Editorials
To screen for depression or not?
Screening may be appropriate to reconsider once we can ensure adequate
response to any identified potential cases
D
epression presents a significant public health
challenge for both the community and the medical
profession. In Australia, depression and anxiety
affect a substantial proportion of the population (4.8% of
men and 10% of women) and is responsible for 8% of the
total loss in disability-adjusted life years.1 It is the topranking cause of non-fatal disease in the Australian
community for women,2 and is also associated with an
increased risk of ischaemic heart disease and suicide, both
causes of early death.
Depressive disorders present diagnostic challenges, not
least because in some cases depression is the first presentation of bipolar disorder. Further, treatment may be
complicated and limited owing to the symptomatic
heterogeneity of depression; complex comorbidities
with anxiety, substance abuse, physical health problems
or other factors; and the ongoing stigma that hinders
many individuals from openly discussing their mood
problems. As a result, rates of detection, diagnosis based
on clinical presentation, and sufficient intervention
remain inadequate. Indeed, a recent meta-analysis from
the United Kingdom suggests that the diagnosis was
only correct in 47% of cases presenting in primary care.3
This does not account for those cases that fail to present
in the first place, supporting calls to consider widespread screening for depression, especially in primary
care settings where the majority of depressive disorders
are treated. But is screening for depression in primary
care a useful and viable option?
Malcolm J Hopwood
MB BS, MD, FRANZCP1,2
Gin Malhi
FRCPsych, MD, FRANZCP3,4
1 Department of Psychiatry,
University of Melbourne,
Melbourne, VIC.
2 Royal Australian and
New Zealand College of
Psychiatrists,
Melbourne, VIC.
3 Kolling Institute of
Medical Research,
Sydney, NSW.
4 Northern Clinical School,
University of Sydney,
Sydney, NSW.
mhopwood@
unimelb.edu.au
doi: 10.5694/mja16.00217
Podcast with Professor
Malcolm Hopwood available
at www.mja.com.au/
multimedia/podcasts
In January 2016, the United States Preventive Services
Task Force published its latest recommendation statement in relation to screening for depression in adults.4 The
statement recommended that sufficiently reliable selfreport tools are now available to make screening for
depression feasible and reliable in primary care. The task
force further opined that screening leads to accurate
diagnosis and treatment in this setting. Clearly, the latter
component is critical to render screening valuable, and
the authors drew heavily on the developing evidence
around models of collaborative care and depression care
management.5,6 The task force recommended use of the
Patient Health Questionnaire-9 (PHQ-9), but as noted in
an accompanying editorial,7 the statement acknowledged
that the positive predictive value of the PHQ-9 is only
50%, and that it cannot be considered a replacement for
appropriate clinical assessment. In other words, screening
is important but it cannot be relied upon.
The idea of screening-led prevention and early intervention
is inherently attractive. Within Australia, efforts thus far
have focused on high-risk groups such as pregnant or
perinatal women and Aboriginal and Torres Strait Islander
populations.8,9 However, a pragmatic perspective that
acknowledges the limitations of current mental health service delivery for broader treatment of depression would
also have to recognise that international evidence for broad
primary care population screening is mixed.
“international evidence for broad primary care
population screening is mixed”
After several years of research and development, the
Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders were
released in late 2015.10 The guidelines conceptualise both
depression and bipolar disorder along a spectrum with
considerable overlap, and discuss in detail the diagnosis
and management of both conditions. The guidelines do
not specifically recommend screening in primary care or
other settings. This is because self-assessment via the
internet and other self-report screening measures is likely
to raise concerns but not necessarily identify those who
need help or ensure that they seek proper advice. Once
suspicion of depression has been raised by a clinician, the
use of a standardised psychiatric measure is preferable
but the question remains as to whether general practitioners should initially use their clinical judgement or a
screening tool to identify depressive illness. To this end,
they can be equipped with measures that corroborate key
symptoms but reliance should never rest solely on selfreport measures.
Historically, depression has been underdiagnosed, and
the stigma of its incidence remains a challenge to
encouraging patients to access treatment. We can
anticipate increased capacity for the treatment of
depression in the new world of integrated mental health
service delivery promised in the Australian government’s response to the National Mental Health Commission review of mental health programs and services.
The stepped care model has the potential to provide
optimal support for people with a major depressive
disorder. Once these initiatives are established and
further data have been gathered as to their suitability
and appeal, perhaps then it will be time to revisit the
recommendations regarding screening. However, at this
point in time there does not appear to be sufficient evidence of pragmatic value to warrant the burden that
implementation and continuous screening for depression in primary care would impose.
Competing interests: No relevant disclosures.
Provenance: Commissioned; externally peer reviewed. n
ª 2016 AMPCo Pty Ltd. Produced with Elsevier B.V. All rights reserved.
References are available online at www.mja.com.au.
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1
Australian Bureau of Statistics. National survey of mental
health and wellbeing: summary of results, 2007 (ABS Cat. No.
4326.0). Canberra: ABS, 2007. http://www.abs.gov.au/
ausstats/abs@.nsf/mf/4326.0 (accessed Feb 2016).
6
Gaynes BN, Rush AJ, Trivedi MH, et al. Primary versus specialty
care outcomes for depressed outpatients managed with
measurement-based care: results from STAR*D. J Gen Intern
Med 2008; 23: 551-560.
2
Begg SJ, Vos T, Barker B, et al. Burden of disease and injury in
Australia in the new millennium: measuring health loss from
diseases, injuries and risk factors. Med J Aust 2008; 188: 36.
https://www.mja.com.au/journal/2008/188/1/burden-diseaseand-injury-australia-new-millennium-measuring-health-lossdiseases
7
Thase ME. Recommendations for screening for depression in
adults. JAMA 2016; 315: 349-350.
8
Highet NJ, Purtell CA. The National Perinatal Depression
Initiative: a synopsis of progress to date and recommendations
for beyond 2013. Melbourne: beyondblue, the national
depression and anxiety initiative, 2012. http://cope.org.au/
wp-content/uploads/2013/12/Final-Synopsis-Report_PDF.pdf
(accessed Mar 2016).
9
Esler D, Johnston F, Thomas D, Davis B. The validity of a
depression screening tool modified for use with Aboriginal and
Torres Strait Islander people. Aust N Z J Public Health 2008;
32: 317-321.
10
Malhi G, Bassett D, Boyce P, et al. Royal Australian and New
Zealand College of Psychiatrists clinical practice guidelines for
mood disorders. Aust N Z J Psychiatry 2015; 49: 1087-1206. n
3
Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in
primary care: a meta-analysis. Lancet 2009; 374: 606-619.
4
Siu AL; US Preventive Services Task Force. Screening for
depression in adults: US Preventive Services Task Force
recommendation statement. JAMA 2016; 315: 428.
5
Coventry PA, Hudson JL, Kontopantelis E, et al. Characteristics
of effective collaborative care for treatment of depression: a
systematic review and meta-regression of 74 randomised
controlled trials. PLoS One 2014; 9: e108114.
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