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This website is made possible by third party financial support from Sage Therapeutics, Inc. and Biogen Inc.

Addressing Gaps in Screening, Diagnosing, and Treating Major Depressive Disorder (MDD)

Addressing Gaps in Screening, Diagnosing, and Treating Major Depressive Disorder (MDD)

March 24, 2023

Gaps in care can be detrimental.

Gap in Care

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Depression is a serious public health issue associated with decreased quality of life, disability, and high healthcare expenditures. It is a rather prevalent condition in primary health care (PHC), affecting up to 20% of attendance and increasing the cost on the health care system. Depression treatment improves functioning and lowers healthcare costs. Longer periods of untreated disease have a deleterious impact on the course and prognosis of depression; yet, more than half of probable instances of depression go undiagnosed in high-income nations. Most persons whose depression is effectively identified and treated have unstructured and insufficient access to therapy.1

The focus of primary care practitioners on ensuring that their overall decision making is correct rather than on diagnosis may account for some of the poor detection and kind of care offered. However, the belief that depression and other mental disorders are the specialist's responsibility, a lack of appropriate tools, such as diagnostic and treatment guidelines, a lack of confidence in dealing with depression, the clinical environment, and user level barriers are all critical barriers to the detection and treatment of depression.1

Because of the high frequency and severe degree of impairment associated with depression, prioritizing identification and care of depression, as well as taking a public health approach, is crucial for a variety of reasons.1

Primary health care is the initial point of contact with the healthcare system and provides the best potential for sickness identification and treatment beginning. The significant treatment gap, along with the worldwide commitment to increase access to treatment for mental diseases, involves making effective use of the PHC system to close the treatment gap. Recognizing depression is thus a critical first step on the route to treatment. The fact that over half of persons with diagnosed depression do not receive proper care, even in high-income nations, represents a significant wasted opportunity to address the population-level burden of depression, including suicide prevention. As a result, enhancing detection must be matched with increasing capacity to offer treatment.1

When possible, people want to be treated for depression through primary care. The primary care facility offers service users an accessible and reasonably priced option for receiving treatment for ignored health concerns such as melancholy. Most persons with depression seek primary care on a regular basis due to the predominance of somatic symptoms.1

The U.S. Preventive Services Task Force (USPSTF) discovered 13 primary studies (N=8706) and eight previous systematic reviews on the accuracy of depression screening tests. The systemic reviews evaluated several versions of the Patient Health Questionnaire (PHQ), the 2- and 3-item Whooley screening questions, the Center for Epidemiologic Studies Depression Sacale (CES-D), and the Edinburgh Postnatal Depression Scale (EPDS). One study compared different versions of the PHQ with structured or semi structured interviews using a series of individual patient data meta-analyses. When compared to a semi structured interview reference standard, the PHQ-9 identified 88% of participants with major depression and 85% of those without major depression at the standard cutoff of 10 or greater.2

Seventeen screening studies (N= 18 437 individuals) investigated the effects of depression screening on health outcomes. Unscreened control groups were used in four experiments. The remaining trials screened all participants but only provided the screening results to the clinicians of the intervention groups. Trial participants included adults of all ages and perinatal populations: six studies included general adult populations, four studies included older adults, six studies included postpartum patients (between 2- and 12-weeks postpartum), and one study included pregnant patients.2

Depression screening is recommended by the American College of Physicians for all individuals. Adults who are postpartum, have a personal or family history of depression, or have concurrent medical disorders are at higher risk. The American College of Preventive Medicine advises that all individuals be screened for depression. Based on patient presentation, risk factors, and particular groups, the Institute for Clinical Systems Improvement advises universal screening for suspected depression (eg, pregnant, and postpartum persons and individuals with cognitive impairment).2

1.    Fekadu A, Demissie M, Birhane R, et al. Under detection of depression in primary care settings in low and middle-income countries: a systematic review and meta-analysis. Syst Rev. 2022;11(1):21. doi:10.1186/s13643-022-01893-9
2.    Draft Recommendation: Screening for Depression and Suicide Risk in Adults. United States Preventive Services Task Force; 2022. Accessed November 1, 2022. Published September 20, 2022..