Brief depression questionnaires could lead to unnecessary antidepressant prescriptions

Short questionnaires used to identify patients at risk for depression are linked with antidepressant medications being prescribed when they may not be needed, according to new research from UC Davis Health System published in the September-October issue of the Journal of the American Board of Family Medicine. 

Known as "brief depression symptom measures," the self-administered questionnaires are used in primary care settings to determine the frequency and severity of depression symptoms among patients. Several questionnaires have been developed to help reduce untreated depression, a serious mental illness that can jeopardize relationships, employment and quality of life and increase the risks of heart disease, drug abuse and suicide.

The UC Davis team was concerned that the questionnaires might lead to prescriptions for antidepressant medication being given to those who aren't depressed. Antidepressants are effective in treating moderate-to-severe depression but can have significant side effects, including sexual dysfunction, sedation and anxiety. They also have to be taken over several months to be effective.

"It is important to treat depression, but equally important to make sure those who get treatment actually need it," said Anthony Jerant, professor of family and community medicine at UC Davis and lead author of the study.

The exploratory study included 595 patients of primary care offices affiliated with Kaiser Permanente in Sacramento, San Francisco VA Medical Center, Sutter Medical Group in Sacramento, UC Davis, UC San Francisco and VA Northern California Healthcare System.

Patients selected for the study were considered at low risk for depression and therefore poor candidates for antidepressants, based on results of a widely-employed brief screening tool known as the Patient Health Questionnaire - 9 (PHQ-9), which was administered by the research team. The screener, which includes questions about changes in sleep, concentration, energy and appetite, was completed the same day the patients had appointments to see their primary care physicians, who were unaware their patients had completed the PHQ-9.

Based on a review of medical records, the patients were divided into two groups: those who were asked during their doctors' office visits to complete brief depression symptom questionnaires, besides the one administered by the researchers, and those who were not. The groups were compared in terms of rates of depression diagnoses and prescriptions for antidepressants received from their physicians.

Of the 545 patients who did not complete brief depression questionnaires during their doctors' office visits, 10.5 percent were diagnosed with depression and 3.8 percent were prescribed antidepressants.

Of the 50 patients who completed brief depression questionnaires during their doctors' office visits, 20 percent were diagnosed with depression and 12 percent were prescribed antidepressants.

Jerant said the study highlights the need for research to determine the best ways to apply brief depression questionnaires in daily practice, as use of the screeners tripled the likelihood that patients in the study who were not apt to be depressed would receive depression treatment.

Part of the problem could be in how questionnaire results are interpreted, Jerant said. Depression symptoms such as insomnia, fatigue and poor concentration are associated with many health conditions.

"The questionnaires aren't diagnostic in the sense that there's a certain score that means the patient definitely does or does not have depression," Jerant said. "Formal interviews are required to help doctors decide whether a patient's fatigue, for instance, is caused by depression. That fatigue could also be due to chronic lung or heart disease. It could also be due to an adjustment disorder that is usually transient and isn't likely to respond to antidepressants. We need to give providers good guidance on how to use brief symptom measures in evaluating patients and making treatment decisions."

Additional study researchers were senior author Peter Franks and co-authors Richard Kravitz, Erik Fernandez y Garcia, Camille Cipri, Denyse Nishio, Anca Knoepfler, M. Kaleo Wooddell and Victor Baquero of UC Davis, and Mitchell Feldman of UC San Francisco. Their research was supported by grant 1R01MH079387 from the National Institute of Mental Health.

A copy of the study, titled "Potential Antidepressant Overtreatment Associated with Office Use of Brief Depression Symptom Measures," is available online at http://www.jabfm.org/content/27/5/611.abstract.

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