William Cayley: Are you depressed?

bill_cayley_2“Do you feel down, depressed, or hopeless? Are you bothered by little interest or pleasure in doing things?”

Now that the practice I work for is part of an accountable care organization, one more measure on which our (supposed quality of) patient care is being assessed, is our screening for depression. While that sounds initially good on the face of it (after all, who wants to be depressed?), in reality I fear it not only flies in the face of current best evidence, but also contributes to over-medicalization and “too much medicine.”

While asking about feelings seems inherently a good idea, the United States Preventive Services Task Force (USPSTF) recommends screening adults for depression “when staff assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up.” Without a clear plan for accurate diagnosis and follow-up, screening is not shown to improve outcomes. Unfortunately, the way depression screening is often implemented in (busy!) office practices, the options “triggered” or suggested by a positive screen generally focus on mental health referral or medication prescription. In other words, “screening” blurs into “diagnosis” of sad feelings as being the same as depression.

As I’ve written before, I cannot think of a single patient for whom the now mandated screenings for depression or falls risk have told me something I did not already know. However, I think the bigger problem with mandated depression screenings (and “triggered” follow-up actions) is that they miss the point of listening to and caring for the patient. An excellent blog from the PRIME network tackles the problem of lumping feelings of loss or grief under a diagnosis of major depression (with the usual response of adding an antidepressant). Another facet of the overly quick jump to a “depressed” diagnosis, is that we “pathologize” the responses of our patients to the losses or physical declines that come with normal aging.

More than once, as I’ve worked with an older patient on exploring feelings of loss, lack of interest, or sadness, it has emerged that the story fundamentally has to do with missing the activities or people that were parts of life at a younger age. Sadness and feeling down are a normal response to losing friends, family, or abilities as life goes by. They don’t make us or our patients feel good, but they do not necessarily mean that medication is needed either. What is needed is a listening ear, a comforting presence, and the skill to help our patients sort out what is painful yet tolerable, from that which is painful and needs to be addressed.

Our patients need us fundamentally as carers and healers, but the more we focus on rote screenings (and forget the difference between screening and diagnosis), the more we risk becoming simply automatic prescribers—and that leaves me depressed.

William E Cayley Jr practices at the Augusta Family Medicine Clinic; teaches at the Eau Claire Family Medicine Residency; and is a professor at the University of Wisconsin, Department of Family Medicine.

I declare that that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare.