The most surprising study result I’ve come across during the past couple of weeks was this — only 4.2% of adult consumers receive depression screenings during primary care visits (see 4.2% Of Adults Receive Depression Screening In Primary Care). I thought that integration of physical and mental health care had moved further than this, but these study results tell a different story.
In this study, the researchers analyzed data for 33,653 physician-patient encounters from the 2012 and 2013 National Ambulatory Medical Care Survey with the goal of estimating national rates and patterns of depression screening among visits to office-based primary care physicians. Additional findings included:
- African-Americans were half as likely to be screened compared with whites.
- Adults age 65 and older were half as likely to be screened compared with middle-aged people.
- People with a chronic condition were more likely to receive depression screening than those without a chronic condition. The likelihood of being screened increased with each additional chronic condition.
So why is this the situation? Why the poor performance? I turned to my colleagues for answers — OPEN MINDS Senior Associates Sharon Hicks, Sarah Fine, Ph.D., George Braunstein, Bob Dunbar, and Alan Bragwell. They identified the following issues as impediments to depression screening in primary care settings:
- Lack of knowledge and training
- Lack of referral sources and resources
- Focus on the “presenting” problems
- High primary care productivity expectations
“While we still have a stigma against persons who have these diseases (thinking them weak, vulnerable, or somehow ‘less than’), we will continue to see the screening questions as special rather than a routine part of a full physical evaluation.” – OPEN MINDS Senior Associate Sharon Hicks.
“When a primary care professional (PCP) has limited time with a consumer, they might be more inclined to avoid the question if the consumer does not seem obviously distressed emotionally, out of concern that questions about mental health will be awkward or imply personal failing or weakness. Of course, the avoidance is self-perpetuating, because it keeps the PCP from developing comfort or expertise with discussing the issues as well as a sense that discussion of mental health is routine rather than a rare and distressing event. In addition, if consumers aren’t receiving the message that mental health issues are acceptable and appropriate to discuss with a PCP, then they are far less likely to spontaneously initiate the conversation.” – OPEN MINDS Senior Associate Sarah Fine Ph.D.
Lack Of Knowledge & Training
“Patient failure to disclose depression to their primary care physician but instead to present with back pain, headaches, chronic pain, or other conditions. Failure to identify the existence of depression by a primary care physician becomes, in part, a lack of training in behavioral health and failure to value the psychological variables influencing health.” – OPEN MINDS Senior Associate Bob Dunbar
“Although information regarding the devastating and costly nature of depression is slowly saturating the field, I suspect there is still some uncertainty among professionals regarding what kind of screening to do, or what measures are best. PCPs are far more comfortable with how to screen for purely physical ailments, of course, and feel far more competent in terms of how to respond if a screening result is positive. Further, PCPs may avoid ‘opening that can of worms’ in a brief check-up or office visit out of concern that it would divert time and resources from things s/he feels more able to address successfully.” – Dr. Fine
Lack Of Referral Sources & Resources
“If a PCP does not have a reliable and responsive referral network, it’s easy to see how s/he might avoid screening for depression simply because a result indicating need for further intervention might be met with a lack of availability of resources able to provide timely and high-quality assistance. I suspect this feeling of helplessness adds to the avoidance of screening, particularly if the first two factors I mention are in play.” – Dr. Fine
“Primary care practices are highly unlikely to screen for depression if they lack resources, either directly or through referral, necessary to professionally diagnose and treat depression. Certainly there would be concern that failure to treat could increase malpractice liability risk.” – Mr. Dunbar
Focus On The ‘Presenting’ Problems
“My experience with both federally qualified health centers (FQHC) and free clinics is that they are so busy and focused on the presenting problem that the screening is very limited. Even screening driven by the Patient Protection and Affordable Care Act (PPACA) can miss problems if it is a “task to get done and move on” to the presenting problem.” – OPEN MINDS Senior Associate George Braunstein
“Primary care physicians have very high productivity expectations, which may well prohibit exploration of behavioral health contributions to physical health conditions.” – Mr. Dunbar
“In the rural health clinic setting, and I suspect in federally qualified health centers (FQHC), there is a billing glitch that is holding down reimbursements for depression screenings. The problem is that the billing code for a depression screen (G0444), can only be paid to the rural health clinic if it is billed by itself on the day. This prevents warm hand offs by the Physician or nurse practitioner. We have tried it and it won’t pay and 99.9 % of consumers won’t come for just a screening.” – OPEN MINDS Senior Associate Alan Bragwell
Mental health is too often overlooked in primary care visits, and even primary care practices that aim to remedy this situation bring a steep learning curve. What are the solutions to this situation? For more, tune in tomorrow for our team’s recommendations for better depression screening.