Depression guideline: why universal screening isn’t recommended

Rates of depression in Canada are rising, but a new CMAJ guideline advises against universal screening in primary care. The Canadian Task Force on Preventive Health Care found no evidence that routinely administering depression questionnaires to all adults improves outcomes and raised concerns about false positives, overdiagnosis, and strain on limited mental health resources.

Dr. Eddy Lang, lead author of the guideline and professor of emergency medicine at the Cumming School of Medicine, University of Calgary, explains the rationale behind the Task Force’s recommendation. He describes how the review found no benefit from universal screening in improving depressive symptoms or quality of life and that commonly used questionnaires frequently misidentify patients, generating false positives and false negatives. Lang emphasizes that while physicians should remain attentive to patients’ mental health, questionnaires are not the answer to identifying depression in the general population.

Dr. Jennifer Young, a family physician in Collingwood, Ontario, and past president of the Ontario College of Family Physicians, reflects on what this recommendation means for everyday practice. She agrees that routine screening would add little value, pointing out that vigilance and continuity of care already allow family doctors to identify depression through clinical judgment and patient relationships. She underscores that time spent on universal questionnaires could displace care for patients with other pressing needs.

For physicians, the key takeaway is clear: be alert to signs of depression, especially in vulnerable patients, but don’t rely on blanket screening tools. Thoughtful conversation, familiarity with patients, and clinical intuition remain the best ways to identify those who need help.

For more information from our sponsor, go to medicuspensionplan.com

Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.

You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole

X (in English): @CMAJ
X (en français): @JAMC
Facebook
Instagram: @CMAJ.ca

The CMAJ Podcast is produced by PodCraft Productions

Transcript

0:00

Dr. Blair Bigham I'm Blair Bigham. Dr. Mojola Omole I'm Mojola Omole. This is the CMAJ Podcast. Dr. Blair Bigham Jola, today we're going to be talking about something near and dear to a lot of us, and that is depression. Specifically, a new guideline that's come out, a single recommendation on how people might spot depression. Dr. Mojola Omole Yes, so this was a great guidelines article by a repeat guest on the podcast, Eddy Lang, about using a single questionnaire for screening for depression in family physician offices. Dr. Blair Bigham So it's brought to us by the Canadian Task Force on Preventative Health Care. It is titled Recommendation on screening adults for depression using a screening tool. And I guess we don't see a lot of guidelines that have a single recommendation or such a focused question. Dr. Mojola Omole So this is a screening guideline for depression to be used in primary care, and it's using a tool that's for screening for everybody. And whether or not this is effective or not. Dr. Blair Bigham And we see this come up quite often in health care, Jola, where there's a screening tool for almost everything these days. We certainly keep asking our triage nurses in the ER to keep screening for more and more things. So it'll be really interesting to talk to Eddy Lang about what the task force found. And then we're going to pivot and talk to a family doctor about what this means for the front line. That's up next on the CMAJ Podcast. Dr. Eddy Lang is the lead author of the guideline in CMAJ. He is the former academic department head in emergency medicine and a professor in the department of emergency medicine at the Cummings School of Medicine at the University of Calgary. And he is a friend of the podcast. Eddy, welcome back. Great to be here, Blair. All right, Eddy, let's start with the original rationale for routine screening for depression. What problem was it meant to solve? Dr. Eddy Lang The burden of mental illness is quite serious across the developed world and really across the globe. And we know that when the situation arises where there is this big burden of illness, there often are efforts put forward to try to address it somehow. And we knew that there could be efforts underway and there are recommendations in some parts of the world that want physicians to screen for depression. And we thought it was a really important question for us to answer to shed some light onto whether this was an appropriate practice or whether this was something that maybe carried more harms than benefits. Dr. Blair Bigham Let's start with the importance of the moment here. How has the prevalence of depression been changing in Canada? Dr. Eddy Lang We've seen quite a concerning rise in the prevalence. It's gone from about a 12-month prevalence of 4.7 percent in 2012 all the way up to 7.6 percent. That's about a 60 percent increase over the last decade. Now, that also includes the impact of the pandemic, but that's quite an alarming rise. So the burden of depression with Stats Canada measuring it through population surveys has gone up quite considerably. That means that everyone has about a 10 percent likelihood in their lifetime of undergoing and experiencing a major depressive episode. Dr. Blair Bigham That's obviously a lot. It's obviously rising. So tell me about the actual screening. How is it supposed to be done? Dr. Eddy Lang So when we refer to screening, we talk about it as a universal application of a questionnaire. And what people often think about as screening is just normal, everyday vigilance and attention to someone's mental health, which is really part of someone's routine practice. So what we did with the guideline is we focused in very specifically on the question of whether primary care providers should be using a questionnaire on all of their patients to either detect depression in an earlier state or to uncover it when it might not already be evident. Dr. Blair Bigham I mean, intuitively, it seems like we would pick up on more depression that way and have an opportunity to treat it. Tell me, what did you find when it comes to questionnaires? Dr. Eddy Lang So we conducted a systematic review based on the methodology we use at the Canadian Task Force to look very specifically at the question of whether administering this questionnaire in a systematic way to people who are not otherwise at risk, whether that improves outcomes. Does it reduce depression? Does it improve quality of life? And we actually came across three studies done in populations that can inform that question. We saw it studied in patients with acute coronary syndromes, patients with osteoarthritis, and in Hong Kong in a postpartum setting. And what's really important is that these studies were unique in that they teased out the effect of administering the survey alone. Other studies will combine the screening procedure with offering of mental health resources and support and treatment. That's a different question. What we were really focused on was what is the effect of doing the screening test in and of itself. And in those three studies, we did not see benefits and we even think there may be harms in doing so. So, for example, the most commonly used questionnaire will elicit 22 positives when administered to 100 otherwise healthy individuals, but only nine of those are true positives. The other 13 are false positives, meaning that they're going to be probably referred along for further evaluation and maybe even receive unnecessary treatments as a result of having undergone the screening procedure. Dr. Blair Bigham If there was a test in the emergency department where 13 out of 25 positives were false, that would be a pretty garbage test study. You and I would never order that test. Dr. Eddy Lang Absolutely. But that's the situation we find ourselves in. That is the current screening instrument. And part of the reason that we're not seeing a benefit from this approach is partly because that questionnaire does not perform very well. In the perfect world, there would be no false negatives. There would be very few or if any false positives. And we would only be able to identify those people who really need to move on to the next stages of evaluation and possibly treatment. Dr. Blair Bigham So, Eddy, I don't want to lose anything nuanced here. Were there any outcomes that showed a benefit from these questionnaires? I mean, big things like suicidality or maybe other things like being able to go to school or work, how you exist day to day. Were the surveys good for any of that? Dr. Eddy Lang So those are definitely outcomes we were interested in. We got input from our patient partners, other stakeholder groups, and we definitely looked for that. Unfortunately, we didn't find it. None of those three trials that met our inclusion criteria had those kinds of details. It was only about depressive episodes and quality of life, both of which did not improve as a result of the screening. And our philosophy at the task force is that you really shouldn't be administering a screening test to a healthy population unless there's clear evidence of benefit. You know, we do work in a resource constrained setting. Not everybody can have ready access to mental health professionals. If we're going to be evaluating people for further psychiatric and psychological treatment, it better be the right people so that we don't create an unfair use of resources by those who may not even need it. Dr. Blair Bigham Especially when those resources are so short to come by nowadays. So that covers the application of this questionnaire universally. How about using it in vulnerable populations such as pregnant people or people who are postpartum? What's the recommendation there? Dr. Eddy Lang Well, we have already published a guideline on screening for depression in pregnancy and postpartum. That was in 2022. And while we do say that that is a high risk group that requires perhaps more attention and vigilance, even there, the administration of questionnaires do not provide a meaningful benefit. So in 2022, we made a recommendation. It wasn't a strong recommendation. It was more of a conditional recommendation. That's a more nuanced way of allowing health care providers in particular settings to apply the recommendation. So there we really had a minimum of evidence to work with. Here we have three randomized trials telling us it really doesn't work, hence leading us to a strong recommendation. Again, in the backdrop of a resource constrained setting where we know that family physicians are currently carrying the burden of depression treatments in Canada and that for those cases that test positive, that may require further treatment, we need to be more careful and selective in who goes down that road and not rely on a questionnaire which yields lots of false positives and even misses some cases and false negatives. Dr. Blair Bigham So what is the best way for someone in family practice to pick up on depression or risk of depression in pregnant or postpartum people? Dr. Eddy Lang Well, I think, and this is the general advice we give in the guideline, we know that there is a higher incidence of depression in these populations and the hormonal changes, all of which contribute to sometimes very serious cases of depression. So it requires a certain amount of general attention and vigilance, asking about mental health, educating the public about the signs of postpartum depression. It would be great if we had a questionnaire that worked and was able to identify and catch the cases of serious postpartum depression early on or pregnancy associated depression. But the surveys and the survey approach doesn't work. It's all about common sense, remembering to ask and being attentive to the patient's mental state. Dr. Blair Bigham Got it. One of the things that I'm personally really interested in is how different parts of the world have different guidelines. And the reason I'm interested in that, Eddy, is because when the public hears different things from different sources, I think it generates confusion now more than ever before. In the United States, the Preventative Services Task Force recommends screening. Do you have a sense of how they came to a different conclusion? Dr. Eddy Lang That's such an important point, Blair. And one of the other motivations for us to go ahead with this guideline is we wanted to make sure that if they had found something that was important, that merits a positive recommendation, that we should be able to share it. So I think the fundamental difference and what I consider a bit of an error in their process is, as I mentioned earlier, they looked at studies that not only looked at screening, but screening plus treatment. And of course, if you offer that combination and take those who screen positive and offer them psychotherapy and medications, for sure you're going to see a benefit. But that may be largely the result of the associated treatments and follow up that those groups receive in those studies. So that's what led to the positive recommendations from the USPSTF. It's not the only time that we've differed with them. And there are also probably some mental health lobby groups and other sort of contextual factors that may have led to the USPSTF making a positive recommendation for depression screening when we have come out resoundingly on the opposite side of the coin. Dr. Blair Bigham It sounds like we have a bit of a combination here of maybe applying a bad tool, a tool that has too many false positives, to an overly broad population, and those two factors combine to then basically put people on a road they don't need to be on. Is that the Canadian perspective here? Dr. Eddy Lang That's a great point. And nowadays, because of the limited access to primary care, people are using other tools and other approaches, including mental health apps, to evaluate their well-being and possibly even to do the kinds of questions and surveys that we've been talking about that can lead someone to a self-diagnosis of depression. Now, that's not within the scope of our guideline, but it speaks to the general idea that if you are worried about a problem, then digging in with tools and questionnaires to identify it early by nipping it in the bud, you're going to do something that's beneficial and better in the long term. And what we've shown in the studies that we looked at and in the recommendations that we're making, that that's not always the case. Part of the problem that we are concerned about, known as overdiagnosis, is about the medicalization of normal life experiences. So we all have periods of sadness, bad days. If you were to catch someone with one of these questionnaires during those negative periods, that's where the false positives come in. And that's where people may have a chance of getting overdiagnosed and then subsequently overtreated. Dr. Blair Bigham So what's the takeaway? What's the bottom line for busy clinicians? Don't use a questionnaire, but we don't want to throw the baby out with the bathwater here. How do physicians and frontline primary care practitioners find people who are depressed so they can get them the help that they need? Dr. Eddy Lang You know, one of the great advances in mental health care over the years in Canada has been a removal of the stigmatization associated with mental illness. So we're hopeful that simply by speaking to patients, even if they're coming in for another problem, to find out about their mood, their sleep, their appetite, their well-being. Key questions about sadness are going to be essential in finding out if patients have a burden of symptoms and unwellness that merits further discussion and investigation, possibly referral to a mental health professional. So our message is clear. Be vigilant. Depression can be devastating and can have very difficult consequences for people and their families. But don't go about it in a systematic way of administering questionnaires across the board. Dr. Blair Bigham Eddy, as always, very clear, very helpful. Thank you so much for joining us today. Dr. Eddy Lang For sure. No problem at all. Dr. Blair Bigham Dr. Eddy Lang is the former academic department head in the Department of Emergency Medicine at the Cummings School of Medicine, where he is also a professor. Dr. Mojola Omole Of course, the new guidelines are most relevant to family medicine physicians like Dr. Jennifer Young. She is the past president of the Ontario College of Family Physicians, and she's a part-time physician advisor for the College of Family Physicians of Canada. She's a comprehensive family physician who joins us from Collingwood, Ontario. Thank you so much for joining us, Jennifer. Dr. Jennifer Young Thanks for having me. Great to be able to talk about something that I certainly do a lot of in my practice. Dr. Mojola Omole I can imagine. So let's just start off. What was your first impression of the guidelines? Dr. Jennifer Young So the first impression of the screening guideline, which indicated that routine screening of everybody did not make a difference for outcomes, didn't surprise me. And that's not to say that I don't think depression is a huge problem. I tell you, 30% of my day is dealing with mental health, and that comes up in so many other ways. But it is that if I was to ask every single person in my practice in a very standardized way, would that make a difference to the outcomes for depression above and beyond what I feel we're already doing in my practice? I don't think that it would be a really good use of our time as physicians, but also in our interactions with our patients. So no, it didn't surprise me. Dr. Mojola Omole And just give us a sense of how routine screening would affect your practice if it was adopted. Dr. Jennifer Young OK, so that question, those two. So for example, the PHQ-2 is two questions. And in the last two weeks or last month, have you felt down, depressed or hopeless? In the last month, have you felt less interest in your normal activities? The evidence would indicate that there is probably like about 12% of people who don't actually have depression are going to say, yeah. And so that leads to a conversation that leads to time that leads to perhaps investigations when it was just a bad couple of weeks or a bad month. And so if I dial that back down to, in a full day, I might see 25, 30 people. If I'm spending two minutes on average per person, that's almost an hour of my time asking that question. That translates to five appointments. So if that's five appointments that I'm not available for, those five people might be going to emerg for their exacerbation of their COPD, for their abdominal pain, their kid who's got a wheezing illness. So it is lost opportunity. So if in the course of my day, someone comes in with fatigue and that particular complaint, we've looked at evidence around the percentages of that. About 10% of people come and say they have fatigue. One of the questions I'm going to ask is, are you feeling down, depressed or hopeless? So you're choosing the conditions. Insomnia, chronic pain, higher risk things like, well, obviously history of postpartum or history of depression. It comes up so often in the course of my day that I will ask about mood as it relates to other presenting symptoms. Dr. Mojola Omole So because the guidelines had mentioned that physicians need to be vigilant and attentive in spotting depression. So for you, is that what it looks like, is using your clinical judgment to pick out, OK, this could be a symptom of depression. Dr. Jennifer Young Yes, that's absolutely it. And the thing about family medicine as well is that I know my patients and I will have, I hope, a good spidey sense around presenting symptoms. The way someone says something, the fact that they're in at all, I might, might cue me to ask again or ask more. And then also follow up. So somebody comes about X and then we say, OK, for example, fatigue, I'm not going to say, oh, well, as you know, if they say they're feeling down and depressed, I'm not going to say, oh well, then that's it and then not do anything. But I'll do that initial workup, ask around other symptoms, other physical things that could be a cause of the illness, and then on the follow up, review other components of, depending on results, etc. So that continuity of care really does allow us to pick it up in the course of our practice. Dr. Mojola Omole So how do you, so once, let's say you suspect depression, how do you use the screening tools then? Dr. Jennifer Young I'd ask those first two questions. So the PHQ-2 is pretty sensitive. It's those two questions down, depressed, hopeless, lack of interest. And then there are seven other questions that go into that. And then that's the PHQ-9. I mean, it's not just going to be formulaic in that I then go and ask those nine questions and then that's it. And then I give them a score and I say, oh, you're depressed. It's going to be more of a flowing, natural conversation than just slamming those nine questions through and giving them a score. I normally will say, well, tell me more about that. And they'll give their narrative. And in the course of that narrative, I'll have a sense of the answers to the other questions. And then if I need to, and then if I need to fill it in with the specific questions that are on that PHQ-9, I would ask those specific questions. And yeah, so it's always a combination of narrative and then score and effect on life. How is it affecting their function? And then what approach do they want to take with that? And the vast majority of people are going to want to talk to someone about it. And that would be the first thing that I would generally do. And some will say, jeez, I've already been doing that and I'm just not, I'm stalled. I'm not doing well. And medications they're already thinking about. Dr. Mojola Omole So you've been in practice for 25 years. So you are a seasoned vet in the trenches. But is there ever a concern, because I have some friends who before they were younger starting out, of missing cases of depression if you're not routinely screening? Did you ever before feel that way? Do you still feel that way? Dr. Jennifer Young I would say that, of course, there are people whose depression I have missed who didn't choose to disclose, didn't choose to come to me. And, you know, I'm sure now, even now, there will be cases of depression that I will miss. I guess that the imperfectness of being able to catch everything is just that's the reality. And if I was to have seen evidence with this systematic review where there were RCTs that showed that it really made a difference, that wow, there's this. If we ask those two questions of everybody, we could save lives from suicide. We could save jobs. We could save relationships. Then it would motivate me to be more systematic in those questions. At this point, I don't have that evidence to do so. And I have, just there's just so many questions that one could ask. So many screening things that are out there. There has been an evidence paper around the amount of time that it takes to do all of the recommended guidelines. And if you were to do everything for both preventive, chronic and acute care medicine for a panel of 2,500 patients, it would take family doctors 26 hours a day to do that. So I'm waffling here if it would be nice, but I guess I would want to do stuff that makes differences. And if I have evidence that it makes a difference, that's what I would want to spend my time doing. And I don't see the evidence here. Dr. Mojola Omole Perfect. Thank you so much for joining us. Dr. Jennifer Young OK. Thanks for having me. Dr. Mojola Omole Dr. Jennifer Young is a comprehensive family physician joining us from Collingwood, Ontario. Dr. Blair Bigham So, Jola, on the surface, I love this guideline, right? This guideline says figure it out clinically, be a good clinician, be a good person and do your job. You don't need some script in order to do that, because I feel like medicine is moving towards scripting what I do. Dr. Mojola Omole I understand what you're saying in terms of, you know, the guideline is saying you don't need a script. My question always, though, is how do we make sure we capture vulnerable populations? Because those are the ones when, if we miss depression in them, could have dire consequences. So as much as I found this guideline to be very helpful and takes a huge burden off our family physician colleagues, I do think the next step in terms of forecasting is how do we, how do we screen in vulnerable populations? Dr. Blair Bigham It does beg the question, if it's not a script, if it's not a questionnaire, then what is it? Is there something about the culture? Is there something about our communication style? Is there something about our body language that needs to shift so that these organic conversations, if that's truly how we're picking up depression, or at least suspecting depression to then apply a questionnaire. You know, how do we pick up what's being missed now? Because it's clear that A, not everybody gets picked up and B, not everybody has a longitudinal relationship with a family physician. Dr. Mojola Omole It goes back to some of the previous topics we've had in terms of changing the sphere of how family medicine is practiced in Canada that allows for, you know, everyone to be attached to a family physician from birth. To have, you know, the space and the breath to build longitudinal relationships with your family physician. And we just don't have a system that catches that. And so that does make it challenging for us to build that. Dr. Blair Bigham Absolutely. I don't think it's easy for anyone to talk about depression and a host of other personal topics in an emergency department or in a walk-in clinic. You really do need that longitudinal relationship just to feel safe and comfortable, you know, to have that trust with someone that you can open up and have that conversation. Dr. Mojola Omole For sure. But for now, no screening needed. Dr. Blair Bigham That's it for this episode of the CMAJ podcast. The link to the guideline is in our show notes. Please rate, share, review our podcast and spread the word. It helps us get the message out. The podcast is produced for CMAJ by Neil Morrison at PodCraft Production. Catherine Varner is our deputy editor at CMAJ and senior editor of the podcast. I'm Blair Bigham. Dr. Mojola Omole I'm Mojola Omole. Until next time, be well.