Regular Screening for Depression Can Help, but Treatment Needs to Be Timely

What if at every check-up, your doctor asked you about your mental health? A recent study of a healthcare system that screens for depression symptoms at regular check-ups found mixed results on whether it helps people get the treatment they need.

Providers regularly checking in on mental health can help detect symptoms early, as well as connect patients to potentially life-saving support and care. But this care, the study found, doesn’t always happen in a timely manner. The study was published in JAMA Network Open in early March.

Lucinda Leung, MD, PhD, MPH, study author and physician at West Los Angeles Veterans Affairs (VA) Medical Center, and colleagues traced the paths of care of more than 600,000 VA patients who screened positive for depression. They found that most patients who screened positive and were diagnosed didn’t get timely follow-up care. Almost a quarter didn’t receive even minimal treatment within the year.

According to experts, these findings support the need for more integrated systems of healthcare. Leung told Verywell that integrated healthcare, and collaboration among healthcare practitioners in treating the individual, can be extremely beneficial.

“We know that this is what we are supposed to do,” she said. “The tough part is changing culture and restructuring clinics to spread this model of care.”

This study reflects how the historical lack of a person-centered approach to depression and mental health treatment is still acting as a barrier to care for many people.

Universal Screening as a Step Forward

When you go to a healthcare provider for a check-up, you are likely greeted by the same familiar steps.

This might look like stepping on the scale to measure height and weight, having a cuff wrapped around your arm to check blood pressure, and feeling the stethoscope against your chest to evaluate lung health. Your provider may also ask you questions to see if you might be dealing with depression.

If, after the screening, your provider then follows up and diagnoses you with depression, “timely follow-up care” from there is defined as receiving at least one of the following within three months:

• Three or more mental health specialty visits
• Three or more psychotherapy visits
• Three or more primary care visits with a depression diagnosis

To see how common and timely this follow-up care actually was, Leung and colleagues traced the paths of care of those who had screened positive for depression across 82 VA clinics in California, Arizona, and New Mexico. The sample included more than 607,000 veterans. During the years analyzed (2015–2019) about 8% of people screened positive for new depression symptoms at one of the VA clinics.

But an initial positive screening does not diagnose depression. Physicians need to do more evaluations to confirm. The study found that of those veterans who were later officially diagnosed, the majority did not end up utilizing one of the three follow-up care options on time—only 32% did within three months.

“Depression is the leading cause of disability worldwide,” Leung said. This is why addressing depression and getting folks connected to treatment options on time is so important.

Leung and colleagues did find that 77% had completed at least minimal recommended treatment—which includes at least one of the following within 12 months:

• Sixty days or more of antidepressant prescriptions filled
• Four or more mental health specialty visits, or
• Three or more psychotherapy visits

However, this follow-up care was not considered timely, and still meant that about a quarter of people did not get it within a year after screening positive for depression.

Leung and colleagues also noted that healthcare systems outside of the VA have struggled to follow up with patients at an even higher rate. On average, only about a third of patients even start medication and/or have at least one psychotherapy session in the three months following a new depression diagnosis. Follow-up is even less common for patients of color and patients aged 60 and over.

To understand this issue further, the authors wrote, continued research in “mapping” access to care pathways is needed. For example, further research could more clearly outline barriers to care, ways that medical professionals could further collaborate on care, or if universal screenings lead to over-detection of depression.

Racial Disparities in Care

Although the findings didn’t indicate a perfect system, they did note something surprising and hopeful: There was an absence, and possible reversal, of some racial disparities in receiving care.

The original group of patients was overwhelmingly male (90%), mostly White (56%), and had an average age of about 60 years old. Black veterans were treated with antidepressant medication at lower rates than White veterans, as has been observed in the past.

However, when accounting for all veterans, including those who chose to seek non-medication treatment or traditional talk therapy, historical racial disparities evaporated. Black veterans were more likely than White veterans to receive timely follow-up overall.

“This study continues to support that systematic quality improvement of screening and treatment are potential tools to mitigate racial and ethnic disparities in mental health care,” the authors wrote.

However, Leung and colleagues still found that follow-up was less likely for folks of certain backgrounds who had already been identified as experiencing unequal access to care. Usually, people over 65 and those with chronic physical health comorbidities struggle more in accessing treatment.

A Model for Other Healthcare Systems

For more than two decades, the VA has mandated annual depression screenings for all patients. But only just a few years ago, in 2016, did the U.S. Preventive Services Task Force recommend universal depression screening for all adults.

In that way, Leung said, the VA has been a model for other healthcare systems. It can show them what integrated healthcare could look like. “I thought, now’s the time to show people that we’ve been doing this at the VA,” she said.

When a veteran screens positive for depression at the VA, both they and Leung are already connected to a larger network. “Right next door to me is a psychologist, a social worker,” she said. “I have access to a psychiatrist if I need more help in digging into treating the problems that the patient is telling me about.” The matter can be addressed in the clinic right then and there, she added. For example, if a patient needs further evaluation at the psychiatrist’s office, the provider and patient can walk over together.

The evidence for integrated healthcare, and collaborative care models in general, is strong: It allows for easier, seamless access to different healthcare practitioners, as well as facilitates experts working together in treating the individual.

“I think a lot of places are recognizing that it’s a good system to have for not just veterans, but all civilians as well,” Leung said.