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Study: Diagnosing depression rarely requires trip to psychiatrist

Review of 25,000 patients shows primary care doctors can detect, treat most cases with online help

DALLAS – July 8, 2019 – Seeing a psychiatrist is not necessarily the most pragmatic solution to diagnosing and treating the growing number of Americans with depression.

Amid limited adherence to national guidelines calling for expanded depression screening, a study of 25,000 patients determined that primary care doctors could successfully detect and treat most depression cases without extra mental health personnel – if given the proper guidance.

In this case, UT Southwestern researchers equipped physicians with web-based software that guided them through protocols for screening patients, prescribing treatments, and measuring their progress. The results, published in the Annals of Family Medicine, show patients had outcomes similar to those seen in psychiatric care.

“It’s difficult to do proper screening for depression in a busy clinical practice,” said Dr. Madhukar Trivedi, founding Director of UT Southwestern’s Center for Depression Research and Clinical Care. “This study shows that primary care physicians can do this, and do it well, with the right tools.”

Online guidance

Depression app on tablet
VitalSign6 provides patients with questionnaires on a tablet computer at the beginning of their visits and is supplied to physicians with guidance on diagnosing, prescribing treatments, and monitoring the results of those treatments.

The study tracked patients across 16 primary care clinics in the Dallas area for two years. Each site agreed to use a software program developed at UT Southwestern called VitalSign6, which provided patients with questionnaires on a tablet computer at the beginning of their visits. The software also supplied physicians with guidance on diagnosing, prescribing treatments, and monitoring the results of those treatments.

From 2014-2016, the sites reported that 17 percent of patients screened positive for depression and more than half of those were officially diagnosed with depression. Nearly 42 percent who had three or more ensuing visits overcame their depression; this remission rate is comparable to results from STAR*D, the world’s largest depression study that Dr. Trivedi led more than a decade ago.

“We learned from STAR*D that most people don’t need to go to a psychiatrist to get better,” Dr. Trivedi said. “But many primary care physicians either haven’t been screening for depression or haven’t been using measurement tools that are essential for patients to achieve full remission. What we did is test if this screening could be done in busy primary care practices, without adding extra personnel or prohibitive costs.”

Slow change

Dr. Trivedi’s project is among multiple efforts launched in recent years to help doctors curb a rising depression rate and follow revised national guidelines calling for screening of all patients 12 and older. But change has come slowly: A 2017 study showed less than 5 percent of patients were receiving mental health screening, despite estimates that up to 15 percent of patients who visit their primary care physicians are in need of mental health services.

Doctors have cited numerous reasons for their hesitance to conduct mental health screening, including a heavy patient caseload and lack of personnel with the expertise to treat depression patients. But proponents say better tools would make all the difference, in particular a measurement-based system that enables physicians to track patient progress and change treatments if necessary.

“Measurement-based care is what truly differentiates the VitalSign6 approach,” said Lisa Rigby, Executive Director of Woven Health Clinic, among the sites included in the study. “I’m shocked at how other health care providers are trying to screen and treat depression, if they’re doing so at all. It’s common to see a one-time screen, with perhaps a prescription and no follow-up to see if the treatment is working.”

Dr. Namrata Babaria, a physician at Woven Health, acknowledges the clinic did a poor job of screening patients before joining the study. She said she was initially skeptical of the idea until she began seeing patients become more proactive in seeking help.

“Patients don’t often bring up their depression when they visit a primary care doctor,” Dr. Babaria said. “We ask them how they’re doing and they say, ‘Fine.’ Surprisingly, the patients are more open to admitting there’s a problem if we first give them questions through the app.”  

Patient perspective

VitalSign6 is expanding into other settings in North Texas, from hospitals and clinics to foster care and ministries that provide health care screenings to low-income patients.

The software has been integrated into a major electronic health record system being utilized in large medical centers such as Children’s Health and UT Southwestern. This integration simplifies the tracking of patients’ progress as they continue treatment.

Nisha Bursey was among the beneficiaries of the software. When the mother of two arrived at a nonprofit ministry for a health care appointment, she didn’t anticipate being handed a tablet computer that asked questions about her mental health.

But the questionnaire results helped Mrs. Bursey and her doctor eventually realize that for years she had been ignoring symptoms of depression and mental trauma, perhaps stemming from domestic violence and other difficult ordeals.

“I’m sure there are other people going through the same thing I’m going through,” she said. “If you admit you have a problem, that’s where it all starts. … Talking about it really helps.”

Expanded research

Dr. Trivedi’s team is collecting more data on patient screening, including from children in pediatric clinics and women with postpartum depression. The blood- and brain-based test results collected from these study participants, including Mrs. Bursey, will be tied into related research to help doctors identify biological markers for depression and which treatments are most appropriate.

For now, Dr. Trivedi is hopeful this latest research encourages more primary care physicians to implement mental health evaluations into all their patient visits.

“Doctors test a patient’s blood pressure, pulse, and other vital signs. I would like the VitalSign6 study to show patients and primary care physicians that it’s just as important to test for the sixth vital sign – depression.”

Dr. Madhukar Trivedi
Dr. Madhukar Trivedi, Director of UT Southwestern’s Center for Depression Research and Clinical Care

About the study

The study was supported by the Center for Depression Research and Clinical Care, The Rees-Jones Foundation, The Meadows Foundation, the Hersh Foundation, and the Gaston Episcopal Hospital Foundation. Dr. Trivedi is a Professor of Psychiatry and member of UT Southwestern’s Peter O’Donnell Jr. Brain Institute. He holds the Betty Jo Hay Distinguished Chair in Mental Health and the Julie K. Hersh Chair for Depression Research and Clinical Care. He has no relevant financial interests but other interests are noted in the study. 

The STAR*D study was funded by the National Institute of Mental Health.

About UT Southwestern Medical Center

UT Southwestern, one of the premier academic medical centers in the nation, integrates pioneering biomedical research with exceptional clinical care and education. The institution’s faculty has received six Nobel Prizes, and includes 22 members of the National Academy of Sciences, 17 members of the National Academy of Medicine, and 15 Howard Hughes Medical Institute Investigators. The full-time faculty of more than 2,500 is responsible for groundbreaking medical advances and is committed to translating science-driven research quickly to new clinical treatments. UT Southwestern physicians provide care in about 80 specialties to more than 105,000 hospitalized patients, nearly 370,000 emergency room cases, and oversee approximately 3 million outpatient visits a year.