New depression screening guidelines outline very helpful, yet achievable goals

Michael Craig Miller, M.D.
Michael Craig Miller, M.D., Senior Editor, Mental Health Publishing, Harvard Health Publications

Every once in a while, a simple idea comes along that has the potential to bring enormous health benefits. Screening for depression is one of them. It is a low-cost, high-impact intervention that should be a regular part of primary care medicine.

This idea is not new, as we pointed out back in October of last year. But it’s gotten another helpful boost — and was in the news last week — because the U.S. Preventive Services Task Force (USPSTF) released updated recommendations reinforcing this message.

Depression is common and potentially disabling. Yet despite decades of research and publicity about the problem, depression often goes unnoticed. Unnecessary suffering can be prevented if the task force recommendations are followed:

  • They encourage primary care practices to have systems to detect depression: Screening can be done with a simple questionnaire.
  • If a person is diagnosed with depression, treatment can be offered: psychotherapy, medication, or a combination of the two.
  • After initiating treatment, provide follow up: A phone call to the person and/or return visits to the primary care provider.

Screening can be as simple as a two-item questionnaire. The Patient Health Questionnaire-2 (PHQ-2) asks,

Over a 2-week period, have you been bothered by (1) little interest or pleasure in doing things; or (2) feeling down, depressed or hopeless?

Answering yes to either item means the problem should be evaluated more fully. The primary care provider may make a referral to a mental health provider, but there is enormous value when initial evaluation and treatment can begin in the primary care setting.

The task force focused special attention this time on women who are pregnant or who have recently given birth to a child. This is quite important because mood problems are surprisingly common during these periods. A majority of women experience transient changes in mood, but up to 15% of new mothers may experience significant depression during pregnancy or after the baby is born.

Anyone who is suffering should not debate what it means to have a “significant” mood problem. If you’ve gotten to the point of wondering about it, that’s the time to speak up, get support, and consider helpful options.

What I find heartening about the current report is its emphasis on matter-of-fact, achievable goals. Identification of mood problems and better access to support and treatment in primary care practices, can significantly improve outcomes for both mothers and children.

You can find more details at the USPSTF website, where you can read the full recommendations or browse a complete list of information for consumers.

Comments:

  1. St. Louis Behavioral Medicine Institute

    Depression is a serious medical illness that involves the brain. It’s more than just a feeling of being “down in the dumps” or “blue” for a few days – the feelings do not go away

  2. Claudia R

    Depression is Real, And yes lot’s of people have it and are in denial of it. It is such a stigma. I suffer from it. I was scared to be on meds Because of what my mother would say so I hide it. I keep it to myself. “Your weak, and it’s bad for you if you are medicated” And or ” crazy” It’s really sad!
    I wish more people/ parents were more open to this. It is a little scary to medicate your child, but your child needs your support and love.

  3. Dr. Imam

    After reading the article I am compelled to feel that PHQ-2 may not be able to assess the level of depression people in general are suffering. Instead of applying PHQ-2 by an untrained person it would be more viable to apply PHQ-9 that gives us the full picture. Assessment must be done by a trained professional as that comes out to be very healing process and of course therapeutic interventions follows after that.

  4. Edward L Kelly, MD, JD

    Nothing mentioned about borderline personality disorder, which per a very large federal government study was determined to have 6% prevalence, which is 2-3 times bipolar disorder, which it is often mistakenly diagnosed as (including by the screening instrument suggested to primary care providers). Getting the diagnoses correct in mental health is as important as in the rest of medicine, but primary care providers are usually not as competent in psychiatry as in other fields. In fact the emphasis is on “depression” and “anxiety,” which are only symptoms. For example patient compliance with 1-2 medications is all that is usually required to manage bipolar disorder. However, meds are just the start of treatment for borderline personality, which is a serious mental illness with rapid (as opposed to long and infrequent in bipolar) and nearly constant mood swings, but also usually substance abuse, chronic relationship problems, rage and hostility, suicidal ideas and for many psychic relief from self injurious behaviors like cutting, feeling empty most of the time, very good at manipulating the emotions and behaviors of others, and impulsive risky behaviors. In fact primary care providers should not treat people with BPD, but unless correctly diagnosed (not as depression or bipolar) that will not occur and the patient will not get the other treatments that can be very helpful for BPD. Likewise there are many causes of not just depression, but also anxiety. It is important to get the correct anxiety diagnosis and treatment of all anxiety conditions is not primarily medications but other treatments specific to the correct anxiety diagnosis.

  5. R. Albertson

    As a followup to my statement above, I feel I must reveal my own experience with mental health care, and the lack thereof. After many years struggling with emotional disfunction and coming to the point of self-harm at one point, I was hospitalized for depression. Following that the psychiatrist who treated me effectively deserted me, so i turned to my PCP to continue to write my script. However, I was at a loss why the med did not take care of my needs. I had already been in counseling on and off for many years. Eventually after nine years I found a brilliant therapist who determined there were additional conditions I was struggling with, bi-polar disorder with chronic anxiety. Referred to a respected psychiatrist who confirmed that diagnosis I received the proper care and medication. With a more stable brain chemical status, cognitive therapy began to produce helpful results. Unfortunately, these conditions did lead to the end of my career. Now retired and relieved from much of the stress that aggravated my symptoms, I find life much happier and fulfilling.

    I have acquaintances and colleagues who have similar experiences. The 25% of the population who deal with mental and emotional disorders and the persons who love and care for them need every avenue possible to find effective treatment to be able to live lives that are balanced, productive and happy.

  6. Ronald Albertson

    I feel I must reveal my own experience with mental health care, and the lack thereof. After many years struggling with emotional disfunction and coming to the point of self-harm at one point, I was hospitalized for depression. Following that the psychiatrist who treated me effectively deserted me, so i turned to my PCP to continue to write my script. However, I was at a loss why the med did not take care of my needs. I had already been in counseling on and off for many years. Eventually after nine years I found a brilliant therapist who determined there were additional conditions I was struggling with, bi-polar disorder with chronic anxiety. Referred to a respected psychiatrist who confirmed that diagnosis I received the proper care and medication. With a more stable brain chemical status, cognitive therapy began to produce helpful results. Unfortunately, these conditions did lead to the end of my career. Now retired and relieved from much of the stress that aggravated my symptoms, I find life much happier and fulfilling.

    I have acquaintances and colleagues who have similar experiences. The 25% of the population who deal with mental and emotional disorders and the persons who love and care for them need every avenue possible to find effective treatment to be able to live lives that are balanced, productive and happy.

  7. Claudia

    There you go Paula!

    Not a ‘crippling’ topic anymore!

    Cheers,
    Claudia

  8. Kesto Roy

    Depression is not bad. It helps you gear for future and become stronger. It is bad when it goes out of control. Some selfish and self indulging people just think about themselves and think of suicide when they do not get what they want. I think it requires a life style change. To start with – (1) Do not give anything to a kid if he/she did not ask you. Also, let them feel that things are not easy to get in life (2) Like in Thailand and other Buddhist countries each child has to go and become a monk for a month, shaving hair from body, put on a robe and go from door to door begging for food and eat in a limited amount (3) Teach them to handle failures, do not help them on pretty matters of life. Let them know in school that life is difficult and they have to handle it themselves. If they are groomed that way they will never get depressed in life. It is like heat treatment given to a metal to make it hard. Depression is easy money for drug companies. Their is a nexus between research facilities and drug company.

    • Ronald Albertson

      Mr. Roy,
      I respectfully disagree. I cannot speak to the practice of Buddhists withholding from children and requiring monk participation. But, I seriously doubt that those societies have any idea of what “clinical depression” really is. Yes, most everyone feels “depressed” at times, but persons with clinical depression cannot recover without medical/ psychological intercession. Depression is an increasingly common cause of suicide and a contributing cause of other forms of violence. Serious depression destroys health and quality of life along with productivity.
      I invite you to do some research on the subject and educate yourself on this silent killer. It is statically certain that someone you know actually has clinical depression or some other emotional or mental disorder that needs treatment. Don’t be part of the problem, help shine a light of hope on it.

      • Claudia

        I agree with you Mr. Albertson.

        Thank you for expressing your truth, that as that of Mr. Roy is very personal and therefore valuable/

        Cheers,
        Claudia

    • Robert Dillon

      I am professed Buddhist who follows the Dharma, and the 3 jewels, nowhere is it written that one must follow one path to enlightenment and freedom from suffering. In fact, Buddha suggests that we question everything and accept not even his teachings as fact until tested by living truth…. thus your opinion is just that… and actually reflects a lack of enlightenment with regards to domains of science. To be sure drug companies, in fact most big companies have no purpose but to make money, which is at odds with Buddhism, I get you…. but please try to to consider that some of right path, right livelihood, right action may include things you have not yet discovered, since you have not lived all lives yet.

  9. Kathy

    I’m wary, it’s so hard , as the field truly has a lot of guess work to it. Then the seemingly never ending associative stigmatism.It makes being honest harder. CAN ANYONE RELATE TO ALL/PARTS OF THIS?: One common example is seeing other medical persons. I fractured my ankle recently,Visited an orthopedist,(MD). Basic paperwork,understandably,asks what meds your on.(Note: I’ve never been suicidal). Long story short differed giving me pain meds to my PCP. His notes claimed “intermittent crying”&agittated behavior. I went for second opinion.I still intermittently cried when ankle was manipulated& yes pain still caused agitation.I didn’t put my clonazopan/Buspar on sheet, this time, or history of PTSD/social anxiety disorder-Treated respectfully,Given appropriate pain meds(Note:No History of med abuse/addiction).This is not isolated root canals, broken toe, E.R kind prior to speaking to my PCP abrup&short after speaking to my PCP,ect, Basically 8 out of 10 times in past 10 years,(coincidently,or not,increasing from 1/2 as I age). Statements like: “well when you get older”, talking to my daughter(18), instead of me.Her saying”she’s right there,tell her”?(Doubting myself,brought her last 2 years& she agrees the difference when I put meds&mental diagnosis down & when not,can’t be disputed oddly to her”).
    *Questn/Point#2:I agree that finding the right therapy/med combo match is important but whose correct , when diagnosed using th PHQ2 by 2 different/equally trained & expierenced psychiatrist, both standing by thier different diagnosis having seen the results( they said test answers where same interpretations where different?!? Labels and results based on personal interpretations. I hope this entire post is posted. I can’t be the only one who would like to hear input. Thank you.recommended in thier field. I didn’t start out with cyansism. Only the last year, I’ve more health conditions brought on by stress too like pre diabeties, & a stres test that couldn’t rule out a past heart attack. I live in PA I never had this problem with the doctors I saw in MA. Good mental & physical Health cares hard to find. I just want to be treated with equal respect I give. Not shamed at those doctors with unproffesional attitudes.

  10. Jeanine Joy

    At least 1/3 of Americans who need mental health care receive it from their primary care physicians, which means drugs, not therapy. The problem with any drug-only approach is that it treats the symptoms of the illness, but does nothing to cure it. (1)
    “Mental health disorders are common in the United States, affecting some 44 million adults and 13.7 million children each year. . . Despite the facts that mental health disorders are as disabling as heart disease or cancer in terms of premature death and lost productivity . . . fewer than half of adults and only one-third of children with a diagnosable mental disorder receive treatment”. (2)
    (2)Russell, L. (2010). Mental Health Care Services in Primary Care: Tackling the Issues in the Context of Health Care Reform. Washington D.C.: Center for American progress.
    (1)Wang, P. S., Demler, O., Olfson, M., Pincus, H. A., Wells, K. B., & Kessler, R. C. (2006). Changing Profiles of Service Sectors Used for Mental Health Care in the U.S. American Journal of Psychiatry, 163(7), 1187-1198.

    The smart thing to do is look at what empowers humans to thrive. The right mindset is the answer. How do people achieve the right mindset? They use metacognitive processes to self-regulate their emotions. Effective use of cognitive reappraisal leads to lower stress levels and protects against depression, anxiety, psychosis and many physical diseases as well that suffer from the immunosuppression that occurs with negative emotional states. These skills should be taught in schools and adults should learn them as well. The potential power of using a Primary Prevention approach to mental, physical and behavioral health is extremely high.

    • Debbie

      Metacognitive skills can only take you so far if you have a chemical imbalance. Using these strategies can feel as though you are swimming against the current or caught in a rip tide. I agree that these skills are important, however, the importance of drug therapy should also be stressed. When therapy alone does not work, medication must be added. The stigma associated with mental illness and the use of antidepressants, must be irradiated from our society. Too many people, still today, are in denial and are afraid to admit they have a problem. These people suffer in silence. If their primary doctor asks just a few simple, caring questions, the people who need help the most, could finally wind up on a path to both mental and physical health.
      This being said, I agree that primary doctors should stop handing out prescriptions without requiring a psychiatric follow up, either with a psychiatrist or qualified psychologist. Only then will the patient truly be helped.

      • Claudia

        Debbie,
        Thank you for your insighful comment.Ihumbly point out a typo in your narration: “The stigma associated with mental illness and the use of antidepressants, must be IRRATIATED (instead of ERRADICATED) from our society.
        Cheers,
        Claudia

      • Debbie

        Thanks Claudia.
        I really must proof read before hitting send. I quickly typed that on my phone. How embarrassing…haha.

    • Ana

      Jeanine,

      A little bit confused. What do you mean by “cognitive reappraisal”? Could you give some examples of what you mean by “meta-cognitive processes to self-regulate […] emotions”? What are those skills that prevent us from suffering mental illnesses without (or with?) the use of medication? I like your life approach. I’m a type of “do-it-yourself” person, but I failed to use that approach to control my PTSD symptons. Any suggestion?

  11. Isaac Dust

    Dr. Miller,
    Are you aware of Dr. Allen Frances’s perspective on this matter? Frances (the former DSM-IV chair) thinks that these new depression screening guidelines are a “very bad idea” and an “absolute disaster in practice,” despite the good intentions behind them. In a nutshell, Frances believes that the PHQ-2, especially in the hands of a primary care provider (i.e., NOT a highly trained mental health professional), is a woefully inadequate screening method that will greatly increase the already too-high rate of over-diagnosis and over-medication. As you mention in your article, the primary care providers using the PHQ-2 “may” make a referral to a mental health expert, but in practice this usually doesn’t happen. What does usually happen, according to Frances (a highly respected psychiatrist with 40 years of experience), is that poorly trained (in mental health matters) primary care docs use these very imprecise screening tools in such a way as to generate way too many “false positives.” Obviously, you do not agree with Frances’s assessment, but I’m curious how you would respond to his critique? As a mental health professional myself, I find this matter to be confusing, because doing more screening seems to be such a no-brainer, in theory, yet in practice it may have serious drawbacks.

    • C Welsch

      I agree with Dr Frances & I am a patient with a long history of depression & misdignose for many years! I finally found a psychiatrist that listened and worked with me to get me on correct meds. along with seeing my therapist. I am now able to make a life of contentment & take care of myself, so I am not feeling like the victim, nor letting myself become one!!! I am stronger mental & know I matter & look for the joy in my life & know if it is not there I am responsible for my own happiness!! It has but a long road but at the age of 75 I finally am on a good path & I know Therapy & a Psychiatrist that you feel hears you is so important along with being willing to being open & looking at how & why you are depressed!

    • Margaret

      I agree with Dr Frances. I was a nurse for 38 year’s and saw how many times a script was given to the pt by the pcp, only for the pt to either not comply because they didn’t feel like the medication was helping. Unfortunately I too found myself in a severe depressive state many year’s ago, and only due to having the resources from my peers and education that I received both medication and cognitive thereapy. If you want success, both modalities should be applied to each patient. On the other hand with our insurance industry governing who gets what if anything I think that the reference to a psychiatrist is your safest bet first. Their knowledge in the field of psychopharmacology is better than a pcp and they generally have stronger pull with thereapy based services for patients.

  12. Anne Loo

    Love this idea! Additionally, we should carefully screen for other mental illnesses, like schizophrenia, for both adults and young people. It may have prevented a tragedy from occurring in a family close to us.

  13. Paula De Jesus

    My last visit with my primary she did give me a questionnaire about how I felt she suggested I speak with someone unfortunetly my health insurance is limited to covering this expense. I am on sertraline and colonazapam and there are days I don’t feel this is enough . Thank you for opening up and making this very crippling topic validated