Case-Finding for Depression Among Medical Outpatients in the Veterans Health Administration

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Abstract
We sought to determine the rates and predictors of screening, screening positive, follow-up evaluation, and subsequent diagnosis of depression among medical outpatients. This was a cross-sectional study using chart-review data from the Department of Veterans Affairs (VA) 2002 External Peer Review Program merged with administrative data. We studied a national sample of VA medical outpatients with no depression diagnosis or mental health visits in the past 6 months (n = 21,489) and used chart-review and administrative data to follow the chain of events from depression screening to diagnosis. Overall, 84.9% of eligible patients (n = 18,245) were screened for depression in the past year. Of the 8.8% who screened positive, only 54.0% received follow-up evaluation and, of these, 23.6% (n = 204) subsequently were diagnosed with a depressive disorder (representing 1.1% of the originally screened sample). Patients who were younger, unmarried, and had more medical comorbidities were less likely to be screened; however, if screened, they were more likely to screen positive. Male gender and greater medical comorbidity were associated with decreased odds of follow-up evaluation after a positive screen. At the facility level, likelihood of depression screening was inversely associated with spending on teaching and research but positively associated with spending on mental health care. VA's depression case-finding activities yielded relatively few positive cases, raising questions about cost-effectiveness. Targeted strategies may increase the value of case-finding among patients at greatest risk for depression and at more academically affiliated medical centers. Targeted efforts also are needed to ensure proper follow-up evaluation of suspected cases, particularly among male patients and those with increased medical comorbidity.