficacy of enhancement.

2010 National Institute for Health and Clinical Excellence (NICE)

Depression Management Guidelines

United Kingdom

Instead of screening, NICE Instead of screening, NICE recommended…recommended…

Physicians be alert to possible depression, particularly when there is a past history or when patients have a chronic physical health problem with functional impairment, and that physicians inquire about symptoms of depression when there is a specific concern.

Potential harmsPotential harms

2010 NICE Depression Management Guidelines identified number of serious concerns about routine depression screening.

High false-positive rates of screening tools, which are often well over 50%.

Likelihood that most individuals identified only by screening would have relatively mild symptoms of depression and often recover without formal intervention.

Whose side was I on in the antidepressant wars?

Our skepticismOur skepticism

Whether screening for depression is effective is a different question from there is evidence that collaborative care depression management interventions improve depression outcomes over routine care.

Of the 4 trials cited by the USPSTF as evidence supporting depression screening, none actually evaluated depression screening. In each of the 4 studies, patients were required to have depressive symptoms or a diagnosis of depression to be eligible for the trial.

Conclusions of ReviewConclusions of Review

No trials have found that patients who undergo screening have better outcomes than patients who do not when the same treatments are available to both groups.

Existing rates of treatment, high rates of false-positive results, small treatment effects, and the poor quality of routine care may explain the lack of effect seen with screening.

Developers of future guidelines should require evidence of benefit from randomized controlled trials of screening, in excess of harms and costs, before recommending screening.

Can we assume that screening Can we assume that screening will benefit patients?will benefit patients?

We know of no clinical trial in which patients screened for depression had better depression outcomes than patients who were not screened when the same depression treatment resources were available to both screened and non-screened patients, as would be the case in actual primary care settings.

Raffle, A and Gray, M. (2007). Raffle, A and Gray, M. (2007). Screening: Screening: Evidence and PracticeEvidence and Practice. Oxford Press.. Oxford Press.

Screening must be delivered in a well functioning total system if it is to achieve the best chance of maximum benefit and minimum harm. The system needs to include everything from the identification of those to be invited right through to follow-up after intervention for those found to have a problem.

Recommendations for adultsFor adults at average risk of depression, we recommend not routinely screening for depression. (Weak recommendation; very-low-quality evidence) For adults in subgroups of the population who may be at increased risk of depression, we recommend not routinely screening for depression (Weak recommendation; very-low-quality evidence)

The politics of publishing on screening, depression, and

antidepressants

Why JAMA (Journal of the American Medical Association) refused to even consider this article, without seeing it.

How the world has been How the world has been changing while we debate changing while we debate screening for depression. screening for depression.

More patients are now prescribed an

antidepressant at some point in their adult life.

More patients in the waiting room where screening is done are already on an antidepressant or have them at home but are not taking them.

More antidepressants are being given out to patients who cannot possibly benefit from them.

Rates of medication were going up, but rates of psychotherapy tend to be going down.

Many depressed patients do not renew prescriptions.

About half would benefit from dosage adjustment, medication changes, or education about adherence at five weeks to achieve benefits, but don’t get followed up.

Differences between countries American practice guidelines recommend either

antidepressants or psychotherapy to all patients with a diagnosis of depression.

Other countries such as Canada, the UK, and the Netherlands do not recommend antidepressants as first-line treatment for patients with mild, but diagnosable depression.

Emergence of stepped care whereby patients with mild depression encouraged to try self-help strategies, then psychotherapy or counseling, before going on to antidepressants.

Drug company supports monitoring screening with quality indicators:

Pfizer gives $10 million grant to American psychologist to develop quality indicators to monitor oncologists’ screening for distress.

Talking to patients is not longer cheap.

An American woman Susan Krantz, received national news attention when she complained about her physician charging her $50 for her having asked questions during her annual physical.

Her insurance company paid her physician for the physical, but not for answering her questions. She had not been warned of the extra charge ahead of time.

Talking to patients is a (billable) procedure.

Conversations occur with the meter running

“We’re not paid to solvepatients’ problems, we arepaid to do procedures.”

Screening contributes to bureaucratizing talking to patients

Quality indicators. Rationing. Requires mental health backup and

further screening. Requires patients to have repeat

discussions in order to get their needs met.

Rather than routinely screening patients for depression and placing them in inadequate routine care without follow-up:

•Concentrate on ensuring better follow-up care for known cases of

depression.

•Concentrate on patientsat high risk for depression.

What have we learned?

Thank you

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