Treatment Strategies of Screening for Depression in Primary Care
Alan G. Silverman, M. D.
The U. S. Preventive Services Task Force recommends screening adults for
depression in clinical practices that have systems to assure accurate diag-nosis,
effective treatment, and follow-up. 1
Depression disorders cause a substantial
amount of under recognized morbidity and mortality in primary care patients.
Each year, nearly one out of ten adults has a depressive disorder, and up
to 20% of patients examined by primary care physicians meet the criteria for
major depressive disorder. Major depressive disorder is present in 40%-65%
of patients with significant coronary heart disease, 10%-27% of stroke survivors,
and 25%-50% of cancer patients.
Twelve-month disability rates for patients
diag-nosed with depression exceed those for myocardial infarctions and diabetes.
Up to 15% of patients with major depressive disorder die by suicide. 2 The
patient with depressive disorder is generally initially seen by the primary
care physician. A series of studies have found that up to 50% of cases of
major depressive disorder are missed by the primary care physician, and more
than 70% receive inadequate treatment. 3
Many formalized screening tests are
available, such as the Zung Self-depression Scale, Beck Depression Inventory,
General Health Questionnaire, and Center for Epidemiologic Study Depression
Scale. These screening instruments ask two major questions about mood and
anhedonia. 1) Over the past
two weeks have you felt down, depressed, hopeless? 2) Over the past two weeks
have you had little or no interest or pleasure in doing things? There is little
evidence to recommend one screening method over another, most have good sensitivity
(80%-90%), but only fair specificity. With this in mind, a pilot project was
undertaken to improve diagnostic accuracy and coordination of care with anti-depressants
and psychi-atrists. In a parallel project, UCLA psychiatrists used the same
instrument for screening and treating patients. The study established a \"shared
lab test\" for efficient consults, referrals, and treatments.
The systems delineated
impairment of function, improved diagnosis, identified high-risk patients
(those needing hospitalization or immediate psychi-atric referral), established
treatment guidelines, moni-tored compliance, and streamlined the referral process.
The two projects enrolled over 4,000 patients (in a number of medical settings)
and 60 physicians. Our office had 18 patients registered in the program.
In fact, one of the patients was a psychiatrist who, to his amazement, learned
he was depressed and agreed to receive treatment.
The evaluation was automated
(no one-on-one questioning), which made it more objective and accessible
over the phone or via the Internet (a 10- minute phone call with the questions
to be answered). The results were faxed to the primary care office within
15 minutes, noting functional impairment and diagnosis. Treatment was left
to the discretion of the primary care physicians. The physicians received a
line graph that plotted both the major depression score and function score
assessed at specific time intervals over a 5-month period. A significant decrease
in the major depression score to below 20 with an increase in function represent
a successful response to the treatment program.
For non-responders, treatment
options included increasing the medication dosage, changing to an alternative
medication, or adding another medication from a different family. The clinical
guidelines and algorithms were a compilation from various psychi-atric programs.
These guidelines included selection of medications, length of treatment,
side effects of drugs, and drug interactions. 3
In depression with anxiety,
our choices would include the SSRI anti-depressants such as paroxetine, sertraline,
fluoxetine, nefazodone, citaloprol, bupro-pion, and venlafaxine. With the
addition of anxiety that may be profound at this time, we would add benzodi-azepines
as needed for at least 1-2 weeks until the other medications became effective.
Most of these SSRI medications will take at least two weeks to start taking
effect and 4-6 weeks to evaluate their significant effect. It is important
that once the diagnosis of depression is made and there is successful response
that the patient should be reevaluated in 9-12 months. The physician then
determines whether tapering of medication is indi-cated. Guidelines for length
of treatment were included. First episodes were treated for approximately
nine months. For second episodes, treatment continued
for greater than one year after remission. The third episodes were treated
Patients were encouraged to call or log onto the system weekly
to monitor their progress. Follow-up results such as treatment reevaluations
or support, medication compliance, and side effects were again graphically
represented. The program was developed to utilize technology to improve the
quality and effi-ciency of care.
Clinically, the system worked very well
in uncov-ering major psychiatric disorders or demonstrated graphically to
the patients their response to treatment. The pilot project was stopped when
funding expired. This pilot study provided a novel way to standardize diagnosis
and treatment strategies of depression. This process should be initiated
by the primary care physi-cian with back-up support from the psychiatric team.
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