Challenges and implications of routine depression screening for depression in chronic disease and multimorbidity: a cross sectional study

Abstract

Background: Depression screening in chronic disease is advocated but its impact on routine practice is uncertain. We examine the effects of a programme of incentivised depression screening in chronic disease within a UK primary care setting.

Methods and findings: Cross sectional analysis of anonymised, routinely collected data (2008-9) from family practices in Scotland serving a population of circa 1.8 million. Primary care registered patients with at least one of three chronic diseases, coronary heart disease, diabetes and stroke, underwent incentivised depression screening using the Hospital Anxiety and Depression Score (HADS). 125143 patients were identified with at least one chronic disease. 10670 (8.5%) were under treatment for depression and exempt from screening. Of remaining, HADS were recorded for 35537 (31.1%) patients. 7080 (19.9% of screened) had raised HADS (≥8); majority had indications of mild depression with HADS between 8 and 10. Over 6 months, 572 (8%) of those with raised HADS (≥8) were initiated on antidepressants, while 696 (2.4%) patients with normal HADS (<8) were also initiated on antidepressants (relative risk of antidepressant initiation with raised HADS 3.3 (CI 2.97-3.67), p value <0.0001). Of those with multimorbidity who were screened, 24.3% had raised HADS (≥8). A raised HADS was more likely in females, socioeconomically deprived, multimorbid or younger (18-44) individuals. Females and 45-64 years old were more likely to receive antidepressants.

Limitations: retrospective study of routinely collected data.

Conclusions: Despite incentivisation, only a minority of patients underwent depression screening, suggesting that systematic depression screening in chronic disease can be difficult to achieve in routine practice. Targeting those at greatest risk such as the multimorbid or using simpler screening methods may be more effective. Raised HADS was associated with higher number of new antidepressant prescriptions which has significant resource implications. The clinical benefits of such screening remain uncertain and merits investigation.

Figure 1. Distribution of patients across three diseases for the year 2008-09.

Figure 2. Flow chart showing the outcome of depression screening.

Figure 3. Antidepressant initiation time for the screened and non-screened population.

Figure 4. Title-Depression Screening and Socioeconomic deprivation.

Rate of positive depression screening found from total screened (upper plot); and rate of anti-depressant initiation from those with raised HADS ≥8 (lower plot), versus socioeconomic deprivation status.

Figure 5. Title- Depression screening and Age.

Rate of positive depression screening found from total screened (upper plot); and rate of antidepressants initiation from those with raised HADS ≥8 (lower plot) versus age.

Figure 6. Relationship between probability of new antidepressant treatment, gender, and age and HADS categories, adjusted for deprivation and comorbidity.