HOPE Center Investigator Assesses Depression Screening Rates

We need more awareness of the necessity of depression screening among adults.
"The question that intrigued us was what was happening to adults who don't have a depression diagnosis..."

More people are being screened for depression now than they were 10 years ago, but screening rates still remain low, new research suggests.

Investigators used data from the National Ambulatory Medical Care Survey to review close to 300,000 adult nonpsychiatric health care visits from 2005 to 2015. They found that although screening rates had risen from less than 1% in 2008, they continued to remain low, with only 3% of adults screened during office visits in 2015.

"We need more awareness of the necessity of depression screening among adults," lead author Sandipan Bhattacharjee, PhD, assistant professor, Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, told Medscape Medical News. "Health care providers and large health care systems should routinely use depression screening in their practice so that necessary interventions can be put in place at the right stage to prevent negative outcomes associated with depression, as well as overcome the underdiagnosis of depression," he said.

The study was published online July 9 in Psychiatric Services.

Nonpsychiatric Settings

Depression affects approximately 16.1 million US adults. It is associated with functional disability, increased health care expenditures, and higher risk for morbidity and mortality. Despite its serious, far-reaching negative consequences, depression remains underdiagnosed, the authors write. Screening for, identifying, and treating depression in primary care settings has been shown to lower morbidity. Routine depression screening of all adults is recommended by the US Preventive Services Task Force (USPSTF).

"There are few studies that have examined the depression screening rate in the general population. However, the question that intrigued us was what was happening to adults who don't have a depression diagnosis, in terms of getting depression screening in a nonpsychiatric setting," said Bhattacharjee. "A depression screening recommendation was published in 2009, and we wanted to see how that might have influenced depression screening in the US," he added.

To investigate the question, the researchers utilized pooled data from the National Ambulatory Medical Care Survey 2005-2015, which captured nationally representative health care services provided in ambulatory care settings in the United States. The sample consisted of adults (≥18 years) who had not been diagnosed with depression and who had made an ambulatory care visit to a nonpsychiatrist health care provider. The dependent variable for the study was depression screening (yes/no). Depression screening was identified on the basis of responses to a broader question regarding the health care visit: "Were any examinations, blood tests, imaging, other tests, non-medication treatment, or health education ordered or provided at this visit?"

Each individual record was assigned a patient weight (called an inflation factor), which was used to predict the total number of office visits made in the United States. All estimates were subject to sampling variability.

Rural America

Of the 298,896 (unweighted) visits by adults that met study inclusion criteria, 3986 (unweighted) visits included depression screening. This translates into approximately 105 million visits in which depression screening was reported between 2005 and 2015 at the national level, which represents 1.4% of the visits by adults without a depression diagnosis during this entire period (95% confidence interval [CI], 1.19% - 1.56%). The lowest rate was seen in 2008 (.65%; 95% CI, .35 - .95), and the highest in 2015 (3%; 95% CI, 1.93 - 4.07).

Approximately 66% of the adults in the overall sample were aged 18 to 64 years, 60% were women, 73% were white, 89% resided in metropolitan areas, and 39% resided in the southern United States. Multivariable findings showed differences between subgroups across these factors and were consistent. Univariate analyses showed that sex, physician specialty, metropolitan location, geographical region, and time spent with physician were significantly associated with receipt of depression screening. The multivariable logistic regression analyses showed an increased likelihood of depression screening each year (odds ratio [OR] = 1.12; 95% CI, 1.06 - 1.18; P < .001).

When the researchers performed a piecewise regression analysis, they found a statistically significant interaction (P < .001) between year and change in depression screening rate, with a significant increase of screening rates after 2009. Additional piecewise regression analysis revealed that there was less likelihood of depression screening during the pre-recommendation period (OR, .78; 95% CI, .65 - .91; P =.002).

By contrast, during the immediate and late postrecommendation periods, the odds of depression screening were higher (OR, 1.46; 95% CI, 1.07 - 1.98; P = .016; and OR, 1.34; 95% CI, 1.21 - 1.49, P = 001, respectively), with screening rates of roughly 3% in 2015.

The researchers observe that their findings of regional disparities in screening "may be explained by the greater number of rural communities and lower numbers of large metropolitan areas in the western United States, compared with the rest of the country." They suggest that screening "may need to be promoted in rural America to address these regional disparities."

"It is difficult to comment on the reason for higher depression screening in 2015," said Bhattacharjee. He suggested several possibilities, including more awareness of depression screening among health care providers and the Affordable Care Act of 2010, which "made these preventive services free of cost to the patients."

Falling Short

Commenting on the findings for Medscape Medical News, Mark Olfson, MD, MPH, professor of psychiatry and epidemiology, Columbia University, New York City, who was not involved with the study, said that the "new findings confirm that community practice falls far short of the USPSTF recommendations for depression screening, which remains uncommon in medical practice."

He noted that, "despite the availability of safe and effective treatments, most adults with depression are not diagnosed or treated, and until depression screening becomes the norm in primary care, this is unlikely to change." However, "hopefully, the availability of brief screens such as the PHQ-2 [Patient Health Questionnaire–2] and applications that permit patients to complete screens prior to their visit will extend the reach of depression screening in primary care," he added.

Bhattacharjee suggested that the 2016 USPSTF depression screening recommendation "can even help further to increase the depression screening rate."

Psych Serv. Published online July 9, 2018.

This article was originally published in Medscape on July 13, 2018.