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Vol. 284 No. 11, September 20, 2000 Letter Screening for Depression in Primary Care To the Editor: In his Clinical Crossroads discussion of a 52-year-old suicidal man,1 Dr Jacobs rightly emphasizes the importance of suicide risk assessment by the primary care physician. Unfortunately, he endorses a broad program of screening for depression, noting that "Depression screening is simple, cost-effective, reliable, and potentially money saving. . . ." He notes that the suicidal ideation of the patient presented "would have been detected by a primary care physician using a depression screening tool." However, there are no data to support either statement, nor was there evidence that this suicidal patient had contact with a primary care physician during which an opportunity for suicide risk assessment was missed. Jacobs reaches the erroneous conclusion that the complex problems of detecting and treating depression or suicide can be addressed with simple screening maneuvers, a conclusion for which there is no empiric basis.2 Because the natural history of major depressive disorder and its associated suicide risk has a waxing and waning course in patients who present to primary care physicians, screening is more likely to be inaccurate in primary care than psychiatric settings.3 All screening questionnaires have high sensitivity and poor specificity when used in primary care settings, thus leading to poor positive predictive value. Essentially, all questionnaires measure daily stresses and mood, rather than stable depressive symptoms. The criterion-based diagnoses detected are often mild and cause minimal impairment, thus leading to uncertainties regarding the appropriate course of treatment.4 Patients in primary care typically have a high level of resistance to routine queries about depressive symptoms, as compared to the more receptive attitude of the occasional patient who is truly suicidal. In short, the depressed patient seen in primary care is far different from the one seen in psychiatry, and the appropriate approach to diagnosis and treatment is unclear.5 The same uncertainties apply even more to the detection of active suicidal ideation, which is rarely seen in routine primary care practice and for which effective detection and prevention programs have not been demonstrated. The foregoing should not be a reason for negativity, which is neither compassionate nor productive, but rather skepticism regarding recommendations for broad screening programs. There is no evidence that such programs save either money or lives, despite the obvious desirability of such outcomes. Primary care physicians have a critical role to play in suicide risk assessment, but awareness and suspicion by a skilled, inquisitive, concerned physician are all that can be recommended at present. Thomas L. Schwenk, MD University of Michigan Health System Ann Arbor 1. Jacobs DG. A 52-year-old suicidal man. JAMA. 2000;283:2693-2699. FULL TEXT | PDF | MEDLINE 2. Schwenk TL. Screening for depression in primary care: a disease in search of a test. J Gen Intern Med. 1996;11:437-439. MEDLINE 3. Fechner-Bates S, Coyne JC, Schwenk TL. The relationship of self-reported distress to depressive disorders and other psychopathology. J Consult Clin Psychol. 1994;62:550-559. MEDLINE 4. Coyne JC, Schwenk TL, Fechner-Bates S. Nondetection of depression by primary care physicians reconsidered. Gen Hosp Psychiatry. 1995;17:3-12. MEDLINE 5. US Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, Md: Williams & Wilkins; 1996. In Reply: Dr Schwenk asserts that depressed patients in primary care are different than those seen in psychiatric settings. Although I agree, this is only because many depressed patients seen by primary care physicians are unrecognized as such or have yet to be referred for psychiatric treatment. Data illustrate that nearly 50% of depressed patients seek help through a primary care physician.1 In addition, Schwenk comments that suicidal patients are rare in primary care. However, the undeniable trend in managed care is to place the primary care physician at the point of entry to the health care system where he or she determines the referral or treatment path of all patients, including those with psychiatric illness, often in just a few minutes. The consequence of this trend and the need for a brief screening intervention are illustrated by National Depression Screening Day (NDSD)2 and its Primary Care Outreach. The NDSD Primary Care Outreach provides the Harvard Department of Psychiatry/National Depression Day Scale (HANDS), a simple 10-question screening form that has been validated in primary care settings.3 Fully 22% of the primary care patients screened through this program score positive for depression, and many have comorbid physical conditions such as stroke, cancer, and arthritis (author's unpublished data). In addition, it is misleading to state that the prevalence of suicidality in primary care is low. Of more importance is the high utilization of primary care services by suicidal patients. More than two thirds of people who commit suicide may consult their primary care practitioner in the previous month and as many as 40% in the previous week.4, 5 It is important to view the screening tool as just 1 instrument available to the physician, along with emotional sensitivity, awareness, and clinical skill. The screening tool is never to be used as a diagnostic instrument, but rather as a way of separating patients who have clinically significant symptoms from those who do not and broaching the subject of depression and suicide with those who are at risk. Douglas G. Jacobs, MD Screening for Mental Health Wellesley Hill, Mass 1. Narrow WE, Regier DA, Rae DS, Manderscheid RW, Locke BZ. Use of services by persons with mental and addictive disorders: findings from the National Institute of Mental Health Epidemiologic Catchment Area Program. Arch Gen Psychiatry. 1993;50:95-107. MEDLINE 2. Jacobs DG. Depression screening as an intervention against suicide. J Clin Psychiatry. 1999;60(suppl 2):42-45. MEDLINE 3. Baer L, Jacobs DG, Meszler-Reizes J, et al. Development of a brief screening instrument: the HANDS. Psychother Psychosom. 2000;69:35-41. MEDLINE 4. Hirschfeld RM, Russell JM. Assessment and treatment of suicidal patients. N Engl J Med. 1997;337:910-915. MEDLINE 5. Kelly MJ, Mufson MJ, Rogers MP. Medical settings and suicide. In: Jacobs DG, ed. The Harvard Medical School Guide to Suicide Assessment and Intervention. San Francisco, Calif: Jossey-Bass; 1999. 2000 American Medical Association. All rights reserved. "http://jama.ama-assn.org/issues/v284n11/ffull/jlt0920-3.html" janet paterson 53 now / 44 dx cd / 43 onset cd / 41 dx pd / 37 onset pd tel: 613 256 8340 url: "http://www.geocities.com/janet313/" email: [log in to unmask] smail: POBox 171 Almonte Ontario K0A 1A0 Canada