Challenges and implications of routine depression screening for depression in chronic disease and multimorbidity: a cross sectional study

Background -- Depression screening in chronic disease is advocated but its impact on routine practice is uncertain. We examine the effects of a programme of incentivised depression screening in chronic disease within a UK primary care setting.

Methods and Findings -- Cross sectional analysis of anonymised, routinely collected data (for 2008-9) from family practices in Scotland serving a population of circa 1.8 million. Patients registered in primary care with at least one of three chronic diseases, coronary heart disease, diabetes and stroke, underwent incentivised depression screening using the Hospital Anxiety and Depression Score (HADS).

125143 patients were identified with at least one chronic disease. 10670 (8.5 were under treatment for depression and exempt from screening. Of the remaining, HADS were recorded for 35537 (31.1 patients. 7080 (19.9% of screened) had raised HADS (8805;8); the majority had indications of mild depression with a HADS between 8 and 10. Over 6 months, 572 (8 of those with a raised HADS (8805;8) were initiated on antidepressants, while 696 (2.4 patients with a normal HADS (lt;8) were also initiated on antidepressants (relative risk of antidepressant initiation with raised HADS 3.3 (CI 2.97-3.67), p value lt;0.0001). Of those with multimorbidity who were screened, 24.3% had a raised HADS (8805;8). A raised HADS was more likely in females, socioeconomically deprived, multimorbid or younger (18-44) individuals. Females and 45-64 years old were more likely to receive antidepressants.

Limitations -- retrospective study of routinely collected data.

Conclusions -- Despite incentivisation, only minority of patients underwent depression screening, suggesting that systematic depression screening in chronic disease can be difficult to achieve in routine practice. Targeting those at greatest risk such as the multimorbid or using simpler screening methods may be more effective. Raised HADS was associated with a higher number of new antidepressant prescriptions which has significant resource implications. The clinical benefits of such screening remain uncertain and merit investigation.