Depression Screening: Challenges and Solutions at the Primary Care Level

Though it may be understated relative to the influx of avenues by which people can initiate psychiatric or mental health care today, primary care remains a vital and common opportunity to initially flag signs and symptoms of depression and to initiate care. Of course, the ever-busy primary care team is burdened with time and resource hurdles that may hinder their ability to adequately screen patients.

In an interview with HCPLive during the American Academy of Physician Associates (AAPA) 2024 Conference & Expo in Houston, TX, this week, Beth Browning, PA-C, LPC, a physician assistant with Baptist Community Health Services, discussed her AAPA 2024 session topic on treating depression in the primary care setting. As is the case in her practice, a common standard is to provide the Patient Health Questionnaire (PHQ-9) to patients coming in for appointments.¹

“It is an interesting screener, and I do mean screener,” Browning said. “We can't diagnose purely based on that questionnaire, even though it does go through most of the requirements from the DSM-5 TR. However, there are a lot of confounding variables with it.”

As Browning explained, even if a primary care provider has 15 - 20 minutes to meet with a patient, their engagement with the PHQ-9 may only be a review of the patient’s final score; patients may also be digitally filling the questionnaire prior to their visit, or in their accompanying visit paperwork in the waiting room. The end-result can very easily be a clinician misdiagnosing or under-treating a patient based on a review of the final score without any context.

“In my primary care clinic, we do it with the medical assistants and the intake; we consider it another vital sign, and it actually sits under our vital signs,” Browning said. “If your clinic’s not putting it as a priority, it's never going to be a priority.”

Browning has also encountered an issue of primary care clinicians purposefully avoiding the PHQ-9 review conversation with their patients largely due to the last prompt: ‘Have you had any thoughts about harming yourself in the past two weeks?'

“We don't ask because we don't want to know,” Browning said. “I found that to be very frequent.”

When asked why in particular men, minority patients and non-English speaking patients may be at particularly greater likelihood of missing a primary care depression screening, Browning acknowledged the idea that these same groups also more frequently live with chronic conditions that warrant more focus during the tightly-scheduled wellness visits.

“If you have a patient who comes in and their diabetes is out of control, their blood pressure was high, you're trying to treat their blood pressure in clinic to get it down so they can safely go home, asking if they've been sad the past 2 weeks definitely gets put on the back burner,” Browning said. “We're trying to treat the more emergent things in the clinic. Unfortunately, though, what we miss is that about 50% of patients who attempt suicide have seen a medical provider in the past 30 days. And they aren't coming to psychiatry—they're coming to primary care.²”

Browning advised her colleagues seek out unique moments of the care visit to prompt such patients on depression screening, such as during a blood pressure check or when they’re received bandaging or sutures for a wound. Her colleagues could also consider offering a follow-up visit in the coming week to ensure screening still occurs within a short time of the initial visit.

Additionally, care team members including case managers can help compensate for the lessened availability of primary care providers. She also assures all her patients leave the clinic with resources including the suicide hotline and contact information for area-specific response care teams.

Regarding adequate depression diagnosis, Browning said primary care providers must ensure they’re ruling out underlying causes—chronic issues with the thyroid system, or sleep-affecting conditions like obstructive sleep apnea (OSA) may be particularly contributing to poor PHQ-9 scores. There’s also a standard for family psychiatric history questions to help contextualize the PHQ-9.

Regarding treatment strategy, Browning emphasized a heterogeneous approach—many of the therapies lack significant superiority over one another for depression. She stressed an emphasis on detecting the symptoms that both a patient and their clinician would like to resolve or prevent—an exercise that may foster more trust and buy-in to a regular dose regimen. That said, many caregivers have a specific preference for antidepressants.

“I would say bupropion has been kind of the go-to for most primary care, because it helps with energy, it helps with that (depressive) sadness,” Browning said. “It works a little bit faster than SSRIs, but not significantly. If they're a smoker, it off-label can treat smoking cessation, and it's weight neutral, which most of our patients are very happy to hear that they're not going to gain weight on it.”

That said, bupropion is also limited in its treatment of anxiety, Browning said—meaning the symptom can even be exacerbated while the patient’s depressive symptoms improve.

“Part of is understanding what are we trying to treat here, what are the side effects?” Browning said. “Or, most PCPs have a SSRI they feel comfortable with and they roll with, and most of the time that's fine within the SSRI class, to just have one that you feel comfortable with.”

References

1. ^{Costantini L, Pasquarella C, Odone A, et al. Screening for depression in primary care with Patient Health Questionnaire-9 (PHQ-9): A systematic review. J Affect Disord. 2021;279:473-483. doi:10.1016/j.jad.2020.09.131}
2. ^{Raue PJ, Ghesquiere AR, Bruce ML. Suicide risk in primary care: identification and management in older adults. Curr Psychiatry Rep. 2014;16(9):466. doi:10.1007/s11920-014-0466-8}