Screening for Depression and Suicide in Primary Care

Screening for Depression and Suicide in Primary Care

A Review of Some Recent Journal Articles

Background:

The World Health Organization predicts that by the year 2020, depression will be the leading cause of disability in the world (Murray & Lopez, 1997 in Arroll, et.al., 2005).  According to “A Report on Mental Illness in Canada” (Health Canada, 2002) 8% of Canadians will experience a mood disorder at some point in their lifetime.  The annual prevalence for Major Depressive Disorder in Canada is 4.5% (Patton & Beck, 2004).  Depression is associated with increased risk of suicide (Lesage, 2005).  Suicide is the 11th leading cause of death in Canada (Stats Canada, 1997).  Approximately 90% of persons with a major depressive episode visit their family physicians during the year of the episode (Patton & Beck 2004) and 45% of suicide victims had contact with primary care providers within 1 month of suicide (Luoma et.al., 2002).

Questions:

Are primary care providers in a unique position to identify depression and suicidality?  Should screening for depression and / or suicide be routine practice in primary care?  How could such screening be conducted?


SCREENING FOR DEPRESSION IN PRIMARY CARE

International Recommendations:

Canadian Recommendations

The Canadian Task Force on Preventive Health Care (CTFPHC) released updated recommendations on screening for depression in primary care in July 2004 (MacMillan et.al.).  After reviewing the prevalence of depression in primary care settings, the burden of suffering, screening processes used, treatment outcomes and the evidence and recommendations of others, the CTFPHC concluded that “there is fair evidence to recommend screening adults for depression in primary care settings since screening improves health outcomes when linked to effective follow-up and treatment” (2004, p. 7).  It further concluded that “there is insufficient evidence to recommend for or against screening adults for depression in primary care settings where effective follow-up and treatment are not available.”

“Effective follow-up and treatment” was identified as screening programs that were integrated with both feedback to the clinician regarding depression status, as well as a system for managing treatment, such as antidepressant medications and psychotherapeutic interventions.  Case management or mental health care as part of the system of care were found to be particularly effective in reducing depressive symptoms.  The CTFPHC acknowledged that “since integrated screening and feedback/treatment systems are not the norm in Canadian primary care practice, clinicians are encouraged to advocate for them,” (p. 7).

U.S.A. Recommendations

The U.S. Preventive Service Task Force (USPSTF) issued a similar recommendation (2004).  It recommends “screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and followup.”  The USPSTF goes on to provide the following information:

Trials that have directly evaluated the effect of screening on clinical outcomes have shown mixed results.  Small benefits have been observed in studies that simply feed back screening results to clinicians.  Larger benefits have been observed in studies in which the communication of screening results is coordinated with effective followup and treatment.

Australian Recommendations

Australia has also concluded that “although controversial, the evidence is now in favour of the appropriate use of screening tools in primary care”, (Hickie, et.al., 2002).  In a systematic evaluation of available research into screening for depression and outcomes, the authors tried to answer the following questions:

  • Can screening tools efficiently and accurately identify patients with depression?
  • Do clinicians use the information obtained from screening tools to assist with diagnosis and treatment planning?
  • Is the outcome of patients with depression improved within practice settings that use screening tools (alone or in combination with other techniques)?
  • Is there evidence that the benefit is limited to specific subpopulations of patients?

Hickie, et.al. (2002) found that brief self-report screening instruments have acceptable psychometric properties and are practical.  They also found  that when screening instruments are used appropriately, clinician recognition of depression was increased, and when accompanied by commitment to implement system changes to provide prompt and coordinated follow-up of diagnosis and treatment, better outcomes were achieved.  They caution, however, that screening should only be conducted by “those health services that are committed to using the information to provide enhanced care,” (p. S112).

British Recommendations

The National Institute for Health and Clinical Excellence (NICE) in England and Wales has taken a more cautious approach to screening.  It recommends that screening should be offered only to those who are at high risk for depression, (Gilbody, et.al., 2006).

Screening should be undertaken in primary care and general hospital settings for depression in high-risk groups—for example, those with a past history of depression, significant physical illnesses causing disability, or other mental health problems such as dementia.

NICE bases its caution on the lack of access to timely diagnosis, follow-up, and treatment following a positive screen for depression, and lack of commitment to use such follow-up when it is available.

Cautions Regarding Screening:

Several researchers and reviewers have identified other considerations when thinking about implementing a universal screening process for depression in primary care settings.  A major consideration is the existence of and access to effective follow-up and treatment, which is specifically mentioned in the recommendation of the CTFPHC.  Other considerations include:  commitment to use effective, available treatments by both referring primary care clinicians and the clients themselves; scarce available resources, including the time of the primary care clinician; the type of depression that would benefit most from early recognition and intervention; the nature of depression and the need to re-administer screening instruments to identify ongoing depression; the particular populations that are most at risk and the differing screening instruments/processes needed for each population.  Finally, some authors argue that there is a need for a paradigm shift regarding depression, from one of acute episodes to a view of depression as a chronic illness.

Commitment to Follow-up

The question of “commitment” to providing “effective follow-up and treatment” has been raised by some reviewers.  Palmer and Coyne (2003) reviewed studies of screening and follow-up in the U.S. and suggest that there are “significant barriers on the part of both physicians and patients to the implementation of depression screening and treatment as a routine part of clinical practice,” (p. 5).

They note that studies of screening and follow-up in primary care bring the benefit of administrative and logistical supports that are not likely available in most primary care settings:  provision of nursing and non-clinical staff support, pre-selected self-report screening tools, and brief structured interviews for clinicians.  Palmer and Coyne report that between 30 to 60% of patients refuse to complete the screen.  Of those that do complete, 80% screen positive and require the diagnostic interview.  In one study, of those screening positive, about 30% were diagnosed with major depression, dysthymia or both, but half of those already had a diagnosis and were being treated.  The number of “undiagnosed and potentially treatable patients” discovered was small, and only 19 out of 128 were offered antidepressant medication.  In another study, again 80% of respondents screened positive but only 21% of those were followed up with support.  Eight weeks after the withdrawal of added support for the study, there was no use of the screening tool or the brief structured interview by clinicians.  One of the researchers also questioned how often the guidelines were appropriately applied even during the study (Valenstien in Palmer & Coyne, 2003, p. 5).

In a related vein of inquiry, Carol Herbert (1995) looked at the Canadian context to see how many Canadian physicians were aware of and followed the guidelines issued by the Canadian Task Force on Periodic Health Examination, related to clinical health promotion.  She found that while various attempts have been made at dissemination of the guidelines, the task force has been limited in its influence on practicing physicians.  She concludes that “as medical organizations continue to develop strategies for implementation and dissemination of clinical prevention and health promotion in practice, it is essential that these be practical and realistic for physicians in the real world and that they be tested as o their utility before wholesale adoption,” (p. 281-281).

Resources

Another related issue identified with a cautionary note in the literature is the use of limited resources.  A U.S. study by Blumenthal, et.al, (1999) determined that the average length of a primary care visit for adults was about 16 minutes.  Older patients, new patients and those referred by other physicians, as well as patients with psychosocial problems had “significantly longer visits”.  The performance of three or more preventive screening tests, such as screening for depression, increased the visit length by 25%.  A Global Healthcare Productivity Project review of data (GHP, 2001) indicated that the average length of a primary care visit in Canada was less than 15 minutes.  In the Palmer and Coyne review mentioned previously (2003), clinicians averaged 8.4 minutes in follow-up interviews after a positive screen for depression, representing “a substantial increase in the length of a routing visit for primary care,” (p. 281).

If 80% of respondents in a primary care setting will screen positive for depression, and require a physician conducted diagnostic interview and intervention, this will result in more time spent with patients, reducing the number of patients that each physician can see daily.

Type of Depression & GPs Ability to Identify

Researchers and reviewers also raise questions about the type of depression encountered in primary care.  Klinkman, Schwenk and Coyne (1997) have questioned the assumption that “depression is depression” and suggest that “’depression’ in primary care may be very different from depression seen in psychiatric settings,” (p. 971).  They conclude that patients with depression in primary care have “less severe” depression and “greater functional status” than those seen in psychiatric settings.  They also found that the onset of depression seen in family practice settings is often preceded by a severe life event, but this was not the case in psychiatric settings.  Others have also raised the question about the type of depression and have found that screening in primary care settings often identifies “depression and transient distress, found in response to psychosocial problems and life events” with symptoms that resolve in two to four weeks, (Gilbody, et.al., 2006).  Gilbody and co-authors also note that evidence based treatment guidelines recommend an initial period of ‘watchful waiting’ before undertaking active intervention.

Kessler (2005) argues that “G.P.s are effective at identifying mental health problems in patients that they know” and that “the diagnosis of a mental health disorder is a process that often takes more than one consultation and evolves in a context of trust,” (p. 000).  Klinkman, et.al. (1997) also found that primary care physicians were quite sensitive in detecting depressed patients who were overtly psychologically distressed, had more symptoms of greater intensity, and displayed their psychological distress as anxiety….Undetected depressed primary care patients had milder depression and functioned at a higher level than those who were detected, who were in turn more mildly depressed and more functional than psychiatric patients.  (p. 969)

Primary care physicians may ‘miss’ detecting depression that is less severe, less disabling, results from a significant life event, and is likely to resolve itself in 2 to 4 weeks.  Some researchers question whether universal screening is the best approach to take, or would it be better to use selective screening for groups at high risk for depression?

Targeted Screening vs. Universal Screening

The National Institute for Health and Clinical Excellence (NICE) in England and Wales has previously been quoted as advocated selective screening for those at high risk for depression.  Sharp and Lipsky (2002) also recommend targeted screening in high-risk patients as an alternative approach to identifying patients with depression.  They identify the following as indications for screening in adults (p. 1006):

  • First-degree biologic relative with history of depression
  • Two or more chronic diseases
  • Chronic pain (e.g., backache, headache)
  • Impoverished home environment
  • Financial strain
  • Experiencing major life changes
  • Pregnant or postpartum
  • Socially isolated
  • Multiple vague symptoms (e.g., gastrointestinal, cardiovascular, neurological)
  • Fatigue or sleep disturbance
  • Substance abuse, such as alcohol or street drugs
  • Loss of interest in sexual activity
  • Elderly age

Appropriate Screening Instruments

Sharp and Lipsky also provide a review of possible screening instruments that could be used in primary care settings across the lifespan.  They note “depression measures should be selected based on the patient population,” (p. 1007) meaning one size will not fit all.  This makes screening more complex, but also relies on the physician to know her/his patients and their circumstances before screening.

The USPSTF review (2002) recommends the Beck fast scan or the patient health questionnaire for use in primary care settings as general screening instruments.  The Beck instrument is seven questions long and has a cost involved.  The patient health questionnaire is nine questions long.  As an alternative, two questions have been identified (Whooley, et.al., 1997) that have similar sensitivity (96%) and specificity (57%) to the other longer screening instruments.  They are:  “during the past month have you often been bothered by feeling down, depressed or hopeless?” and “during the past month have you often been bothered by little interest or pleasure in doing things?”   Arroll, et.al. (2005) have found that adding a third question, “is this something with which you would like help?”, with three possible responses of “no,” “yes, but not today,” or “yes.”  The addition of the ‘help’ question significantly decreases the chance of a false positive screen, which would reduce the number of follow-up diagnostic interviews and interventions the primary care clinician would have to make.

Some researchers have questioned the validity of most screening instruments with a primary care population, (summarized in Klinkman, et.al., 1997).  They argue that diagnostic criteria derived from the psychiatric research setting may not be valid for primary care patients, based on the different type of depression commonly seen in primary care.  Dowell (2004) echoes this thought when he says:

This classification and diagnosis of mental health disorders based on secondary care thinking does not fit well into primary care diagnostic and management frameworks, yet often shapes and constrains our clinical thinking.  Many of our patients who are distressed or ‘act funny’ are classified according to predefined criteria that bear little resemblance to patterns of symptoms and disability recognized by a GP.  (p. 371)

Relationship Between Patient & Primary Care Clinician

Primary care providers, including physicians, have a unique relationship with their patients and see symptoms/behaviours and presentations that are unique to the treatment setting.  The MaGPIe study in New Zealand (Mental Health and General Practice Investigation, 2003) supports the concept that GPs are able to identify depression and other mental disorders in patients they knew well.  If the patient had been seen five or more times in the previous year, they were able to identify 80% of their patients who had clinically significant symptoms, but that fell to only about one third of those patients who had not been seen in the previous 12 months, (Dowell, 2004).  In Australia, Hickie, et.al. (2002) note that the self-report instruments used to screen for depression require the person to disclose the symptoms of mental disorder voluntarily.

Importantly, such instruments are predictive of a person’s recognition of need for appropriate psychological assessment.  In essence, such methods are less about screening and more about efficient methods for prompting voluntary disclosure of key psychological symptoms.  Other doctor and patient factors clearly influence disclosure of psychological symptoms, so acceptance of screening tools will be affected by those same factors (eg, doctor’s communication skills, patient’s understanding of the nature of their symptoms, time that the doctor is likely to spend with the patient, doctor’s confidence ink providing psychological treatments, doctor’s training in mental health.  (p. S115)

The MaGPIe research also identified patient-related barriers to identification.  Up to one third of patients with a diagnosable disorder gave a reason why they found it difficult to disclose problems to their doctor.  The most common reasons were that they believed they should be able to dealt with the problem themselves and that a GP was not the right person to talk to about psychological problems, (Dowell, 2004).  Other studies in New Zealand, summarized by Dowell, indicate that between 3.1% and 7.6% of patients identified a mental health problem as the main presentation at the consultation.

Alternative to Universal Screening

Dowell (2004) suggests an alternative to universal screening that advocates screening of new and infrequently seen patients and to restrict more routine screening to situations where continuity is not a feature of care such as after-hours or urgent and emergency medical clinics.  This thought is echoed by Arroll and colleagues (2005) who suggest that screening questions “be presented to all new patients attending general practice and to patients who have not been to see their general practitioner for about two years,” (p. 3 of 4).  This may still translate into almost universal screening in Canada, where it is reported that on average people see their family physician less than two times per year, (GHP, 2001).

General Discussion:

Much attention has been given to the question of universal screening for depression in primary care settings over the past decade.  While some jurisdictions, including Canada, have issued formal statements in support of universal screening, they have done so with a cautionary statement—that such screening should only be undertaken where there is a strong commitment to provide follow-up and treatment.  There is also recognition that such follow-up and treatment is not always readily available.

Many researchers have raised questions about the feasibility of such screening, as well as the resulting patient outcomes following screening.  There is consensus that screening alone does not produce positive outcomes, (Gilbody, et.al., 2006, Dowell, 2004, Kessler, 2005, Hickie, et.al., 2002, Palmer & Coyne, 2003).

What is telling is that physicians have written to medical journals, questioning the need for screening for depression, (Dowell, 2004, Kessler, 2005).  It may be a hard sell to convince primary care clinicians to conduct routine screening, even with training and resource materials made available to them.  A better use of time and resources may be to increase the general populations understanding and appreciation of depression so that individuals might self-identify to care providers with depression.   Guidelines for treatment and/or referral of cases of depression would then be helpful for primary care providers.


SCREENING FOR SUICIDE IN PRIMARY CARE

International Recommendations:

Canadian Recommendations

In 1994, the former Canadian Task Force on the Periodic Health Examination (now the CTFPHC) found insufficient evidence to recommend for or against routine evaluation of suicide risk and recommended that physicians should remain alert to the possibility of suicide in high risk patients, particularly if there is evidence of psychiatric disorder, depression, or substance abuse or if the patient has recently attempted suicide or has a family member who committed suicide, (McNamee & Offord, 1994 in USPSTF, 2004).  Patients who are asymptomatic for any of the high risk categories do not require universal screening.

U.S. Recommendations

The U.S. Preventive Services Task Force (USPSTF) conducted a review of the research from 1966 to 2002 and “recommends neither for nor against screening for suicide as part of routine primary care,” (2004, p. 820).  It goes on to say that both doctors and patients should address suicide risk during primary care visits if either believes a patient is in danger of intentionally harming him or herself.

Rationale

The USPSTF review found no evidence that screening for suicide risk reduces suicide attempts or mortality; limited evidence of the accuracy of screening tools to identify suicide risk in the primary care setting; insufficient evidence that treatment of those at high risk reduces suicide attempts or mortality; and no studies that addressed the potential for harms of screening and/or treatment for suicide risk in primary care settings.  Based on this evidence or lack thereof, the recommendations were made.

The review did, however, note that while the evidence was only fair and mixed that treating those at risk for suicide reduces the number of suicide attempts or completions, there was mild to moderate evidence that interventions addressing suicidal ideation, severity of depression, severity of hopelessness, and level of functioning resulted in improvements of these “intermediate outcomes.”  This seems to suggest that while interventions may not improve the quantity of life, they seem to improve the quality of life.

The USPSTF review also noted the number of false positives that result from screening that could result in a substantial time and cost burden.  The task force commented on the rarity of suicide in the primary care population and the challenge of finding an accurate screening strategy.

Populations at High Risk for Suicide:

The USPSTF review identified the following as risk factors for suicide:

  • Demographic
  • Clinical
  • Other
    • Age 65+
    • White males, 85+
    • Age 15 to 24
    • Males more completions
    • Females more attempts
    • Psychiatric diagnosis
    • Hopelessness
    • Previous attempts
    • Widowed, divorced or living alone
    • Recent adverse life event
    • Severe anxiety
    • Chronic medical illness
    • Family history of suicide

Of these risk factors, some are of particular note.  The elderly have the highest risk for completed suicide, almost 6 times as many per 100 000 persons as adolescents.  Nearly 75% of all completed suicides are by white men.  More than 90% of those who complete suicide have a diagnosable mental illness at the time of death.  Hopelessness is more indicative of suicidal ideation than depression.  Two thirds of suicide occurs on the first attempt, (Gaynes, et.al., 2004).

Guidelines for Management of Suicidal Risk:

New Zealand and the U.S. both published best practice guidelines on the management of identified suicidal risk in 2003, (New Zealand Guidelines Group & American Psychiatric Association).  These guidelines begin at the point where an individual has identified suicidal ideation—either through talking about it or by making an attempt at self-harm or suicide.   The guidelines explain how to assess for level of risk and how to intervene, but do not address the issue of how to identify individuals at risk who have not yet self-identified.

Identifying Individuals in High Risk Populations:

Much has been made of studies that report on the prevalence of visits to primary care clinicians by individuals who later complete suicide.  On average, 45% of suicide victims had contact with primary care providers within one month of suicide, (Luoma, et.al., 2002).  But what are these visits like?  Do individuals who complete suicide present differently than individuals who do not?  Schulberg and colleagues (2004) found after reviewing medical records that patients seldom explicitly inform primary care physicians of their plans.  Individuals have “complex, subtle, and even convoluted ways in which they overtly or covertly seek and respond to help when experiencing death wishes,” (p.340).  They found that in about 60% of pre-suicide primary care visits, there were components of depression, worries, psychosocial disturbances, and reports of daily pain.  They also found that about 205 of physicians responding to case vignettes of suicidal patients feared stimulating suicidal ideation by asking about it, (Stoppe, et.al., 1999 in Schulberg, et.al., 2004).  Physicians may suspect suicidality but be reluctant to ask about it out of fear and not knowing how to respond.

Screening Patients with Depression

A common suggestion has been to ask all patients with depression if they are suicidal, as depression has been identified as highly correlated to suicidal ideation, (Pfaff & Almeida, 2004; Chochinov, et.al., 1998; Lesage, 2005; Schulberg, et.al., 2004; Links & Hoffman, 2005; Luoma, et.al., 2002; & Sanchez, 2001).  Asking specifically about suicide when treating people for depression is a good idea.  However, a recent Canadian study (Rhodes, et.al., 2006) has found that two thirds of people who are suicidal have no depression.  In their study that used data from the Canadian Community Health Survey, Rhodes and colleagues also found that individuals who are suicidal but not depressed are considerably less likely to seek mental health service, either from specialist services or from primary care providers.

Moving Beyond Screening to Health Promotion:

Some people have called for alternative approaches to preventing suicide other than identifying and treating those at risk.  Thompson (2005) has stated that the medical model is ineffective in suicide prevention because:

Suicide s strongly linked to other social problems:  rates are higher in communities with a weak social fabric, they are higher among individuals who are left out of the mainstream…a comprehensive approach cannot be forthcoming from a services that does not mobilize until after the appearance of major problem and that is unable to alter the social and family environment of potentially and actively  suicidal individuals.  (p. 510)

Others also call for a way to address other risk and resiliency factors, both at the individual level and at the population level to prevent suicide, (van Praag, 2004; Sanchez, 2001; Heisel, 2006).  Heisel states “resiliency factors include integration in social networks and clubs, religious practice, having a hobby, and perceiving that life is meaningful and worth living,”  (p. 151).  These are all factors that go beyond the ability of a primary care physician to treat.

General Discussion:

Suicide is the eleventh leading cause of death in both Canada and the U.S. (Statistics Canada, 1997; Gaynes, et.al., 2004) and is the seventh leading cause of years of potential life lost in the U.S. (Gaynes, et.al., 2004).   Since a significant number of individuals who later commit suicide have contact with a primary care provider in the year or month leading up to their death, suggestions have been made that universal screening for suicide should take place in primary care.  To date, no such recommendation has been made by any North American body.  Arguments against such screening include lack of evidence about the effectiveness of screening and/or treatment on suicide rates.  There is a question about valid screening instruments for use in primary care, as well as the number of false positives that would occur and the time and cost that would result from assessing all of these false positives.  In addition, a recent Canadian study suggests that many people who are suicidal are not depressed, and are less likely to seek help from service providers, including primary care physicians, than people who are both suicidal and depressed.

Despite evidence that asking about suicidal ideation does not increase rates of suicide, many physicians are reluctant to broach the subject with patients.  It would seem advisable to provide primary care clinicians with education about high risk factors for suicide in order to help them identify when asking about suicide is indicated.  Further education about how to ask the questions and how to assess level of risk would also be helpful, perhaps using a risk factor model.  Finally, establishing guidelines for primary care clinicians about when they are suited to provide intervention (as well as what type of intervention) and when it is best to refer to specialist services would seem to be more useful than implementing universal screening at this time.


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