Physicians May Overprescribe Antidepressants Based on Brief Depression Questionnaires
Brief depression screening questionnaires are popular, especially with primary care providers (PCPs). However, a new study suggests that PCPs who use these questionnaires might be prescribing antidepressants to patients who don’t need them.
This was a prospective study of patients at six primary care office locations in California. Each patient was administered the Patient Health Questionnaire-9 (PHQ-9) by the researchers immediately prior to a primary-care office visit. The PHQ-9 assesses how often respondents have experienced various symptoms (such as feeling down, sleep problems, thoughts of harming oneself) in the previous two weeks. Scores can range from 0 to 27. PHQ-9 results were not shared with the physicians.
For this study, the researchers focused on a specific population of 595 patients, those with a PHQ-9 score less than 10, since this group is considered to be at low risk for depression and poor candidates for taking antidepressants. In this group, most (545) did not complete a separate measure of depressive symptoms during their office visit. Very few of these patients were diagnosed with depression (10.5%), were recommended an antidepressant (1.6%), or were prescribed an antidepressant (3.8%). However, for those patients who were administered a brief depression symptom measure by their primary care provider, 20% were given a diagnosis of depression, 12% were recommended an antidepressant, and another 12% were prescribed an antidepressant.
Use of the screening measures, which was more common during office visits in HMO and Veterans Affairs settings, increased the likelihood that patients who were not likely to be depressed would receive depression treatment (odds ratio 3.2; 95% confidence interval 1.1-9.2). The study highlights the need for more research to determine the best way to use brief depression questionnaires in primary care practices, and to balance benefits and risks of treatment, including overdiagnosis of depression and the use of antidepressants (Jerant A et al, J Am Board FamMed 20l4;27(5);6ll-620).
TCPR’s Take: Most psychiatrists are aware that brief symptom measures are meant to be screening tools, not diagnostic instruments. Nevertheless, this study shows that in the primary care setting these questionnaires may provide the justification for a diagnosis of depression and the prescription of antidepressants to patients who are not clinically depressed. Without more evidence to support the use of screening instruments in primary care settings, this practice should be reconsidered.
Sunshine Linked to Suicide Rates
Sunshine and other forms of bright light are considered to be helpful for depressed patients. Patients with seasonal affective disorder (SAD) feel better as the days lengthen, and bright light therapy is effective for the depression in patients with and without SAD. However, seasonal studies of suicide have found that the prevalence is highest in the spring, which is counterintuitive if we consider light to be an antidepressant. A new study out of Austria clarifies this seasonal finding by separating out the effects of sunshine per se versus seasonality. The results are a bit perplexing.
Researchers analyzed retrospective data on all officially confirmed suicides in Austria for a 40-year period (nearly 70,000 deaths from 1970 to 2010). They then looked at data derived from meteorological stations on the average duration of sunshine per day in hours. Finally, they used mathematical techniques to separate the effect of sunshine exposure from the season.
On each day studied, independent of season, researchers found that the hours of sunshine and the number of suicides were highly correlated. They found a positive correlation between sunshine and suicide that held not only on the day of the suicide but also 10 days prior to the event. Conversely, they found a negative correlation between the number of suicides and the daily hours of sunshine for the 14 to 60 days prior to the suicide, suggesting more daily sunshine over a prolonged period may protect against suicide. This protective effect was more pronounced in men than women.
The implications are that brief exposure to sunshine may increase the risk of suicide, especially in female patients. Why this might happen is unclear. The authors hypothesize that brief sunlight might energize depressed patients before significantly improving mood, and that this could increase their motivation to do something about their condition, no matter how drastic.
Researchers said more study is needed to determine which patients with depression are most susceptible to the effects of sunshine (Vyssoki B et al, JAMA Psychiatry 2014; Epub ahead of print).
TCPR’s Take: There were some limitations to this study—for example, it did not account for other climatic factors (such as temperature, humidity, and air pressure) that vary along with the amount of sunshine to a certain degree. While the findings may represent a statistical anomaly and need to be replicated, you might consider more closely monitoring your suicidal patients, especially women, when the weather takes a sudden turn toward sunny days.