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Abstract & Commentary
We are frequently reminded that depression is more common in women (2:1 vs men), significantly increases morbidity and mortality, and even affects the development of the patients’ children. Because the United States Preventive Services Task Force has recommended screening adults for depression, LaRocco-Cockburn and colleagues set out to determine what the current "state of the art" was (ie, identify the frequency of depression screening, determine the attitudes of practitioners toward screening, and pinpoint the factors that may affect the use of depression screening).
Obstetrician-gynecologists in the state of Washington were surveyed, with 282 individuals eligible for data analysis. Of interest, 49% were in a private group partnership, 68% had attended a CME course in the past 5 years where depression was discussed, and 41% considered themselves primary care physicians. Forty-four percent responded that they always or often screened for depression, 41% reported screening sometimes, and 15% said they never did. The methods used (often more than one method was used by a physician) included: questioning patients regarding mood/mental health (81%); short, validated tool (32%), validated patient self-report (16%); and validated interview (7%).
Other important findings included: 90% agreed that screening will improve the detection rate, but only 58% agreed that screening would lead to improved treatment outcomes; 65% agreed that OB/GYNs should screen for depression; only 24% felt that their patients did not want them to address psychosocial problems; 73% felt that time constraints would interfere with screening all patients; and only 32% felt that they had been appropriately trained to treat depression (LaRocco-Cockburn A, et al. Obstet Gynecol. 2003;101: 892-898).
Comment by Frank W. Ling, MD
All right, so I admit that this isn’t the rigorous scientific article that you’re used to seeing summarized in this publication. As your "down in the trenches," primary care advocate, I wanted to let you know what your colleagues are up to in order to see how you compare. When we consider that up to one-third of women will experience clinically significant depression during their lifetime, the importance of appropriate diagnosis and treatment becomes readily apparent.
Admittedly, this paper is flawed. (Aren’t they all to some extent?) For example, these were physicians in a single state. Also, the study may be limited by responder bias (ie, the respondents may have been more interested in depression and, therefore, more likely to respond). There are useful lessons to be learned, however. Those respondents who had positive attitudes toward depression screening, psychosocial concern, and ease of screening were more likely to screen for depression in their practice. A younger-aged physician was more likely to have been trained to treat depression.
These physicians reported that time constraints, adequacy of training, and whether screening improves outcomes represented barriers to performing screening for depression in their practices. So where do you stand on this? What about the role of depression in the various clinical scenarios that we commonly face (eg, pelvic pain, infertility, spontaneous abortion, death and dying, premenstrual dysphoric disorder, postpartum depression, etc)? How do you screen for depression in your practice? Do you screen at all? Is there some quick and easy way to address the concerns that are raised by these results?
As far as mode of screening, just keep in mind the palindrome offered by Dr. Raphael Good many years ago: "How Are Things At Home (HATAH)." Some variation of this will provide a jumping off point for your patients and their symptoms of depression. As to the training issue, postgraduate courses or monographs are readily accessible wherever we turn. We have not yet proven that screening improves outcomes, but from my personal experience and certainly that of so many of our colleagues, the many cases in which depression has been successfully identified and treated provide enough motivation to continue the practice.
So I ask once again, where do you stand on screening for depression?
Dr. Ling is UT Medical Group Professor and Chair, Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN