National Rates and Patterns of Depression Screening in Primary Care: Implications for Social Work Involvement in Primary Health Care Settings

Background and Purpose

Lifetime prevalence rates for depression range 13-16%.  Untreated depression is a major cause of disability, and associated with premature mortality, increased risk for comorbid medical conditions, and decreased quality of life.  Yet, many individuals experiencing depressive episodes go untreated because it is not diagnosed by a health care provider.  Primary care is an opportune place to identify individuals with depressive symptoms; however, depression goes undetected in primary care up to half the time when it is present.  Importance of primary care sector for depression care is highlighted by the fact that approximately two thirds of depression care in the United States is provided in primary care.

Screening increases the recognition and diagnosis of depression and, when integrated with a commitment to provide coordinated and prompt follow-up of diagnosis and treatment, clinical outcomes are improved.  Our objective is to describe the patterns and correlates of depression screening in primary care settings between 2006 and 2010, using nationally representative data on provider patient encounters.  

Methods

Secondary analyses of data from the National Ambulatory Medical Care Survey (NAMCS), a multistage probability sample of ambulatory care office visits, yielding nationally representative estimates for US.  The survey is conducted by Center for Disease Control and Prevention. Visits included in the current study (n=11,655) were with adult patients (aged 18+) without an existing depression diagnosis, visiting a primary care provider (general and family practice, internal medicine, pediatrics, obstetrics and gynecology).  Data collection instrument captures all elements of the provider patient encounter including patient demographics and clinical characteristics, presenting symptoms, screening and diagnostic services, diagnosis, procedures and therapeutics provided or prescribed during the visit.

Results

Depression screening occurred in less than 5% of visits. African Americans were 51% less likely to be screened for depression compared to Caucasians.  Similarly, the odds of receiving a depression screening was 59% lower among older adults (aged 65+) compared to younger patients. Depression screening was positively associated with longer visit and number of chronic conditions.

Conclusion and Implications  

The very low rates of screening, and disparities for elderly and minorities represent major missed opportunities to improve well being of people suffering from depression.  Screening is effective in improving clinical outcomes only when “staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up (US Preventive Services Taskforce, 2009).”  It is possible that screening rates were low because of the lack of such supports.  Such provision systems would ideally be staffed by social workers, who are best equipped to support ongoing management of depressed patients.  Their skill sets are ideal for assessment, coordinating care, ensuring continuity of care, providing frequent monitoring and follow-up with patient, provide further education, self-management support, and monitor for response in order to aid in facilitating treatment changes and in relapse prevention.  In the current era where Affordable Care Act provides the financial infrastructure for integrated and comprehensive primary and mental health care, our results point to an important avenue for social work involvement in primary health care settings.