PURPOSE: To investigate the ability of alternative depression screening approaches in identifying depression cases among adolescents in primary care.
METHODS: A decision tree was developed to simulate a closed cohort of 10,000 privately-insured adolescents aged 12-18 screened using the Beck Depression Inventory (BDI) test for four scenarios from a private payer perspective: 1) usual care (ad-hoc screening, 43% primary care attendance) 2) increasing primary care attendance (53%) through SMS reminders, 3) increasing screening frequency (annual), and 4) simultaneously increasing both screening and primary care attendance. The primary outcome was cost per depressive case detected. Model inputs were estimated from a literature review, with costs updated to 2017 US dollars. One-way sensitivity analyses included alternative depression screeners (i.e., PHQ-A, MPHQ9, SMFQ) in identifying depression cases. Probabilistic sensitivity analyses simultaneously varied primary care intervention recruitment effectiveness, prevalence of depression, and costs associated with screening and medical consults.
RESULTS: Compared to the number of depression cases detected in usual care (n=299), 29 additional cases were identified when only attendance was increased ($2041 more per case identified), 118 additional cases were identified through increased screening frequency ($2001 more per case identified), and 43 additional cases were identified through increased screening frequency and primary care attendance compared to the base-case ($2010 more per case identified). One-way analyses indicated the PHQ-A resulted in the most depressive cases identified (58.6%), and cost $35.53 less per screened adolescent than the most expensive screener, BDI (56.5%) in the base-case scenario. Probabilistic sensitivity analyses suggested the factors contributing the most uncertainty to the cost of screening were the cost of primary care visits and mental health consultations, followed by depression prevalence.
CONCLUSION: These results confirm the positive health impact of annual screening for depression that has been recommended by the American Academy of Pediatrics In addition, screening annually results in slightly lower costs per detected depression case and nearly 50% more cases detected. Primary care practices would benefit from increasing attendance although this approach is more expensive than screening frequency. Future research is needed to further explore the cost and adolescent outcomes for increasing screening frequency, as well as treatment and referral for positively identified adolescents.
