Yield of practice-based depression screening in VA primary care settings

Abstract

Background: Many patients who should be treated for depression are missed without effective routine screening in primary care (PC) settings. Yearly depression screening by PC staff is mandated in the VA, yet little is known about the expected yield from such screening when administered on a practice-wide basis.

Objective: We characterized the yield of practice-based screening in diverse PC settings, as well as the care needs of those assessed as having depression.

Design: Baseline enrollees in a group randomized trial of implementation of collaborative care for depression.

Participants: Randomly sampled patients with a scheduled PC appointment in ten VA primary care clinics spanning five states.

Measurements: PHQ-2 screening followed by the full PHQ-9 for screen positives, with standardized sociodemographic and health status questions.

Results: Practice-based screening of 10,929 patients yielded 20.1% positive screens, 60% of whom were assessed as having probable major depression based on the PHQ-9 (11.8% of all screens) (n = 1,313). In total, 761 patients with probable major depression completed the baseline assessment. Comorbid mental illnesses (e.g., anxiety, PTSD) were highly prevalent. Medical comorbidities were substantial, including chronic lung disease, pneumonia, diabetes, heart attack, heart failure, cancer and stroke. Nearly one-third of the depressed PC patients reported recent suicidal ideation (based on the PHQ-9). Sexual dysfunction was also common (73.3%), being both longstanding (95.1% with onset >6 months) and frequently undiscussed and untreated (46.7% discussed with any health care provider in past 6 months).

Conclusions: Practice-wide survey-based depression screening yielded more than twice the positive-screen rate demonstrated through chart-based VA performance measures. The substantial level of comorbid physical and mental illness among PC patients precludes solo management by either PC or mental health (MH) specialists. PC practice- and provider-level guideline adherence is problematic without systems-level solutions supporting adequate MH assessment, PC treatment and, when needed, appropriate MH referral.

Trial registration: ClinicalTrials.gov NCT00105820.

Figure 1

Yield of depression screening in practice-based random sample of primary care clinic visitors