Today's Practice: Changing the Business of Medicine TP2018Q2DigitalEditionWeb | Page 16

P RA CT I CE MA NA GE ME NT
We Can Do Better
Dr. Jason Friday, MD
Screening Evaluating
The first step in addressing depression within primary
care is to screen ALL adult and adolescent patients. The
American Academy of Family Practitioners has support-
ed recommendations made by the U.S. Preventive
Services Task Force since 2002, which recommend
screening all adult and adolescent patients for depres-
sion on an annual basis within the primary care setting
6, 7 . Well-validated and brief screening instruments that
are easy to administer within the primary care setting
exist, such as the PHQ-9 Questionnaire 8 . Evaluating patients that screen positive for depression
is one important support system to have in place.
Depression is comorbid with many other physical and
mental health disorders, which can make an accurate
assessment and treatment plan difficult. For this
reason, a behavioral health professional should be used
to evaluate those patients that screen positive. This
could be a psychiatrist, clinical psychologist, psychiat-
ric nurse practitioner, psychiatric physician assistant, or
licensed clinical social worker. (Typically, these licensed
providers will be authorized to provide these services –
check your local regulations and insurance provider
guidelines.)
Although these recommendations have been in place
since 2002, many of the patients that I treat state that
they have not been screened by their primary care physi-
cian. Certainly this isn’t always the case, yet many of the
primary care physicians that I speak with indeed state
that they do not screen their patients for depression due
to challenges such as time, lack of knowledge and staff
in the practice to deal with behavioral health issues, and
the potential to open “Pandora’s Box.”
However, screening in primary care is extremely impor-
tant. 26% of all adults are living with symptoms of
depression, and these patients living with depression 9
and its symptoms are commonly seen in the primary
care setting 10 . Patients that are suffering from depression
often present with medically unexplained somatic
symptoms and make the treatment of other medical
conditions more complicated and expensive. Screening
for depression can result in earlier and more accurate
diagnoses and treatment plans 11 .
However, simply screening patients does not result in
improved health 12 . Support systems need to be in place
to understand each patient’s individual needs and to
develop a plan of care to address and treat.
When evaluating for depression, this behavioral health
professional will assess the patient for co-occurring
behavioral and physical conditions; their use of
substances; risks around suicide, self-harm and harm to
others; severity and history of symptoms; medication;
and family history, among others. This evaluation is
important, because other behavioral health disorders,
such as post-traumatic stress disorder or complicated
grief, could be to blame for a positive depression
screening result.
The evaluation will also result in a treatment plan.
Depending on the results of the evaluation, this could
be a sensitive conversation to have with the patient
(and family and/or caregivers). Patients are often in
denial of depression or afraid of the stigma that they
associate with the illness 13 . Having a health care provid-
er with the training and experience to have this conver-
sation is another reason why it’s important that an
evaluation be done by a behavioral health professional.
6 Summary of Recommendations for Clinical Preventive Services. American Academy of Family Physicians. 2016 Aug.
7 Siu, et al. Screening for Depression in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2016 Jan 26;315(4):380-387. doi:10.1001/jama.2015.18392.
8
Kroenke, et al. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: A Systematic Review. General Hospital Psychiatry. 2010 Jul-Aug;32(4): 345-359.
doi:10.1016/j.genhosppsych.2010.03.006.
9
Wittayanukorn, et al.
10 Siu.
11 Siu.
12 Siu.
13
Keeley, et al. A Qualitative Comparison of Primary Care Clinicians’ and Their Patients’ Perspectives on Achieving Depression Care: Implications for Improving Outcomes. BMC Family
Practice. 2014 Jan 15;15(13). doi:10.1186/1471-2296-15-13.
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TODAY ’ S P R A C T I C E: C H A N G I N G T H E B U S I NE