Primary care providers encounter a large proportion of the population with depression. Yet, many primary care patients with depression remain undiagnosed and untreated.
This study aims to examine depression screening patterns and the role of screening in depression diagnosis and treatment in the outpatient primary care setting.
This is a cross-sectional analysis of nationally representative survey data of visits to outpatient physician offices from the 2005 to 2015 National Ambulatory Medical Care Surveys.
The sample included the first visit in the past year to a primary care provider by patients 12 years and older (N = 16,887).
The associations of visit characteristics with depression screening and of depression screening with depression diagnosis and treatment during the visit were assessed using logistic regression. Logistic regression with propensity score weighting was used to estimate the odds of depression diagnosis and treatment under the counterfactual scenario in which patients who visited providers with lower depression screening rates had visited providers with higher screening rates instead. All models were adjusted for patient and visit characteristics.
A small proportion of sample visits involved depression screening (3.0%). Visits by patients with depressive symptom complaints were associated with higher odds of depression screening than other visits. When visits were weighted to have similar demographic and clinical characteristics, visits to providers with higher screening rates had higher odds of diagnosis (OR = 1.99, p < 0.001) and treatment (OR = 1.61, p = 0.001) compared to visits to providers with lower screening rates.
Physicians appear to use depression screening selectively based on patients’ presenting symptoms. Higher screening rates were associated with higher odds of depression diagnosis and treatment, and even modest increases in screening rates could meaningfully increase population-level rates of depression identification and treatment in primary care. Future research is needed to identify barriers to depression care and implement systematic interventions to improve services and patient outcomes.
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Agency for Healthcare Research and Quality; Medical Expenditure Panel Survey (MEPS), Table 2.1: People Who Have a Usual Primary Care Provider, by Race/Ethnicity, United States, 2014. Rockville, MD; 2014. https://meps.ahrq.gov/data_stats/summ_tables/hc/acc/2014/acctocare_2_1_2014.htm. Accessed 19 April 2018.
Wang PS, Demler O, Olfson M, Pincus HA, Wells KB, Kessler RC. Changing profiles of service sectors used for mental health care in the United States. Am J Psychiatry 2006;163(7):1187–1198. doi:https://doi.org/10.1176/ajp.2006.163.7.1187.
Olfson M, Marcus SC, Druss B, Elinson L, Tanielian T, Pincus HA. National trends in the outpatient treatment of depression. JAMA 2002;287(2):203. doi:https://doi.org/10.1001/jama.287.2.203.
Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet 2009;374:609–619. doi:https://doi.org/10.1016/S0140.
Pence BW, O’Donnell JK, Gaynes BN. The depression treatment cascade in primary care: a public health perspective. Curr Psychiatry Rep 2012;14:328–335. doi:https://doi.org/10.1007/s11920-012-0274-y.
Mojtabai R Clinician-identified depression in community settings: concordance with structured-interview diagnoses. Psychother Psychosom 2013;82:161–169. doi:https://doi.org/10.1159/000345968.
Mojtabai R, Olfson M. Proportion of antidepressants prescribed without a psychiatric diagnosis is growing. Health Aff 2011;30(8):1434–1442. doi:https://doi.org/10.1377/hlthaff.2010.1024.
Rushton JL, Felt BT, Roberts MW. Coding of pediatric behavioral and mental disorders. Pediatrics. 2002;110(1).
Rost K, Smith GR, Matthews DB, Guise B. The deliberate misdiagnosis of major depression in primary care. Arch Fam Med 1994;3:333–337.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, 4th Ed., Text Revision. 4th edn. Arlington: American Psychiatric Association; 2000.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5, 5th Ed. 5th ed. Arlington: American Psychiatric Association; 2013.
Leigh H, Stewart D, Mallios R. Mental health and psychiatry training in primary care residency programs B Part II. What skills and diagnoses are taught, how adequate, and what affects training directors’ satisfaction? Gen Hosp Psychiatry 2006;28:195–204. doi:https://doi.org/10.1016/j.genhosppsych.2005.10.004.
Siu AL, Bibbins-Domingo K, Grossman DC, et al. Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA 2016;315(4):380–387. doi:https://doi.org/10.1001/jama.2015.18392.
Siu AL, U.S. Preventive Services Task Force. Screening for depression in children and adolescents: US Preventive Services Task Force recommendation statement. Pediatrics 2016;137(3):1–8. doi:https://doi.org/10.1542/peds.2015-4467.
O’Connor E, Rossom RC, Henninger M, et al. Screening for Depression in Adults: An Updated Systematic Evidence Review for The U.S. Preventive Services Task Force. Rockville: Agency for Healthcare Research and Quality; 2015.
Thombs BD, Ziegelstein RC, Roseman M, Kloda LA, Ioannidis JP. There are no randomized controlled trials to support the United States Preventive Services Task Force guideline on screening for depressionin primary care: a systematic review. BMC Med. 2014;12:13. doi:https://doi.org/10.1186/1741-7015-12-13.
U.S. Department of Health & Human Services: Office of the Assistant Secretary for Planning and Evaluation. Percentage of Primary Care Physician Office Visits that Include Depression Screening. Health System Measurement Project. https://healthmeasures.aspe.hhs.gov/measure/258. Accessed 12 March 2018.
U.S. Preventive Services Task Force. Screening for depression in adults: U.S. Preventive Services Task Force recommentaion statement. Ann Intern Med. 2009;151(11):785–792.
Schneider D, Appleton L, McLemore T. A Reason for Visit Classification for Ambulatory Care. Vol 2. Hyattsville: National Center for Health Statistics; 1979. https://www.cdc.gov/nchs/data/series/sr_02/sr02_078.pdf. Accessed 12 Oct 2018.
World Health Organization. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). Geneva: World Health Organization; 2008.
Multum. Denver, CO: Cerner Corporation https://www.cerner.com/solutions/drug-database. Accessed 19 April 2018.
StataCorp. Stata Statistical Software: Release 15. 2017.
Using Ultimate Cluster Models with NAMCS and NHAMCS Public Use Files. National Center for Health Statistics, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2004. https://www.cdc.gov/nchs/data/ahcd/ultimatecluster.pdf. Accessed 19 April 2018.
Dugoff EH, Schuler M, Stuart EA. Generalizing observational study results: applying propensity score methods to complex surveys. Health Serv Res 2014;49(1):284–303. doi:https://doi.org/10.1111/1475-6773.12090.
McGoey ST, Huang KE, Palmes GK. Low depression screening rates in U.S. ambulatory care. Psychiatr Serv. 2013;64(10):1068.
Schmitt MR, Miller MJ, Harrison DL, Touchet BK. Relationship of depression screening and physician office visit duration in a national sample. Psychiatr Serv 2010;61(11):1126–1131.
Bhattacharjee S, Goldstone L, Vadiei N, Lee JK, Burke WJ. Depression screening patterns, predictors, and trends among adults without a depression diagnosis in ambulatory settings in the United States. Psychiatr Serv 2018;69(10):1098–1100. doi:https://doi.org/10.1176/appi.ps.201700439.
Pignone MP, Gaynes BN, Rushton JL, et al. Screening for depression: systematic evidence review. 2002.
Forman-Hoffman V, McClure E, McKeeman J, et al. Screening for Major Depressive Disorder Among Children and Adolescents: A Systematic Review for the U.S. Preventive Services Task Force. Rockville: Agency for Healthcare Research and Quality; 2016.
Whooley MA. Screening for depression—a tale of two questions. JAMA Intern Med 2016. doi:https://doi.org/10.1001/jamainternmed.2015.8493.
Richardson LP, Rockhill C, Russo JE, et al. Evaluation of the PHQ-2 as a brief screen for detecting major depression among adolescents. Pediatrics 2010;125(5):e1097–103. doi:https://doi.org/10.1542/peds.2009-2712.
Goldberg D. The value of screening in patient populations with high prevalence of a disorder. 2011. doi: https://doi.org/10.1186/2046-1682-4-13.
Kwan BM, Nease, DE. The State of the Evidence for Integrated Behavioral Health in Primary Care. In: Talen M, Burke Valeras A, eds. Integrated Behavioral Health in Primary Care. New York: Springer; 2013:65–98. doi:https://doi.org/10.1007/978-1-4614-6889-9_5.
Akincigil A, Olfson M, Siegel M, Zurlo KA, Walkup JT, Crystal S. Racial and ethnic disparities in depression care in community-dwelling elderly in the United States. Am J Public Health 2012;102:319–328. doi:https://doi.org/10.2105/AJPH.2011.300349.
Bauer MS, Leader D, Un H, Lai Z, Kilbourne AM. Primary care and behavioral health practice size: the challenge for health care reform. Med Care 2012;50(10):843–848. doi:https://doi.org/10.1097/MLR.0b013e31825f2864.
Trangle M, Gursky J, Haight R, et al. Health care guideline: depression in primary care. 2016.
Gaynes BN, Rush AJ, Trivedi MH, et al. Primary versus specialty care outcomes for depressed outpatients managed with measurement-based care: results from STAR*D. J Gen Intern Med 2008;23(5):551–560. doi:https://doi.org/10.1007/s11606-008-0522-3.
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Samples, H., Stuart, E.A., Saloner, B. et al. The Role of Screening in Depression Diagnosis and Treatment in a Representative Sample of US Primary Care Visits. J GEN INTERN MED 35, 12–20 (2020) doi:10.1007/s11606-019-05192-3
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