I recently saw a patient who came to me looking for an antidepressant. She explained that she is under a great deal of stress at home and work. We talked about the impact of the stress on her ability to function, sleep and participate in enjoyable activities. I asked her about suicidal ideation and administered a standardized, evidence-based, depression screening tool, the PHQ-9 (Physician Health Questionnaire 9. (You can download it here)

At the end of my assessment I came to the conclusion that she did not meet the diagnostic criteria for depression, but she had multiple stressors and needed help coping with them. I explained that a pill would not likely help her, but working on different ways to respond to her stress most likely would. We discussed some strategies, and I offered her counseling to help her reframe and develop new skills for stress reduction. While she agreed with the plan we developed together, she lamented that there isn’t a pill that can fix her problems.

This is not an uncommon experience in primary care. According to a recent article, 1 in 10 Americans now take an antidepressant; among women in their 40s to 50s, that figure is 1 in 4. A study this past April showed that nearly 2 out of every 3 people diagnosed with depression in a community setting did not meet diagnostic criteria for depression; and those most likely to be misdiagnosed were the elderly. While there is a well-documented increase in rates of depression, our diagnostic approach as a profession could also be better. Certainly there are pressures on us to prescribe with increased direct-to-consumer advertising, patient requests and sometimes demands for prescriptions, and limited insurance coverage or access to mental health therapists.

An opportunity for improvement is embedded in our developing ACOs. A new metric is the use of an evidence-based screening tool for depression, such as the PHQ-2 (a shortened form of the PHQ-9) and the PHQ-9 for diagnostic purposes. While this alone won’t stem the external pressures on us to prescribe when it is not indicated, it may help us approach this important health problem in a more evidence-based way. Join me in our efforts to improve the approach to depression. I look forward to hearing from you.

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