The Occupational Mental Health Committee and the Council on Scientific Affairs of the American College of Occupational and Environmental Medicine (ACOEM) have prepared this informational report on screening for depression. The Committee and Council consider this to be a timely topic due to recently published screening recommendations by the U.S. Preventive Services Task Force (USPSTF), and to recent findings in the literature which show the profound effects of clinical depression on work, productivity, and health care utilization and costs.
The U.S. Preventive Services Task Force Report
Recently, the U.S. Preventive Services Task Force issued a recommendation and rationale for screening for depression. 1 The Task Force summarized its findings as follows:
- There is good evidence that screening improves the accurate identification of depressed patients in primary care settings and that treatment of depressed adults identified in primary care settings decreases clinical morbidity.
- Large benefits have been observed in studies in which the communication of screening results is coordinated with effective follow-up and treatment.
- Many formal screening tools are available. Asking the following two simple questions, however, about mood and anhedonia may be as effective as using any of the longer screening instruments:
“Over the past two weeks have you felt down, depressed or hopeless?” and
“Over the past two weeks, have you felt little interest or pleasure in doing things?”
Clinical practices that screen for depression should have systems in place to ensure that positive screening results are followed by accurate diagnosis, effective treatment and careful follow up. Benefits from screening are unlikely to be realized unless such systems are functioning well.
Depression and Work
Depressive disorders are common and costly. Estimates of lifetime incidence rates range from 4.9% to 17.1%. The estimated cost of depression is $43 billion annually; $17 billion of which represents lost workdays. 2 These huge estimates do not include the cost of “presenteeism”—the loss of quality and output by employees on the job—which the ACOEM Task Force on Productivity and Health believes to be the largest single cost of depression.
The College’s Journal of Occupational and Environmental Medicine has published landmark articles on the relationship between depression and work. Goetzel et al. followed 46,000 employees from six large health care purchasers for up to three years after they completed an initial health risk appraisal (HRA). 3 Employees at high risk for depression (those reporting on the HRA that they were “almost always” depressed), and those at high risk for stress (those reporting that they were “almost always” troubled by stress and did not handle stress well) were 70% and 46%, respectively, more costly than those not at high risk in those categories. These differences were the greatest among all the risk factors studied, which included tobacco use, poor nutritional habits, high blood glucose, etc.
Burton et al. studied absenteeism and presenteeism (ie, measurable reduction in productivity) in relation to health risk factors. 4 The absenteeism and presenteeism outcomes were combined into a worker productivity index which was compared to health risk factors on an HRA. Overall, the study found that as the number of health risks increased, productivity decreased. Some risks were more associated with absence, while others were more associated with failure to maintain a production standard. The authors found that the health risks of diabetes, unhealthy weight (high body mass index), and high “general distress” were the most costly in terms of both absenteeism and presenteeism.
Goetzel et al. (in association with the American Psychiatric Association Committee on Business Relations) addressed the subject of employee depression and its impact on business. 5 The authors summarized the literature on the following questions:
- What is the health impact of depression? Persons with depression function at very low levels (equivalent to persons with coronary artery disease) and even lower than persons with hypertension, diabetes, and arthritis.
- What is the impact of depression on productivity? Other studies complementing the above-mentioned Burton et al. study, demonstrate a lowering of productivity, mainly through absenteeism.
- Does treatment work? “Yes,” for both pharmacologic and psychotherapeutic approaches and a combination thereof.
- Does effective treatment save employers money? Despite some small studies indicating a positive answer, the “jury is still out.”
- Does depression treatment enhance worker productivity? Data are generally supportive of a positive answer.
Finally, Druss et al. surveyed more than 6000 employees in three corporations and found that the odds ratio of taking sick days was 2.17 for respondents with chronic depressive illness, and 7.20 for reporting decreased effectiveness at work. 6
Depression As a Comorbid Condition
There is ample evidence in the medical literature that depression is both an independent predictor of cardiovascular disease 7,8 and a predictor of greater morbidity and earlier mortality in persons who have cardiovascular disease. 9,10
Utilizing Screening Results
The USPSTF emphasized the importance of having proper treatment systems in place. None of the screening procedures that have been studied yield an accurate and specific diagnosis. Rather, they are effective tools for identifying employees about whom there should be a heightened level of concern. In accordance with usual medical practice, this concern should prompt a careful diagnostic evaluation. For example, there are many types of depressive disorders, anxiety disorders, substance abuse problems, medical illnesses, and family, social and work problems that can lead to a positive finding on a depression screen. Once an accurate diagnosis is made, proper treatment can be determined (ie, psychotherapy, medication, and/or care for medical illness).
There are many options for providing proper diagnosis and treatment selection. 11 Many employers offer employee assistance programs (EAPs), which, among other things, provide short-term professional counseling assistance and referral toward the best clinical assistance available. EAPs and managed care hotlines can offer rapid access and reassurance, but typically do not provide a comprehensive initial differential diagnosis (and treatment plan) that includes psycho-social factors, psychiatric diagnoses, and physical illnesses. A well-trained psychiatrist has the broadest skill in these areas. The higher short-term costs of a psychiatrist are likely to be offset by more rapid and thorough diagnosis and treatment, with quicker return to maximum effectiveness at work. However, in some regions, especially rural areas, psychiatrists are not readily available.
Occupational physicians may be available at worksites or in consulting arrangements with companies, and many are familiar with psychiatric differential diagnosis. However, sometimes they are limited in the time they can spend with each patient. Occupational physicians frequently encounter employees who are ill or injured and who require proper case management for appropriate return to work. These encounters could be used to screen for depression, and to probe more closely for a diagnosis, or to refer employees with possible depression for a more comprehensive work-up.
A depression-screening program is an effective and inexpensive way to identify some of the most emotionally distressed employees. While there are many screening instruments available, a simple approach may be useful for identifying those employees where there should be an increased level of concern. Not all distressed employees will be identified by use of a screening tool, and the results indicate a need for greater concern, rather than a specific diagnosis. Optimal utilization of the results requires careful attention to differential diagnosis of psychosocial factors, psychiatric diagnoses, and medical illnesses, in order to select appropriate treatment. Proper diagnosis and treatment is likely to lead to significant clinical improvement, with at least some costs offset by enhanced workplace performance and reductions in some other benefits costs. Optimal diagnosis and treatment of employee psychiatric illness should be a focus of further attention.
The Occupational Mental Health Committee and the Council on Scientific Affairs recommends that ACOEM:
- endorse the Report of the US Preventive Services Task Force on Screening for Depression;
- take the position that depression screening is an appropriate part of the practice of clinical occupational medicine, which can be a valuable addition to acute injury or illness care, fitness-for-duty evaluations, and clinical preventive medical examinations; and
- adopt this report as policy.
This ACOEM statement was developed by the ACOEM Occupational Mental Health Committee under the auspices of the Council on Scientific Affairs. It was peer-reviewed by the Committee and Council and approved by the ACOEM Board of Directors on October 27, 2002.
1. U.S. Preventive Services Task Force: Screening for Depression: Recommendations and Rationale. Ann Intern Med. 2002; 136 (10): 760–764.
2. Pignone MP, Gaynes BN, Rushton JL, et al. Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002; 136 (10): 765–776.
3. Goetzel RZ, Anderson DR, Whitmer RW, et al. The relationship between modifiable health risks and health care expenditures: an analysis of the multi-employer HERO health risk and cost database. JOEM. 1998; 40 (10): 843–854.
4. Burton WN, Conti DJ, Chen C-Y, et al. The role of health risk factors and disease on worker productivity. JOEM. 1999; 41 (10): 863–877.
5. Goetzel RZ, Ozminkowski RJ, Sederer LI, Mark TL. The business case for quality mental health services: why employers should care about the mental health and wellbeing of their employees. JOEM. 2002; 444: 320–330.
6. Druss BG, Schlesinger M, Allen HM. Depressive symptoms satisfaction with health care, and 2-year work outcomes in an employed population. Am J Psychiatry. 2001; 1585: 731–734.
7. Ford DE, Mead LA, et al. Depression is a risk factor for coronary artery disease in men. Arch Intern Med. 1998; 158: 1422–14226.
8. Ferketich MA, Schwartzbaum JA, et al. Depression as an antecedent to heart disease among women and men in the NHANES I study. Arch Intern Med. 2000; 160: 1261–1268.
9. Frasure-Smith N, Lesperance F, Talajic M. Depression following myocardial infarction: impact on 6-month survival. JAMA. 1993; 270: 1819–1825.
10. Bush DE, Ziegelstein RC, Tayback M, et al. Even minimal symptoms of depression increase mortality risk after acute myocardial infarction. Am J Cardiol. 2001; 88: 337–341.
11. Kahn JP and Langlieb AM (eds). Mental Health and Productivity in the Workplace: A Handbook for Organizations and Clinicians.
San Francisco, Jossey-Bass, 2002 (In press).