Effectiveness of screening and treatment for depression in ambulatory indigent patients

Abstract

OBJECTIVE:To determine the effectiveness of screening and treatment for depression among ambulatory indigent patients visiting resident physicians. DESIGN: Two-group randomized trial ( N = 33 intervention, N = 28 usual care) with baseline, 6-month, and 12-month outcome measurements. SETTING: Internal Medicine Residency Clinic. PATIENTS:Clinic patients over 18 years of age who screened positive for depression on the PRIME-MD during a visit to their resident physician. Patients were not receiving treatment nor seeking care for any emotional problems. All patients were either enrolled in Medicaid or had income below the poverty line. T he underdiagnosis of depression and the need for screening in primary care settings can be especially severe among patients with a lower socioeconomic status. INTERVENTION: 1-5The high prevalence of depression in internal medicine (IM) clinics, depressed patients' low quality of life (lower than patients with severe physical health problems), and their extensive utilization of health care services (both inpatient and ambulatory) underscores the need for testing the effectiveness of depression screening and management in this setting. 4,[6][7][8][9][10][11][12][13][14][15][16][17] Many recent trials have shown that intervention for depressed patients in primary care settings is usually successful in diminishing morbidity when that screening is coordinated with thorough follow-up and treatment. 1,2,6,18 -20 This randomized trial examined how the combination of simple screening and treatment for major depressive disorder affected indigent IM clinic patients' relief of depression symptoms. For this trial, indigent refers to ambulatory clinic patients who either qualified for Medicaid or had no private insurance and income below the poverty line. In a recent study, income below the poverty line was found to multiply the risk of major depression by a factor of 3.8. 21This risk ratio was the largest found in this study among two dozen other sociodemographic variables. Previous trials with a focus on screening and treating indigent IM clinic patients have not been published. A trial specifically targeted depressed patients over 60 years of age who had psychosocial stressors, and clear improvements were demonstrated with intervention. 22Received from Community Health

Depression, Correlates of Depression, and Receipt of Depression Care Among Low-Income Women With Breast or Gynecologic Cancer

“…At the same time, active screening for depression within already burdened and under-resourced public care systems raises additional considerations, including the potential high prevalence of depression symptoms frequently found in low-income and medically underserved populations [63][64], the needs and preferences of culturally diverse patients [65][66], and lack of availability of low cost depression care in the community [26,67]. Despite these considerations, screening can be effective for indigent patients [68].…”

Depression and multiple sclerosis: Review of a lethal combination

“…The reasons for this underdiagnosis likely parallel those found in general primary care settings where depression is also frequently underdiagnosed. A number of studies have shown that providers' use of guidelines along with a thorough follow-up program in primary care settings can facilitate successful identification and treatment of patients with depression [129][130]. Two frequently cited guidelines for depression treatment were published in 1993 by the Agency for Health Care Policy and Research (AHCPR) [131] and the American Psychiatric Association [132].…”

Is the United States Preventive Services Task Force still a voice of caution?

“…[20][21][22][23] According to the task force, these trials "screened all patients for depression, enrolled only those screening positive, and returned results of screening to clinicians in the intervention group only." 10 The USPSTF told The BMJ that, if anything, this would have led to more conservative estimates of screening benefit.…”

“…24 Critics point out, however, that none of the four studies included an unscreened control group, and three of the studies compared optimized with usual care, meaning that any benefit in health outcomes could be because of optimized care and not screening (though not all found a benefit). [20][21][22][23] The fourth study provided usual care to both arms but found that the intervention arm, in which providers were told of screening results, "did not lead to improved patient outcomes." 22 Wanda Filer, president of the American Academy of Family Physicians, told The BMJ that the academy supported the task force recommendations on depression screening.…”