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NEWS: Deborah Josefson US task force recommends screening for depression BMJ 2002; 324: 1293a [Full text]

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Do all cases of Depression get diagnosed ?

Kommu John Vijay Sagar, Vellore, INDIA.   (31 May 2002)

Task Force Recommendations Downplay Realities of Routine Care

James C. Coyne, Steven C. Palmer, and Patricia Sullivan   (8 June 2002)

Do all cases of Depression get diagnosed ? 31 May 2002
Kommu John Vijay Sagar, Lecturer in Psychiatry Christian Medical College, Vellore, INDIA. Send response to journal: Re: Do all cases of Depression get diagnosed ?	It has been rightly pointed out by US task force that screening for Depression helps in identifying cases at Primary care level . The recent multicentre study by WHO showed that 49 percent of patients presenting with medically unexplained symptoms in developing countries have Depression . At the primary care level , training of physicians is needed to use simple screening tools like Beck depression inventory ,so that they will pick up cases of Depression . The little extra time spent at primary care level in identifying Depression will go a long way in alleviating distress in millions of people suffering from this common Psychiatric illness.
Task Force Recommendations Downplay Realities of Routine Care 8 June 2002
James C. Coyne, Co-Director, Behavioral Science and Health Services Research University of Pennsylvania Cancer Center, Philadelphia, PA 19104, Steven C. Palmer, and Patricia Sullivan Send response to journal: Re: Task Force Recommendations Downplay Realities of Routine Care	Pignone et al.’s (1) recommendations could be interpreted to suggest that simply introducing screening into general medical care substantially reduces the prevalence of depression. This interpretation is contradicted by results of their meta-analyses. Fully 84% of the weight of evidence is carried by 3 studies in Figure 2. Two of these studies (2,3) yielded null results, so the positive effect is carried by the Wells et al. (4) study. It involved not only providing feedback from screening, but staffing to perform screening, training of practice staff, provision of training materials, and academic detailing. In addition, a request was made that an appointment be scheduled within two weeks for patients identified as depressed, practices were provided with tracking lists of study subjects and assistance in initiating and continuing treatment, and access to medication follow-up and brief structured psychotherapy was provided. Practices were selected partly on the basis of their ability to provide in -kind resources of between $30,000 and $72,000. Introduction of routine screening is thus confounded with the availability of exceptional resources, a commitment that cannot be readily expected within the competing demands of routine care, and substantial costs that are not reimbursable in most settings. Moreover, a later article (5) demonstrated that initial outcome differences in depression were not maintained longterm. Pignone et al.’s (1) analysis is more appropriately interpreted as a recommendation for restructuring depression care than for introducing screening. It is unfortunate that many depressed persons remain untreated despite the availability of efficacious treatments. Yet, under conditions of routine care, detection does not reliably lead to improved outcomes (6,7). Without the commitment of substantial resources and sustained effort to insure their effective deployment (5), improving outcomes for already detected patients may be a more pressing priority than identifying new cases, providing ineffective treatment, and further taxing a poorly working system. 1. Pignone, M.P., Gaynes, B.N., Rushton, J.L., Burchell, C.M., Orleans, C., Mulrow, C.D. & Lohr, K.N. (2002). Screening for depression in adults: A summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 136, 765-776 . 2. Callahan, C. M., Hendrie, H.C., Dittus, R.S., Brater, D.C., Hui, S.L., & Tierney, W.M. (1994). Improving treatment of late life depression in primary care: A randomized clinical trial. Journal of the American Geriatrics Society, 42, 839 - 846. 3. Lewis, G., Sharp, D., Bartholome, W.J., & Pelosi, A.J. (1996). Computerized assessment of common mental disorders in primary care: Effect on clinical outcome. Family Practice, 13, 120-126. 4. Wells, K.B., Sherbourne, C., Schoenbaum, M., Duan, N., Meredith, L., Unutzer, J., Miranda, J., Carney, M.F., & Rubenstein, L.V. (2000). Impact of disseminating quality improvement programs for depression in managed primary care: A randomized controlled trial. Journal of the American Medical Association, 283, 212-220. 5. Sherbourne, C.D., Wells, K.B., Duan, N., Miranda, J., Unutzer, J., Jaycox, L., Schoenbaum, M., Meredith, L.S., & Rubenstein, L.V. (2001). Long-term effectiveness of disseminating quality improvement for depression in primary care. Archives of General Psychiatry, 58, 696-703. 6. Simon, G.E., Goldberg, D., Tiemens, B.G., & Ustun, T.B. (1999). Outcomes of recognized and unrecognized depression in an international primary care study. General Hospital Psychiatry, 21, 97-105. 7. Whooley, M.A., Stone, B., & Soghikian, K. (2000). Randomized trial of case-finding for depression in elderly primary care patients. Journal of General Internal Medicine,15, 293-300.