PRACTICE MANAGEMENT
We Can Do Better
Dr . Jason Friday , MD
Screening
The first step in addressing depression within primary care is to screen ALL adult and adolescent patients . The American Academy of Family Practitioners has supported recommendations made by the U . S . Preventive Services Task Force since 2002 , which recommend screening all adult and adolescent patients for depression 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 .
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 physician . 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 important . 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 .
Evaluating
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 , psychiatric 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 .)
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 provider with the training and experience to have this conversation 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 .
11 TODAY ’ S PRACTICE : CHANGING THE BUSINESS OF MEDICINE