"It is clear that mental health diagnosis and treatment must become more fully integrated into the primary care system," says psychologist Mary Meager, who has been testing the effectiveness of a screen at the primary care level.
Working with Rachel Bramson, a family medicine physician on the faculty at Texas A&M's medical school and on the staff of Scott & White, along with colleagues from the University of California - San Diego and the University of Southern Mississippi, Meagher studied 591 patients ranging in age from 18 to 86.
She says a brief, self-administered screening tool consisting of five questions can efficiently and effectively screen for depression and panic disorders among primary health care patients.
The tool, known as the Mental Health Index-5 (MHI-5), is a condensed version of the larger Mental Health Inventory and was developed for use in the general population. Meagher says the MHI-5 can distinguish patients with a psychiatric condition from those without a psychiatric condition and from those with a medical condition. It measures anxiety, depression, loss of behavioral or emotional control, and psychological well-being.
"The MHI-5 meets the criteria of utility and efficiency, and its adoption in clinical practice would be the first, and perhaps most important, step toward improving outcomes for distressed primary care patients," Meagher says.
Based on the results of her research, Meagher found that the overall accuracy of this screening measure in detecting major depression or panic disorder was 82.1 percent. In other words, of all the people identified as possibly suffering from these disorders, about eight out of every 10 actually were clinically diagnosed with these disorders upon further examination.
In addition, this screening measure, Meagher notes, is extremely accurate in ruling out the presence of major depression or panic disorder for those that screen negative.
Because psychologically distressed patients do not typically report their psychological problems, Meagher says it is necessary for a physician to take the initiative in discussions of psychological symptoms, and a screening instrument like the MHI-5 can facilitate the discussion.
Meagher recommends that patients complete a paper and pencil screen in the waiting room or while the nurse is taking other vital signs such as blood pressure, body weight, etc. The nurse could then promptly score the screen before the patient met with the physician. The physician then could follow up or make a referral to a psychologist if the patient screened positive for depression or panic disorder, she explains.
This process would allow physicians to be involved in initial diagnosis, medication management and then referral if needed - an especially important aspect considering there is evidence that primary care providers may be less likely to act on diagnostic information when they are not involved in making the diagnosis, Meager notes.
As for the time constraints faced by nearly all physicians - the typical doctor visit lasts 15 minutes or less - Meagher notes that a particularly impressive finding from her research is the ability of a single question to accurately predict major depression and panic disorder.
"This predictive ability of single-item measures may prove to be extremely beneficial in primary care practices in which support staff is unavailable or physician time is more limited than usual," she says.
Meagher notes that recommendations for screening at the primary level have also been made by the Agency for Health Care Policy and Research as early as 1993 and more recently by a U.S. Preventive Services Task Force study.