Mental health screening of adults in primary care

Research areas: Prevention and screening, Psychological & psychiatric interventions

Duration: April to November 2024
Language: English (with German summary)
Publication: HTA Project Report No. 159: https://eprints.aihta.at/1544

Background:
According to the World Health Organization (WHO), one in eight people (12.5%) had a mental disorder in 2019, with the most common mental health problems being anxiety disorders and depression [1]. In Austria, a representative sample survey in 2017 showed that around 23% of people aged between 18 and 65 suffer from at least one mental illness every year [2]. The most common mental illnesses were again anxiety disorders (Neurotic, stress-related and somatoform disorders – F4 [Classification according to ICD-10]; 14% annual prevalence), depressive disorders (Mood [affective] disorders - F5; 12% annual prevalence) and, in addition, substance abuse disorders (Mental and behavioural disorders due to psychoactive substance use- F1; 5% annual prevalence). Prevalences were higher among unemployed people, those with financial worries and those caring for a sick family member. However, it is important to note that these figures were collected before the COVID-19 pandemic. According to recent systematic reviews, mental health problems increased during the pandemic [3]. Therefore, we can expect a higher prevalence of mental disorders in Austria today.

A ”screening” for mental disorders is carried out to identify people who may have a mental health problem and need a more thorough diagnosis [4]. It can occur during a regular doctor visit and is usually brief and limited in scope. Screening can be done manually or digitally by a health professional or the screened person themselves and may include questions about the emotional state or presence of specific risk factors. If the screened person scores above a pre-defined threshold, a complete diagnosis is made to determine whether the person has a mental disorder and needs treatment. The screening itself is, therefore, not a diagnosis of a mental disorder. In addition, other methods than screening with a standardised instrument may be used to identify a person with a mental disorder and are considered screening in our context. For example, known risk factors for a mental disorder may be used to identify a person at increased risk and further screened with a formal screening tool.

The so-called screening principles can help to decide whether a specific health problem requires screening. They were first formally introduced by Wilson and Junger in 1968 [5]and updated in 2018 following a systematic review and Delphi process [6]. Thus, the condition to be screened should be an important health problem with an identifiable preclinical state and a clearly defined target population. In addition, the screening instrument should be accurate and reliable, acceptable to the target population and cost-effective, and the results should be clearly interpretable. There should also be a defined pathway for people who screen positive, including further diagnosis, treatment or interventions, which should be available, accessible, and acceptable and lead to improved outcomes. There should also be an infrastructure into which screening can be integrated, and its quality should be continually evaluated. Finally, the benefits of screening should outweigh the harms.

Therefore, it is necessary to investigate whether screening for mental disorders at the population level in primary care brings additional benefits compared to no screening. In the revision of the Austrian periodic health examination for adults in 2020, screening for depression was not recommended due to the length of the screening instrument, the limited possibilities for people with mild depression and the fear of overprescribing of psychotropic drugs. Nevertheless, doctors are advised to address the mental health of their patients [7]. A possible benefit of screening for other mental disorders was not assessed. This assessment aligns with the German Institute for Quality and  Efficiency in Health Care’s (IQWiG) 2018 evaluation of screening for depression [8]. In contrast, the US Preventive Services Task Force (USPSTF) recommends screening for depression and anxiety disorders in adults aged 19 to 65 years [9, 10].

Depending on the setting in which screening takes place, a wide range of different tools are available. A 2018 systematic review identified 24 different screening tools for primary care settings. Eight of these were subscales of the „Patient Health Questionnaire“ (PHQ) or the „Patient Stress Questionnaire“ (PSQ) and can be used to screen for specific mental disorders, such as anxiety disorders (GAD-7) or depressive disorders (PHQ-9) [11].

Project aims:
The project aims to summarise the current evidence on the benefits of screening for specific mental health problems (depression, anxiety, and addiction) in adults (people aged 18 years and over) in primary care settings. This will include an overview of possible screening tools and specific risk factors that could be used to identify people with depression, anxiety, or addiction in primary care settings. It will also summarise information from the literature on the practical implications of implementing screening (e.g. development of a care pathway, sufficient range of diagnostic and therapeutic options, training of health professionals) and recommendations for planning needs.

Research questions:
According to the project aims, the following research questions (RQ) will be answered:

1. What is the evidence on the benefits and potential harms of screening for the considered mental disorders (depression, anxiety, and addiction) in adults in primary health care, e.g. in terms of identification and subsequent treatment, earlier recovery, quality of life? What are the recommendations of recent evidence-based guidelines?
2. What screening methods can be used (e.g., specific screening instruments, identification of risk factors/comorbidities), and what are their characteristics (e.g. test quality, length)?
3. What are the implications of implementing screening, and what evidence does the literature provide regarding the capacity required for the different screening steps (e.g. diagnosis and therapy)?

Methods:
To answer the first research question, a systematic search of several databases and a manual search of guideline databases (TRIP Database, Guidelines International Network) and websites of selected guideline institutions (e.g. AWMF, NICE, USPSTF) will be conducted. After literature selection according to the pre-specified inclusion and exclusion criteria (see PICO table), information from systematic reviews and guideline recommendations will be extracted into tables and analysed. The quality of systematic reviews will be assessed using ROBIS [12], and the quality of guidelines will be assessed using AGREE-II [13].

PICO: Inclusion criteria for RQ1

Population	Adults aged 18 and over
Intervention	Screening/ (early) identification of the following mental disorders (classification according to ICD-11*): Anxiety or fear-related disorders (6B00 – 6B0Z) Mood disorders (6A60 – 6A8Z) Disorders due to substance use or addictive behaviours (6C40 – 6C5Z) with a standardised screening tool or via the identification of risk factors, complaints, or symptoms
Comparator	No screening
Outcomes	Outcomes on screening benefits/harms: Mortality Morbidity (Frequency and symptoms of the mental illness) Health related quality of life General and social functioning Potential screening risks (e.g. false-positive results, overdiagnosis and ?treatment) Screening recommendations (including information on methods/instruments, interval, etc.)
Publication type	Systematic reviews HTA-reports Evidence based guidelines
Countries	Countries of the global north
Language	English, German

*According to ICD-11, available on: https://icd.who.int/browse/2024-01/mms/en#76398729 (Accessed 22.04.2024)

For the second research question on screening methods, information from the already identified systematic reviews and guidelines on risk factors/comorbidities and recommended screening instruments for each selected mental disorder and their characteristics will be tabulated and summarised narratively. An additional manual search will be conducted if necessary.

To answer the third research question, recommendations for the implementation of screening for mental disorders will be developed and, if necessary, an additional manual search conducted. Organisational and logistical requirements (e.g. regarding the screening process, care pathway, required capacity) will be addressed, based on the questions of the core model of the European Network for HTA (EUnetHTA) [14].

All work steps (literature selection, quality assessment, data extraction and synthesis) will be carried out by both authors (JK and IR) in accordance with the four-eyes principle.

Schedule:

Schedule	Tasks
April 2024	Scoping and finalisation of the project protocol
May 2024	Systematic literature search Manual literature search
June – July 2024	Literature selection Data extraction
August – September 2024	Data synthesis Writing the report
October 2024	Internal and external review
November 2024	Layout and publication

References:

[1]       World Health Organization. Mental disorders. 2022 [cited 11.04.2024]. Available from: https://www.who.int/news-room/fact-sheets/detail/mental-disorders.

[2]       Wancanta J. Prävalenz und Versorgung psychischer Krankheiten in Österreich. Klinische Abteilung für Sozialpsychiatrie, Medizinische Universität Wien: 2017.

[3]       Penninx B. W. J. H., Benros M. E., Klein R. S. and Vinkers C. H. How COVID-19 shaped mental health: from infection to pandemic effects. Nature Medicine. 2022;28(10):2027-2037. DOI: 10.1038/s41591-022-02028-2.

[4]       American Psychological Association. Distinguishing Between Screening and Assessment for Mental and Behavioral Health Problems. 2014 [cited 11.04.2024]. Available from: https://www.apaservices.org/practice/reimbursement/billing/assessment-screening?_ga=2.102075329.1186226343.1666222147-627372789.1666222147.

[5]       Wilson J. and Junger Y. Principles and practice of screening for disease. Geneva: WHO. 1968.

[6]       Dobrow M. J., Hagens V., Chafe R., Sullivan T. and Rabeneck L. Consolidated principles for screening based on a systematic review and consensus process. Canadian Medical Association Journal. 2018;190(14):E422. DOI: 10.1503/cmaj.171154.

[7]       Arrouas M., Bachinger G., Bachler H., Diem G., Dorner T., Haditsch B., et al. Empfehlungen Vorsorgeuntersuchung 2020. 2020 [cited 11.04.2024]. Available from: https://www.sozialversicherung.at/cdscontent/load?contentid=10008.713298&version=1549356521.

[8]       Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen. Screening auf Depression. 2018 [cited 11.04.2024]. Available from: https://www.iqwig.de/download/s16-05_screening-auf-depression_abschlussbericht_v1-0.pdf.

[9]       U. S. Preventive Services Task Force. Screening for Depression and Suicide Risk in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2023;329(23):2057-2067. DOI: 10.1001/jama.2023.9297.

[10]     U. S. Preventive Services Task Force. Screening for Anxiety Disorders in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2023;329(24):2163-2170. DOI: 10.1001/jama.2023.9301.

[11]     Mulvaney-Day N., Marshall T., Downey Piscopo K., Korsen N., Lynch S., Karnell L. H., et al. Screening for Behavioral Health Conditions in Primary Care Settings: A Systematic Review of the Literature. Journal of General Internal Medicine. 2018;33(3):335-346. DOI: 10.1007/s11606-017-4181-0.

[12]     Whiting P., Savovi? J., Higgins J. P., Caldwell D. M., Reeves B. C., Shea B., et al. ROBIS: A new tool to assess risk of bias in systematic reviews was developed. J Clin Epidemiol. 2016;69:225-234. Epub 20150616. DOI: 10.1016/j.jclinepi.2015.06.005.

[13]     The AGREE Next Steps Consortium. Appraisal of Guidelines for Research & Evaluation II. 2013 [cited 19.04.2024]. Available from: https://www.agreetrust.org/wp-content/uploads/2013/10/AGREE-II-Users-Manual-and-23-item-Instrument_2009_UPDATE_2013.pdf.

[14]     European Network for Health Technology A. The HTA Core Model® for Rapid Relative Effectiveness Assessments. 2015 [cited 19.04.2024]. Available from: https://www.eunethta.eu/wp-content/uploads/2018/06/HTACoreModel_ForRapidREAs4.2-3.pdf.