1. Screening for depression in
medical settings: A 2015 Update
Public Health Research Centre Seminar
University of Hong Kong
9th December 2014
James C. Coyne, Ph.D.
Department of Health Psychology
University of Groningen, University Medical
Center Groningen (UMCG), Groningen, the
Netherlands
jcoynester@gmail.com

2. Screening for Depression
How do we evaluate a medical intervention?
How do we evaluate recommendations for a
medial procedure?
How do we challenge recommendations?

3. I'm a skeptic.
 Controversies are to be resolved by looking
at the available evidence.
 I’m skeptical about the quality of that
evidence.
 I believe that individuals and professional
organizations are not skeptical enough, often
have conflicts of interest that are worth
attention.
 I believe that you should be skeptical about
me and what I say and demand evidence.

4. Recognized in 1990’s
 Depression is a serious
source of suffering,
personal and social
impairment.
 Treatments such as
psychotherapy and
medication are effective.
 Most people who were
depressed were not
getting treatment.

5. The solution?
 Detect untreated
depressed persons,
diagnose them, and get
them into appropriate
treatment.
 The model: detect –>
diagnose –> initiate
treatment –> watch the
recovery.
 How to accomplish this?
Introduce routine
screening for depression.

6. DDeeffiinniinngg SSccrreeeenniinngg ffoorr
DDeepprreessssiioonn

7. SSccrreeeenniinngg ffoorr ddeepprreessssiioonn
 Involves using depression questionnaires or small
sets of questions to identify patients who may be
depressed, but who have not sought treatment
and whose depression has not already been
recognized by healthcare providers.
 Patients identified as possible cases need to be
further assessed and, if appropriate, offered
treatment.

8. SSccrreeeenniinngg ffoorr ddeepprreessssiioonn
 Screening is potentially useful only if it improves
patient outcomes beyond any detection and
treatment provided as part of existing standard
care.
 To be successful, a screening program must
identify a significant number of depressed patients
who are not already diagnosed with depression,
engage those patients in treatment, and obtain
sufficiently positive treatment results to justify
costs and potential harms from screening.

9. Those who propose screening assume a
burden to demonstrate that it improves patient
outcomes more than simply allowing the
patients and their healthcare providers access
to the same resources without screening.

10. WWhhoo ssaayyss ssoo??

12. A Digression: Screening for
Thyroid Cancer in Korea
Screening patients without symptoms has led
to 1500% increase in diagnosis since 1999.
No perceptible decrease in deaths due to
thyroid cancer.
Surgery leaves 10% with problems
metabolizing calcium, 2% vocal cord
paralysis, .2% deaths.

13. Why withdrawn?
The World Health
Organization recently
withdraw its
recommendation that
primary-care physicians
routinely screen women
for domestic violence.

14. I was skeptical about screening
for depression from the start,
but didn't think I would find
many people to agree with me.

15.  Community physicians missed over 2/3 of the
depression in patients coming for a visit.
 Most of the depression missed was mild and patients
were highly functioning.
 Most patients with missed depression had only the
minimum number of symptoms needed for diagnoses or
one more.

17. United States Preventive
Services Task Force (USPSTF)
“An independent panel of experts in primary
care and prevention that systematically reviews
the evidence of effectiveness and develops
recommendations for clinical preventive
services.“
The task force is a panel of primary care
physicians and epidemiologists. is funded,
staffed, and appointed by the U.S. Department
of Health and Human Services.”

18. U 2002 USSPPSSTTFF RReeccoommmmeennddaattiioonn
SSttaatteemmeenntt
Recommended in primary care settings ‘that
have systems in place to assure accurate
diagnosis, effective treatment, and follow-up’’

19. Screening for depression in medical care
Pitfalls, alternatives, and revised priorities
Steven C Palmer & James C Coyne
Change in recommendations based on 1 decisive
collaborative care study (Wells et al)
Personnel to administer and score screening instruments,
Training materials and academic detailing.
Depression management specialists.
Initiatives to ensure scheduling of follow up appointments,
Consultations & training with mental health professionals.
Ready access to antidepressants and psychotherapy.

20. Screening for depression in medical care
Pitfalls, alternatives, and revised priorities
Steven C Palmer & James C Coyne
Accumulating evidence from diverse
sources that recognition alone does not
translate into improved outcome for
depressed patients.
Difficulties sustaining screening programs in
routine care.

21. Rising rates of persons
receiving antidepressants

22. AAnnttiiddeepprreessssaanntt pprreessccrriippttiioonn rraatteess
wweerree aallrreeaaddyy hhiigghh aanndd ttrreennddiinngg
uuppwwaarrdd
 Among adults 35 years of age and older in the United
States, antidepressant use increased from 8.3% to
14.1% from 1996 to 2005 with a third to a half of
prescriptions specifically for psychiatric problems.
 In a 2005 study from Canada, 7% of a general
population sample reported current antidepressant use,
a figure higher than the estimated prevalence of major
depression (4%).

24. One size fits some: the impact of patient treatment
attitudes on the cost-effectiveness of a depression
primary-care intervention
JEFFREY M. PYNE a1c1, KATHRYN M. ROST a2,
FARAH FARAHATI a1, SHANTI P. TRIPATHI a1,
JEFFREY SMITH a3, D. KEITH WILLIAMS a4,
JOHN FORTNEY a1 and JAMES C. COYNE a5

25. Interpretation?
 Detecting cases of depression and having a
collaborative care system (care manager) are
cost effective for the 50% of patients
interested in a particular treatment,
antidepressants.
 Such a system of care is not cost-effective for
the other half of patients who don't want an
antidepressant.

26. Screening ffoorr DDeepprreessssiioonn iinn CClliinniiccaall
PPrraaccttiiccee AAnn EEvviiddeennccee--BBaasseedd GGuuiiddee
ISBN 0195380193
Paperback, 416 pages
Nov 2009 US
Feb 2010 UK

27. Screening for Depression iinn CCaarrddiioovvaassccuullaarr CCaarree
JJAAMMAA

28. SSuummmmaarryy
“The high prevalence of depression in patients with
CVD, the adverse health care outcomes associated
with depression, and the availability of easy-to-use
case-finding instruments make it tempting to
endorse widespread depression screening in
cardiovascular care. However, the adaptation of
depression screening in cardiovascular care settings
would likely be unduly resource intensive and would
not be likely to benefit patients in the absence of
significant changes in current models of care.”

29. AAmmeerriiccaann HHeeaarrtt AAssssoocciiaattiioonn
SScciieennccee AAddvviissoorryy

30. AAmmeerriiccaann HHeeaarrtt AAssssoocciiaattiioonn
SScciieennccee AAddvviissoorryy
 ““Although there is currently no direct evidence tthhaatt ssccrreeeenniinngg
ffoorr ddeepprreessssiioonn lleeaaddss ttoo iimmpprroovveedd oouuttccoommeess iinn ccaarrddiioovvaassccuullaarr
ppooppuullaattiioonnss,, ddeepprreessssiioonn hhaass bbeeeenn lliinnkkeedd ttoo iinnccrreeaasseedd mmoorrbbiiddiittyy
aanndd mmoorrttaalliittyy,, ppoooorreerr rriisskk ffaaccttoorr mmooddiiffiiccaattiioonn,, lloowweerr rraatteess ooff
ccaarrddiiaacc rreehhaabbiilliittaattiioonn,, aanndd rreedduucceedd qquuaalliittyy ooff lliiffee.. TThheerreeffoorree,, iitt
iiss iimmppoorrttaanntt ttoo aasssseessss ddeepprreessssiioonn iinn ccaarrddiiaacc ppaattiieennttss wwiitthh tthhee
ggooaall ooff ttaarrggeettiinngg tthhoossee mmoosstt iinn nneeeedd ooff ttrreeaattmmeenntt aanndd ssuuppppoorrtt
sseerrvviicceess..””
 ““IInn ssuummmmaarryy,, tthhee hhiigghh pprreevvaalleennccee ooff ddeepprreessssiioonn iinn ppaattiieennttss wwiitthh
CCHHDD ssuuppppoorrttss aa ssttrraatteeggyy ooff iinnccrreeaasseedd aawwaarreenneessss aanndd
ssccrreeeenniinngg ffoorr ddeepprreessssiioonn iinn ppaattiieennttss wwiitthh CCHHDD..””
 NNoo ssyysstteemmaattiicc rreevviieeww ooff tthhee eevviiddeennccee wwaass ccoonndduucctteedd..
Circulation, 2008;118:1768-1775

31. Whoops!
How dare we disagree with the American Heart
Association and the American Psychiatric
Association?
There are rules for making policy
recommendations and they didn't follow them.

32. Free Resource
http://tinyurl.com/3t9hj8

33. Guidelines for Screening for
Depression Deficient in
 Systematic review of the literature.
 Transparency.
 Composition of guidelines committee
including formal involvement of patients,
frontline clinicians, and other key
stakeholders.
 Articulation of guidelines in terms of strength
of evidence.
 External review.

34. A difference
USPSTF guidelines have orderly process of
gathering, grading, and integrating evidence.
Room for disagreement, but transparent
enough so you could see process and
challenge results.
Professional organizations consensus-based,
room for bias.

35. WWhhaatt iiss tthhee qquuaalliittyy ooff rroouuttiinnee ccaarree
iinnttoo wwhhiicchh ssccrreeeenneedd ppaattiieennttss wwoouulldd
bbee sseenntt??
 Only 20-30% of depressed persons being
treated exclusively in general medical settings
receive adequate care and follow up.
 About 40% of all depressed patients are
administered treatment with little benefit over
what would be obtained by remaining on a wait
list, representing 20% of the total cost of treating
depression.

36. U 2009 USSPPSSTTFF RReeccoommmmeennddaattiioonn
SSttaatteemmeenntt
 Recommends screening adults for depression when
staff-assisted depression care supports are in place to
assure accurate diagnosis, effective treatment, and
follow-up. (Grade B recommendation)
 Recommends against routinely screening adults for
depression when staff-assisted depression care supports
are not in place.
 Fair evidence that screening and feedback alone without
staff-assisted care supports does not improve clinical
outcomes in adults and older adults.

37. 22000099 UUSSPPSSTTFF RReeccoommmmeennddaattiioonn
SSttaatteemmeenntt
 Evidence from meta-analysis of 11 trials in primary
care settings supported recommendation.
 Several of the trials found that screening increased
identification or treatment of depression.
 None found that screening reduced diagnoses of
depression or improved depressive symptoms.
 Overall effect estimate was virtually zero (standardized
mean difference [SMD] = -0.02, 95% confidence
interval [CI] -0.25 to 0.20).

38. 22000099 UUSSPPSSTTFF RReeccoommmmeennddaattiioonn
SSttaatteemmeenntt
 Patients with depression in the intervention groups
received a collaborative care intervention for
depression, whereas depressed patients in the control
groups received only standard primary care.
 Whereas the results of the trials suggest that providing
collaborative depression care is better than not
providing such care to patients with depression, they do
not address the issue of whether screening would
benefit patients with previously unrecognized
depression.

39. AA cclloosseerr llooookk aatt tthhee eevviiddeennccee cciitteedd ffoorr
22000099 UUSSPPSSTTFF RReeccoommmmeennddaattiioonn
 Among the 3 largest studies cited by the USPSTF
(those with > 100 patients), in one, 44% of patients in
the trial were treated for depression prior to trial
enrollment.
 In another, 44% were receiving appropriate depression
care, defined as specialized counseling or
antidepressant medication, prior to trial enrollment.
 In the third, data on pre-trial treatment rates were not
provided, but already treated patients were not
excluded.

40. Collaborative Care for Depression
 American studies consistently find moderate
(.30) effect size of enhancements of
depression care involving depression care
manager.
 Studies do not consistently replicate in
Europe.
 Reason?: Poorer routine care in US gives
more room to show efficacy of enhancement.

41. 2010 National Institute for Health
and Clinical Excellence (NICE)
Depression Management
Guidelines
United Kingdom

42. IInnsstteeaadd ooff ssccrreeeenniinngg,, NNIICCEE
rreeccoommmmeennddeedd……
Physicians be alert to possible depression,
particularly when there is a past history or when
patients have a chronic physical health problem with
functional impairment, and that physicians inquire
about symptoms of depression when there is a
specific concern.

43. PPootteennttiiaall hhaarrmmss
 2010 NICE Depression Management Guidelines
identified number of serious concerns about routine
depression screening.
 High false-positive rates of screening tools, which are
often well over 50%.
 Likelihood that most individuals identified only by
screening would have relatively mild symptoms of
depression and often recover without formal
intervention.

44. Whose side was I on in the
antidepressant wars?

48. OOuurr sskkeeppttiicciissmm
 Whether screening for depression is effective is a different
question from there is evidence that collaborative care
depression management interventions improve depression
outcomes over routine care.
 Of the 4 trials cited by the USPSTF as evidence supporting
depression screening, none actually evaluated depression
screening. In each of the 4 studies, patients were required
to have depressive symptoms or a diagnosis of depression
to be eligible for the trial.

49. CCoonncclluussiioonnss ooff RReevviieeww
 No trials have found that patients who undergo
screening have better outcomes than patients who do
not when the same treatments are available to both
groups.
 Existing rates of treatment, high rates of false-positive
results, small treatment effects, and the poor quality
of routine care may explain the lack of effect seen
with screening.
 Developers of future guidelines should require
evidence of benefit from randomized controlled trials
of screening, in excess of harms and costs, before
recommending screening.

50. CCaann wwee aassssuummee tthhaatt ssccrreeeenniinngg
wwiillll bbeenneeffiitt ppaattiieennttss??
We know of no clinical trial in which patients screened
for depression had better depression outcomes than
patients who were not screened when the same
depression treatment resources were available to both
screened and non-screened patients, as would be the
case in actual primary care settings.

52. Raffle, AA aanndd GGrraayy,, MM.. ((22000077)).. SSccrreeeenniinngg::
EEvviiddeennccee aanndd PPrraaccttiiccee.. OOxxffoorrdd PPrreessss..
Screening must be delivered in a well functioning
total system if it is to achieve the best chance of
maximum benefit and minimum harm. The system
needs to include everything from the identification of
those to be invited right through to follow-up after
intervention for those found to have a problem.

53. Recommendations for adults
For adults at average risk of depression, we
recommend not routinely screening for
depression. (Weak recommendation; very-low-quality
evidence)
For adults in subgroups of the population who
may be at increased risk of depression, we
recommend not routinely screening for
depression (Weak recommendation; very-low-quality
evidence)

56. The politics of publishing on
screening, depression, and
antidepressants
Why JAMA (Journal of the American Medical
Association) refused to even consider this
article, without seeing it.

58. HHooww tthhee wwoorrlldd hhaass bbeeeenn
cchhaannggiinngg wwhhiillee wwee ddeebbaattee
ssccrreeeenniinngg ffoorr ddeepprreessssiioonn..

59.  More patients are now prescribed an
antidepressant at some point in their adult life.
 More patients in the waiting room where
screening is done are already on an
antidepressant or have them at home but are
not taking them.
 More antidepressants are being given out to
patients who cannot possibly benefit from them.
 Rates of medication were going up, but rates of
psychotherapy tend to be going down.

60. Many depressed patients
do not renew prescriptions.
About half would benefit
from dosage adjustment,
medication changes, or
education about adherence
at five weeks to achieve
benefits, but don’t get
followed up.

61. Differences between countries
 American practice guidelines recommend either
antidepressants or psychotherapy to all patients
with a diagnosis of depression.
 Other countries such as Canada, the UK, and
the Netherlands do not recommend
antidepressants as first-line treatment for
patients with mild, but diagnosable depression.
 Emergence of stepped care whereby patients
with mild depression encouraged to try self-help
strategies, then psychotherapy or counseling,
before going on to antidepressants.

62. Drug company supports monitoring
screening with quality indicators:
Pfizer gives $10 million
grant to American
psychologist to develop
quality indicators to monitor
oncologists’ screening for
distress.

63. Talking to patients is not
longer cheap.

64. An American woman Susan Krantz, received
national news attention when she complained
about her physician charging her $50 for her
having asked questions during her annual physical.
Her insurance company
paid her physician for the
physical, but not for
answering her questions.
She had not been warned
of the extra charge ahead
of time.

65. Talking to patients is a (billable) procedure.
Conversations occur with the meter running
“We’re not paid to solve
patients’ problems, we are
paid to do procedures.”

66. Screening contributes to
bureaucratizing talking to patients
 Quality indicators.
 Rationing.
 Requires mental health backup and
further screening.
 Requires patients to have repeat
discussions in order to get their needs
met.

67. Rather than routinely screening patients
for depression and placing them in
inadequate routine care without follow-up:
•Concentrate on ensuring better follow-up
care for known cases of
depression.
•Concentrate on patients
at high risk for depression.

68. What have we learned?

69. Thank you
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