Screening for Depression at Home Is a Promising Strategy

A new study by PhD student Melissa Franco finds that screening for depression via patient portals offers hope for wider detection.
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Patient portals may be a promising strategy to engage with and identify patients with depression as they appear to be more willing to take online screenings for depressive symptoms at home rather than discussing those symptoms with their health care providers in person.

A study published in the Journal of General Internal Medicine by Stanford Health Policy PhD student Melissa Franco noted that depression goes undetected in about half of symptomatic patients when they’re not screened. Rates from electronic health records (EHR) show that less than 5% of patients are screened for depression during routine primary care appointments. But online surveys by health care providers report that 50% of patients are screened for depression.

“Current strategies for depression screening rely on patients attending appointments,” wrote Franco and her co-authors. “Most importantly, patients with depression are less likely to attend appointments and, therefore, may never be screened. Furthermore, the number of clinical tasks addressed during primary care appointments is high, so it could be challenging to perform screening with high fidelity.”

Neda Laiteerapong, MD, University of Chicago Medicine, is the senior author of the study.

Depression among adults in the United States tripled in the first months of the COVID-19 pandemic, jumping from 8.5% to nearly 28%, according to The Lancet. U.S. Surgeon General Vivek Murthy wrote in his 2021 book, “Togetherness,” that loneliness has become a leading public health concern, leading to epidemics of alcoholism and drug addiction — as well as depression and anxiety.

So screening for depressive disorders has become paramount. And patients with symptoms appear more willing to complete screenings from the comfort of their own homes rather than clinical visits.

We saw this as an opportunity to improve timely case identification as patients may be silently suffering at home from depression and population-based screening strategies would help with timely case recognition and connect them with their health care system.
Melissa Franco, MPH
PhD student at Stanford Health Policy

A typical example might work like this: A patient due for an annual depression screening receives an online message from their health care provider, telling them they’re due for a screening. They are asked to complete the online screening regardless of if they have a scheduled the visit. If they screened positive for depression, a clinical social worker would follow up.

Franco and her colleagues studied 2,731 patients in a randomized trial. About 58% of the patients were screened for depression in clinic and 42% were screened via their health care portal. Patients who filled out the screener at home had a rate of positive screens for depression more than three times higher than those who filled out the surveys in clinic: 16% vs. 4%.

Among the patients who had moderate-to-severe depression screening results via a portal, 94% of them received a follow-up, including contact by a social worker, primary care physician or psychiatrist within one month of that screening.

“Our results indicate that people with moderate-to-severe depression may be more willing to engage with the health care system via the portal rather than by attending clinic visits,” Franco and co-authors wrote. “Therefore, shifting the time spent on screening outside of appointments could save valuable time during appointments for managing active health issues, as well as identifying significantly more patients with depression, which is the key first step to improving depression outcomes.”

Quality measures from health insurers, they note, still require depression symptoms to be measured in patients during appointments or 14 days before appointments.  “Because of these parameters, health care systems are incentivized to only measure depression symptoms in patients with scheduled appointments,” Franco and co-authors said.

The researchers argue that potential improvements to the system could include allowing primary care physicians with established patient panels to receive credit for all negative screens, and for positive screens that had appropriate follow-up and care plans documented, regardless of appointments.

They caution, however, that while the findings are promising, problems in the health care system are likely to hamper widespread dissemination of online depression screens. Regardless, the authors said they remain optimist that incorporating population health approaches with quality measure recommendations may address gaps in mental healthcare.

Melissa Franco

Melissa Franco, MPH

PhD Student, Health Policy
Uses decision science to improve health quality practices.

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