Patients Who Screen Positive For Depression Are Not Getting Timely Follow-Up Care Study Shows

Despite the universal screening that takes place at health care systems in the United States, patients suffering from depression are often not getting the timely follow-up care needed to address their condition, according to a new study.

The research, published in JAMA Network Open, showed that while most patients who were studied met guidelines for requiring at least minimal treatment for depression, only a minority actually received timely follow-up.

"The challenge is getting depression services to patients in a timely way, so that we can get each and every patient identified with depression to engage in treatment," research lead Lucinda Leung, MD, PhD, MPH, an assistant professor of medicine in the General Internal Medicine & Health Services Research division at UCLA David Geffen School of Medicine, told Health.

The lack of follow-up care comes at a time when more than 3.8% of the worldwide population, about 280 million people, suffers from depression, according to the World Health Organization. What's more, the COVID-19 pandemic intensified challenges with mental health. In this country, as many as four in 10 adults reported symptoms of anxiety or depressive disorder during the pandemic. That's a significant uptick from the one in 10 adults who reported such symptoms back in 2019.

Here's a closer look at the study's findings and the ramifications for patients suffering from depression.

Study Finds Breakdown in Care

The study spearheaded by Dr. Leung sought to answer a straightforward question: Do patients who screen positive for depression receive the follow-up treatment they require?

Researchers reviewed treatment data for patients who obtained care at Veterans Health Administration (VHA) primary care clinics throughout the southwestern United States between 2015 and 2019. Among the study group of patients, 15,155 were found by clinicians to have depression and 77% met guidelines for needing to complete at least minimal treatment in one year. However, only 32% received clinical follow-up within three months of their initial screening. Based on this data, the study concluded that access to timely care for depression remains limited.

This breakdown in treatment is significant because appropriate follow-up and effective treatment leads to substantial improvement in a patient's health, according to the U.S. Preventive Services Task Force (USPSTF).

In 2016, the USPSTF recommended that universal screening for depression be conducted by healthcare systems. When making its recommendation, the task force said it had "found adequate evidence that programs combining depression screening with adequate support systems in place improve clinical outcomes," including leading to a reduction or remission of depression symptoms. The support and treatment for depression that the task force recommended at the time included antidepressants, psychotherapy, or both.

The expectation associated with the task force's 2016 recommendation was that screenings would consistently be followed by appropriate treatment for those patients who needed it. Since then, however, it's been difficult to assess what the trajectory has actually been for patients between screening and receipt of care for their condition, Dr. Leung's study explained.

What Should Follow-Up Look Like?

Follow-up care for depression should take place within 84 days of screening positive for depression, and should include three or more mental health specialty visits, three or more psychotherapy visits, or three or more primary care visits, according to the study published in JAMA.

The study also explained that even minimal treatment would involve 60 days or more of antidepressant prescriptions filled, four or more mental health specialty visits, or three or more psychotherapy visits.

In addition to those guidelines, Michele Goldman, PhD, a psychologist with Columbia Health, also suggested the following measures:

• An extensive follow-up depression screening after the initial screening
• In primary care clinics that have behavioral health specialists on staff, a referral for the patient to meet with the specialist.
• A conversation with a medical provider about treatment plan options, which might include medication, therapy, working with a behavioral health specialist, and even implementation of an exercise regimen.
• Ongoing follow-up visits with the medical provider to monitor depression symptoms

Unfortunately, there is no silver bullet to getting all people with depression to receive and accept treatments, added Dr. Leung. "The challenges are many and exist for both patients and healthcare systems," said Dr. Leung.

Historic Barriers to Treatment

There are multiple challenges that can stand in the way of a patient's access to mental health services, which may contribute to the lack of timely follow-up care for depression, Goldman told Health.

"Certain issues are systemic, such as a shortage of mental health providers and limited providers who accept a person's insurance" said Goldman. "Another barrier is a lack of collaboration between physical medicine and mental health providers."

Ronald Lee, MD, a board-certified psychiatrist at Luminous Vitality Behavioral Health, said that while the number of patients not receiving treatment for depression may seem high, there are several reasons why treatment often does not occur.

"Oftentimes patients will not return for a second visit, especially if given a diagnosis or treatment that they do not expect or appreciate," Dr. Lee said. Or they may have walked out of their first visit with a provider feeling great, but experienced unpleasant side effects from a medication prescribed during that first visit, leading them to decide against proper follow-up care.

Another contributing factor may be that patients in high-risk groups—such as those in lower socioeconomic demographics or who are homeless or war veterans—are less likely to receive follow-up care, Jagdish Khubchandani, PhD, a professor of public health at New Mexico State University, told Health.

It's also not unusual for people with mental illness to avoid follow-up care, or drop out from treatment plans and care sequence, Khubchandani said. These factors make it difficult to ensure high compliance with treatment or follow-up. Stigma and lack of resources can also play a role, including lack of access to transportation or availability of qualified mental health professionals in the patient's community or neighborhood, Khubchandani added.

The Importance of Treatment

Appropriate and timely care for depression is critical for a number of reasons that can have short-term and long-term implications for a patient who had a positive screening for depression, said Khubchandani. "Untreated mental illnesses can lead to substance use, loss of employment, poor lifestyle and health behaviors, and self-harm or violence" Khubchandani explained.

Patients whose conditions go untreated can also experience a relapse and suffer from a greater number of episodes of illness, disability, multiple chronic diseases, social withdrawal and isolation, engagement with violent crimes or victimization, homelessness, or imprisonment, Khubchandani added.

In addition, those who suffer from depression may experience a lack of motivation, a lethargic feeling, or a lack of energy, Dr. Lee said. What's more, the longer a patient goes without receiving proper treatment, the longer they are likely to struggle, Dr. Lee added. Depression can have intangible effects as well, such as suffering of the patient and effects on immediate family and friends, Dr. Lee said.

"The longer depression goes untreated, the more it can snowball, leading to worsening symptoms, which could then worsen to passive suicidal ideations, which could then further decompensate to an active suicide attempt, in one of the worst-case scenarios," Dr. Lee added.

Next Steps and Additional Resources

There are avenues available for patients to seek out help after screening positive for depression, including a number of ways people can get connected with mental health resources, said Goldman, who encourages patients to initiate a conversation with their primary care provider and ask about the treatment options.

"Call your insurance company (or go online) and ask for a list of mental health providers in your area that accept your in-network coverage. Take advantage of online resources as well, such as psychologytoday.com to find a therapist," Goldman said.

For low-income individuals, government funded healthcare facilities or insurance policies can be helpful when seeking services, Khubchandani suggested. "In addition, there are many non-profit organizations, such as universities, hospitals, and academic medical centers, that can provide free or low cost care and counseling services," Khubchandani explained.

Finally, organizations such as the National Alliance on Mental Illness can also provide individuals with information about treatment options.