Since 1984, the U.S. Preventive Services Task Force, an independent panel of health-care experts, has regularly issued recommendations for doctors and patients about the best strategies for preventive care, including screenings, counseling services, and medications that help ward off disease. These recommendations don’t take cost-effectiveness into account, instead focusing entirely on maximum benefit for the patient. And a few weeks ago, the USPSTF took a dramatic step in the realm of mental-health promotion: In the first update to its adult depression-screening guidelines since 2009, the group now recommends “screening for depression in the general adult population, including pregnant and postpartum women,” without any other caveats.
The USPSTF assigns all its guidelines a letter grade based on how much they stand to help patients; this one earned a B, which indicates “high certainty that the net benefit is moderate” or “moderate certainty that the net benefit is moderate to substantial.” The grade puts depression screening in the same category as yearly mammograms, diabetes screening in overweight and obese patients, and lung-cancer screening for at risk patients, among other things. In doing so, it also elevates mental health to a higher priority in primary care.
The USPSTF first added depression screening to its collection of guidelines in 2002, when the task force recommended screening for adults only in health-care practices that had “systems in place to assure accurate diagnosis, effective treatment, and follow-up.” The guideline had a C grade, meaning that depression screening wasn’t recommended in situations that didn’t have all those qualifiers in place. Between then and now, the only other change has been to make the guideline even more restrictive: In 2009, the group updated the list of qualifiers to include “staff-assisted depression care.” In practices that didn’t offer such care (along with everything else on the list), depression screening was still discouraged.
Given the prevalence of depression among Americans, this most recent update to expand screening has been sorely needed for some time. Based on census data from the National Health and Nutrition Examination Survey (NHANES), 7.6 percent of Americans over the age of 12—that’s more than 20 million people—suffered from moderate to severe depressive symptoms from 2009 to 2012. The same report found that 43 percent of people with severe depressive symptoms reported significant challenges with their professional and personal lives. Yet under the old guidelines, patients who came to their primary-care doctors with complaints mirroring depression symptoms might still leave their visit without receiving, or even discussing their risk.
This latest screening recommendation, like any preventive-health guideline the USPSTF puts out, comes with a carefully balanced list of risks versus benefits. For colon-cancer screening, for example, the benefits of catching a cancerous or precancerous lesion early on far outweigh any of the risks associated with having a colonoscopy. Similarly, in patients with a significant history of tobacco use, doctors must weigh the benefit of early detection for lung cancer against the risks of radiation exposure from the CT scans (and possible false-positive findings, which could then lead to potentially unnecessary invasive procedures). Depression screening in the primary-care setting, which takes the form of a fairly simple questionnaire, is about as risk-free as any procedure can be, with the potential to majorly benefit patients: Past research has shown that without any sort of systematic screening, general practitioners miss nearly half of all cases of major depression.
Finally, the preventive recommendations for screening line up with what many health-care providers have known for years: Depression is as much a primary-care issue as chronic physical conditions, like diabetes or hypertension. It’s also intimately linked to physical health—managing a lifelong physical condition also requires consistent mental-health management. There’s a long way to go towards breaking down the stigma against mental illness in the U.S., but these updated screening guidelines, by opening up access to depression screening, diagnosis, and treatment, are a start.
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