April Tererri

Anew recommendation by the U.S. Preventive Services Task Force that primary care physicians screen all adult patients for depression shouldn't be a big drain on time and resources, the USPSTF says. Although the task force does not recommend a screening vehicle, it suggests that the procedure can be completed inexpensively and with minimal use of doctors' time.

The task force recommendations supercede its 1996 conclusion that no recommendation could be made for or against routine screening because of insufficient evidence supporting either choice.

To be effective, screening must be just one part of a comprehensive system assuring accurate diagnosis, effective treatment, and careful follow-up.

"The task force found, in 14 randomized trials over the last five years, that the best-quality studies showing the greatest effects of screening were the ones that had the most comprehensive systems in place," says Alfred O. Berg, MD, MPH, who chairs the USPSTF.

Because no two studies used the same system, the task force was not specific about methodology, Berg notes. "What we have tried to say is: Screen, have a system in place, and pay attention to the details of the system. It's kind of like disease management systems."

Evidence base

Susan Pisano, vice president for communications at the American Association of Health Plans, says that the new recommendations are "not causing our community great concern" in terms of cost or impact on premiums.

"I think there is some offset that occurs when you identify people with depression and treat them appropriately," she says, adding that "This already is the case where providers with whom health plans are dealing are screening for depression."

The USPSTF recommendation (its findings are often a starting point for National Committee for Quality Assurance HEDIS recommendations) is likely to carry weight with health plans. "Our community is solidly behind the recommendations because they are evidence-based," says Pisano. "In general, coverage and attention should follow the evidence. If the task force says there is evidence that this is important to do — as is the case with pap smears, blood pressure, and colon cancer screenings — it is basing its recommendations on science."

Two simple questions

Five to nine percent of adults who see primary care providers suffer from depression. Because depression manifests itself in disguised maladies, up to half go undiagnosed and untreated. The cost associated with depression is staggering: $17 billion annually in indirect costs associated with lost work days, according to the task force, in addition to the direct costs of increased utilization.

Although there is a wide range of formal screening tools, the screening process can be as simple as having patients answer two questions: "Over the past two weeks, have you felt down, depressed, or hopeless?" and, "Over the past two weeks, have you felt little interest or pleasure in doing things?" Patients can answer these questions on a screening form, as they do with routine health-history forms.

The Task Force found no evidence-based answer to how often screening should occur. "You might want to screen high-risk individuals more frequently," says Berg. This group includes those who suffered major losses, who may have had depression in the past, who may have a family history of depression, or who are substance abusers.

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