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Current screening practices. Although not specific to depression, Healthy People 2010 identified increased mental health screening in primary care as one of its mental health objectives. Midcourse review data published on their website (http://wonder.cdc.gov/data2010/) reported a baseline rate of 62 percent of adults being screened in 2000, with the goal of achieving a 68 percent screening rate by 2010. By 2003, they report a 74 percent rate of mental health screening. It is unclear what specific disorders are being screened for, but given the prevalence and burden of depression in primary care it seems likely that most general mental health screening programs would include probes for depression. The VA currently requires annual depression screening of patients who are not being treated for depression. A 2006 study of screening in a VA system²²⁹ found that 85 percent of eligible patients were screened for depression during the past year.

Current antidepressant use. A household survey found that 57 percent of community dwelling depressed adults seek treatment for depression, and about half of these receive care in a general medical setting.²¹ Once a primary care patient is identified as depressed, the majority of providers recommend antidepressants, either alone (52 percent of depressed patients) or in combination with psychotherapy (36 percent).⁸⁵ In 2002, 13.2 percent of the US civilian, noninstitutionalized, elderly population and 10.3 percent of non-elderly adults used an antidepressant.²³⁰ Use of antidepressants was much more likely in white non-Hispanics (10.6 percent) than in black non-Hispanics (4.0 percent) or Hispanics (3.6 percent) and in females (11.4 percent) than in males (5.4 percent).²³⁰

Trends in antidepressant use. Concomitant with trends showi ng that more patients are seeing physicians for depression,^77,231 and more primary care physicians in particular,²³¹ several trends are apparent in antidepressants use. Greater numbers of patients are being treated with antidepressants, both overall^77,88,231 and relative to other forms of outpatient treatment.⁸⁸ SSRI use has increased in particular.²³¹

The estimated number of US physician visits by patients with depression in the National Disease and Therapeutic Index increased from 14.4 million visits in 1987 to 24.5 million visits in 2001.²³¹ According to the National Ambulatory Medical Care Survey (NAMCS), the yearly prevalence of depression diagnoses in primary care increased from two percent of visits in 1989 to 3.3 percent of visits in 2000.⁷⁷ Similarly, the rate of outpatient treatment for depression increased three-fold from 1987 to 1997 (from 0.73 to 2.33 per 100 persons in the Medical Expenditure Panel Survey (MEPS), p<0.001).⁸⁸ Over a similar time period, the proportion of visits to primary care physicians for depression, relative to specialty care physicians, increased from 50 percent in 1987 to 64 percent in 2001.²³¹ Regarding antidepressant use specifically, the odds of antidepressant prescriptions in visits with depression diagnosis increased from 1989–2000 (R = 1.07; CI: 1.04, 1.10)⁷⁷ and the rate of antidepressant medication use in patients seeing a physician for depression increased from 70 to 89 percent²³¹ from 1987 to 2001. Similarly, in 1997 twice as many patients (from 37.3 to 74.5 percent, p<0.001) receiving outpatient care for depression received antidepressant medications than in 1987. Significantly fewer (71.1 to 60.2 percent, p=0.006) received psychotherapy, however, and there was also a reduction in outpatient visits (12.6 to 8.7 visits per year, p=0.05).^88,232

Finally, a strong trend away from tricyclic antidepressants (TCAs) toward the use of selective serotonin reuptake inhibitors (SSRIs) and other newer agents is apparent. According to the National Disease and Therapeutic Index (NDTI), the proportion of TCAs prescribed for depression dropped from 47 percent in 1987 to 2.1 percent in 2001. At the same time, SSRI use rose from 9.7 percent in 1988 when they were introduced to 69 percent in 2001.²³¹

Adequacy of treatment. Although a 2005 study of a primary care-based quality assurance program found that 71 to 75 percent of depression patients receiving antidepressants were maintained at adequate doses, and dosages were appropriately increased when depressive symptoms did not remit, this level of care may not be typical of most primary care in the US.²³³ A naturalistic international study of depression care¹⁶⁴, for example, found in a setting determined to be “typical of local primary health care delivery” in Seattle, WA that only 38 percent of the patients who screened positive for depression and had their depression confirmed by a diagnostic interview and were not already being treated for depression received antidepressants, and only 49 percent received any treatment at all. Patients may also limit the benefits of treatment by stopping treatment early. A large-scale study using household interview data⁸⁸ found that 42.4 percent of patients discontinued their antidepressants within 30 days, and only a little over twenty five percent of patients continued taking their antidepressants for more than 90 days. Another review found that up to 50 percent patients who initiate antidepressant use discontinue taking them within 3 months.⁸⁷ In these cases, follow-up contact or case management may provide an important way to track patients for whom treatment isn’t working.

Studies using followup contact as a treatment quality indicator, however, have found that followup contact with depressed patients in primary care settings is often lacking. A household survey²¹ found that 27 percent of community dwelling adults who are depressed receive depression care in a general medical setting. Forty-one percent of depressed participants treated in primary care settings described care that the researchers rated as “minimally adequate.” “Minimally adequate” was defined as either (1) at least four outpatient visits with any type of physician for pharmacotherapy that included use of either antidepressant or mood stabilizer for a minimum of 30 days, or (2) at least eight outpatient visits with any professional in the specialty mental health sector for psychotherapy lasting a mean of at least 30 minutes. No time-frame was specified for these visits. Sixty-four percent of the patients treated in specialty mental health settings received “minimally adequate” care.

A 2003 study²³⁴ looked at usual depression care at a large staff-model medical group in Minnesota. Researchers surveyed patients who had been given a depression diagnosis at a visit during the past week about their depression care. Seventy-eight percent of the patients contacted reported that they were taking antidepressants at the time they completed the one-week post-visit questionnaire. At least 42 percent of the patients were taking antidepressants at the time of their index visit, according to chart audit, so most of these were not new prescriptions. At 3-month followup, 24 percent of the patients re-surveyed reported having received a new prescription for an antidepressant, and 67 percent of these reported that they stopped taking their antidepressants before a clinician told them to stop.⁸⁹ Regarding followup appointments, 59 percent of the patients had at least one followup visit during the subsequent 3 months, and 10 percent had three or more visits. Nearly all of those with three or more visits were seeing mental health therapists rather than primary care clinicians.²³⁴ It is difficult to determine from these data the proportion likely to have received “minimally adequate” care according to the community survey definition, but it seems unlikely that it would exceed the 41 percent reported by the community survey study described above.

Another 2003 study looked at adherence to evidence-based guidelines in the VA system,⁸⁶ where annual depression screening of patients without known depression is the standard of care. They identified nineteen indicators of guideline-concordant care based on guidelines published by AHPCR,^17,97 Veteran’s Health Administration (VA),⁹⁸ and the American Psychiatric Association (APA)⁹⁹ that could be documented in the medical chart, such as exploration of functional limitations or current social stressors, discussion of treatment preferences and options, phone or in-person contact with primary care staff within 2 weeks, and evaluation of depressive symptoms between 12 and 24 weeks. They found that approximately half of the items were completed on average, with some items being completed on only 13.5 percent of the sample (contact within two weeks) and some being completed for 100 percent of the sample (noting a positive screen or exploring depression; initiating or discussing treatment). Other indicators that were met a substantial (>65 percent) portion of the time include exploration of functional limitations or social stressors; assessing drug and alcohol use; completing a physical exam; lab-work of potential relevance to depressed mood; and initiating or offering treatment. Thus, the assessment process appears to be fairly thorough, although review of specific DSM-IV or PHQ symptoms was documented in only 46 percent of the charts.

Treatment discussion and/or initiation were documented in all cases, and 63 percent of patients were prescribed antidepressants, fewer than the 78 percent reporting antidepressant use in the Minnesota HMO study. Seventy-three percent of the VA patients filled at least 90 days of the medication and reached a therapeutic dosage, and the average number of mental health visits was 3.4, among the 40 percent who saw mental health providers. It is difficult to say how many of these patients would have met the criteria for “minimally adequate” care as defined by the community survey, but it may be consistent with the 41 percent seen in the community survey.

In this sample they also collected followup Patient Health Questionnaire (PHQ), data on 46 percent of the patients, an average of 8.6 months after the initial PHQ. Only two of the 51 completing the followup questionnaire met criteria for remission at followup, though this number must be interpreted with caution given the low followup rate.