Screening for Depression: Then What?

Primary Care is now mandated to screen for depression, among a growing host of other conditions. That makes intuitive sense to a lot of people. But the actual outcomes data for this are sketchy.

“Don’t order a test if the results won’t change the outcome” was often drilled into my cohort of medical students. Even the US Public Health Service Taskforce on Prevention admits that depression screening needs to take into consideration whether there are available resources for treatment. They, in their recommendation, refer to local availability. I am thinking we need to consider the availability in general of safe and effective treatments.

If the only resource when a patient screens positive for depression is some Prozac (fluoxetine) at the local drugstore, it may not be such a good idea to go probing.

The common screening test most clinics use, PHQ-9, asks blunt questions about our emotional state for the past two weeks. This, in my opinion, fits right into the new American mass hysteria of sound bites, TikTok, Tweets, Facebook Stories, instant messages, same-day Amazon deliveries and our worsening pathological need for stimulation and instant gratification.

Two weeks??

Does anybody need to be labeled with a mental illness that will follow them for the rest of their life because of a fleeting emotional funk?

What is the likelihood that a person – particularly during a pandemic and a historic economical downturn – who feels down in the dumps for a couple of weeks is going to be better off if started on a dependency-causing, mind altering SSRI that many people can never eventually stop because of severe withdrawal symptoms? And, consider the very modest therapeutic benefit of antidepressants on chronic and severe (but not mild) depression.

If we look at the statistics, a recent JAMA study found that 8.5% of a study population had active, diagnosable depression before Covid and 27.8% after the pandemic took hold. Historically, the lifetime incidence of depression is over 20% according to another JAMA article from 2018.

In many ways, depression is a cultural, societal phenomenon, whether it is fleeting, like the modern American definition allows, or chronic. And I believe that the cure in many cases requires cultural, social, societal, spiritual and existential interventions.

The fact that rates of depression can vary depending on external circumstances brings me back to my previous exploration of the way modern psychiatric treatment has negatively altered the natural history of depression – a disheartening consequence of our well meaning professional interventions.

We Have Lost Track of the Natural History of Disease

Are we wrong in our short perspective of what constitutes clinical depression? I think the past year is telling us that. “This, too, shall pass” needs to be paired with “First, do no harm”. A state of feeling depressed is not necessarily the beginning of a lifelong disease, best treated with drugs.

2 Responses to “Screening for Depression: Then What?”

  1. 1 Eva Hnizdo May 7, 2021 at 5:45 am

    Yes it’s complicated . And there is reactive depression, responding better to cognitive behavioural or other psychotherapy, and of course, there is unhappiness, “‘would other people feel like this in these circumstances?”.
    SSRI ARE good drugs, but only with the appropriate use.

  2. 2 John R. Dykers, Jr. MD May 7, 2021 at 1:10 pm

    The first treatment for tolerable depression may be a warm caring relationship with a primary care physician. The second may be 10 mg of amitriptylline at 5 pm for a good night’s sleep, with no side effects. .

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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