Regular screening for depression can help, but treatment must be timely

Key points to remember

  • A recent study found that even when providers screened all patients for depression, people did not necessarily receive timely treatment.
  • Nearly a quarter of people diagnosed with depression did not receive treatment within a year.
  • Integrated health care has benefits and its ability to fight stigma.

What if at each check-up, your doctor asked you questions about your mental health? A recent study of a healthcare system that screens for symptoms of depression through regular checkups found mixed results on whether it helps people get the treatment they need.

Providers who check mental health regularly can help detect symptoms early, as well as connect patients to potentially life-saving support and care. But that care, according to the study, doesn’t always happen in a timely manner. The study was published in Open JAMA Network early March.

Lucinda Leung, MD, PhD, MPH, study author and physician at West Los Angeles Veterans Affairs (VA) Medical Center, and her colleagues charted the care pathways of more than 600,000 VA patients who tested positive for the Depression. They found that most patients who screened positive and were diagnosed did not receive timely follow-up care. Nearly a quarter did not even receive minimal treatment within a year.

According to experts, these results confirm the need for more integrated health care systems. Leung told Verywell that integrated healthcare and collaboration between medical professionals in treating the individual can be extremely beneficial.

“We know that’s what we’re supposed to do,” she said. “The hardest part is changing the culture and restructuring the clinics to spread this model of care.”

This study reflects how the historical lack of a person-centered approach to treating depression and mental health continues to act as a barrier to care for many people.

Universal screening as a step forward

When you go to a health care provider for a checkup, you’re likely greeted by the same familiar steps.

It can be like stepping on the scale to measure height and weight, having a cuff wrapped around your arm to check blood pressure, and feeling the stethoscope against your chest to assess lung health. Your provider may also ask you questions to see if you have depression.

What does screening for depression look like?

The screening for depression mentioned in this study is called the “2-item Patient Health Questionnaire,” also known as PHQ-2. Health practitioners use it to assess a patient’s frequency of depressed mood and anhedonia, or loss of pleasure, over the past two weeks. A representation of what this might look like can be viewed here.

If, after screening, your provider follows you and diagnoses you with depression, “timely follow-up care” from there is defined as receiving at least one of the following within three months:

  • Three or more specialist mental health visits
  • Three or more psychotherapy visits
  • Three or more primary care visits with a diagnosis of depression

To see how common and timely this follow-up care was, Leung and her colleagues tracked the care pathways of those who tested positive for depression at 82 VA clinics in California, Arizona and New Mexico. The sample included over 607,000 veterans. Over the years analyzed (2015-2019), about 8% of people tested positive for new symptoms of depression at one of the VA clinics.

But a positive first screening does not diagnose depression. Doctors need to do more evaluations to confirm. The study found that among veterans who were subsequently officially diagnosed, the majority did not use one of three follow-up care options in time – only 32% did so within three months. .

“Depression is the leading cause of disability worldwide,” Leung said. That’s why it’s so important to tackle depression and connect people to treatment options in time.

Leung and colleagues found that 77% completed at least the minimum recommended treatment, which includes at least one of the following treatments within 12 months:

  • Sixty days or more of antidepressant prescriptions filled
  • At least four specialist mental health visits, or
  • Three or more psychotherapy visits

However, this follow-up care was not considered timely and still meant around a quarter of people did not receive it within a year of testing positive for depression.

Leung and his colleagues also noted that health systems outside of the VA struggled to keep up with patients at an even higher rate. On average, only about a third of patients even start taking medication and/or have at least one psychotherapy session within three months of a new diagnosis of depression. Follow-up is even less common for patients of color and patients age 60 and older.

To better understand this issue, the authors write, continued research into “mapping” access to care pathways is needed. For example, further research could more clearly define barriers to care, ways in which healthcare professionals might be more collaborative in care, or whether universal screenings lead to over-detection of depression.

Racial disparities in care

While the results don’t point to a perfect system, they did note something surprising and hopeful: There was an absence, and possible reversal, of some racial disparities in receiving care.

The initial group of patients was predominantly male (90%), predominantly white (56%), and had an average age of approximately 60 years. Black veterans were treated with antidepressants at lower rates than white veterans, as has been observed in the past.

However, when all veterans are taken into account, including those who chose to undergo non-drug treatment or traditional talk therapy, historical racial disparities evaporated. Black veterans were more likely than white veterans to receive timely follow-up overall.

“This study continues to support that systematic improvement in the quality of screening and treatment are potential tools for mitigating racial and ethnic disparities in mental health care,” the authors wrote.

However, Leung and his colleagues consistently found that follow-up was less likely for people from certain backgrounds who had already been identified as having unequal access to care. Usually, people over 65 and those with chronic physical comorbidities have a harder time accessing treatment.

A model for other health systems

For more than two decades, the VA has mandated annual depression screenings for all patients. But only a few years ago, in 2016, the US Task Force on Preventive Services recommended universal screening for depression for all adults.

In this way, Leung said, the VA has been a model for other health systems. It can show them what integrated health care could look like. “I thought it was time to show people that we do this at the VA,” she said.

When a veteran tests positive for depression at the VA, he and Leung are already connected to a larger network. “Right next to me is a psychologist, a social worker,” she said. “I have access to a psychiatrist if I need more help to further address the issues the patient tells me about.” The matter can be addressed at the clinic right away, she added. For example, if a patient needs further evaluation at the psychiatrist’s office, the provider and patient can travel together.

The evidence for integrated healthcare and collaborative care models in general is strong: it allows easier and seamless access to different healthcare professionals, as well as experts working together to treat the individual.

“I think a lot of places recognize that it’s a good system not just for veterans, but for all civilians,” Leung said.

What this means for you

If you or someone you know has symptoms of depression, talk to a healthcare provider about treatment options. You can find someone to talk to by calling the SAMHSA National Helpline, 1-800-662-HELP (4357). There is also an online treatment locator.

About Antoine L. Cassell

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