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In a routine checkup, a primary care physician like Lucinda Leung asks all the patients she sees about symptoms of depression. To her, it’s as important as measuring blood pressure or listening to a patient’s lungs.

New research, published Thursday in JAMA Network Open, provides a unique, bird’s-eye view of what happens after a patient screens positive for depression. Leung and her colleagues analyzed data from more than 600,000 patients in Veterans Affairs clinics in California, Arizona, and New Mexico. Tracing the path of care from screening onward, the researchers found that the majority of patients who screened positive for depression did not get timely follow-up care. The study also found that 23% of patients did not receive even minimal treatment for depression.

“This is a very important and timely paper given the likely rise in depression over the past two years,” said Ayana Jordan, an assistant professor of psychiatry and physician at NYU Langone Health. Jordan was not involved in the study.

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A positive depression screening is not a diagnosis. Rather, it tells clinicians that they need to look for further signs and symptoms to confirm whether or not a patient truly has depression. Then, in the best-case scenario, a patient and a provider can decide together on a treatment, such as antidepressants or therapy.

“Ideally, the patient doesn’t have to physically go to a separate building, another hallway, or a different floor in the hospital to meet their mental health provider,” said Leung, a physician at the VA Greater Los Angeles Healthcare System and the first author on the paper.

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But many patients who leave a screening in need of more specialized mental health care run into trouble finding it.

“There’s a scarcity of those providers in many places,” said Lisa Rubenstein, professor of medicine and public health at the University of California, Los Angeles, and the senior author on the paper. “If a provider sent a patient off and didn’t follow up with them promptly, they might not know that the patient couldn’t find a specialist.”

At follow-up appointments, a provider can gauge whether a patient’s depression is worsening, adjust medication doses, and check on side effects, Leung said.

In the study, among patients confirmed to have depression, 68% did not have at least three follow-up appointments with mental health specialists, counselors, or primary care providers within three months of a positive depression screening. And almost a quarter of patients with depression did not receive treatment that met the minimal level of appropriate mental health care laid out in prior studies, which includes at least two months of an antidepressant or multiple visits with a mental health professional. The findings reflect concerns raised in 2016 when the U.S. Preventive Services Task Force recommended universal depression screening for all adults. At the time, the task force stressed that detecting depression must go hand in hand with connecting patients to care.

“There’s still room for improvement,” said Leung. “But if you look for the problem, and offer services to address that problem, people will engage in that kind of care.”

Experts said that a significant part of treating depression is making sure patients get the care that they need when they need it. “If you lose those early months, you’ve lost a lot of time for bad things to happen in a patient’s life. Depression can affect work, family, and physical health,” said Rubenstein. “It’s like uncontrolled diabetes. You have to follow up on a patient, or they may go downhill very fast.”

The study revealed certain groups were more likely to access better care. In line with prior studies, the researchers found that people who were younger and had more mental illnesses had more timely follow-up, perhaps because depression was less challenging to detect in those patients, the authors said. One finding, though, surprised researchers: People who received timely follow-up were more likely to be Black than white. “We know that there are racial and ethnic disparities in accessing mental health services, and those services are typically used less often by Black and Hispanic patients. What we found in our research was the opposite,” said Leung. “Black veterans are more likely to get high-quality care.”

The researchers took a closer look at why their results were different from those of previous findings. While Black and Hispanic veterans were less likely than white veterans to receive prescriptions for antidepressants, they had higher rates of visiting mental health specialists, the authors said.

“If medication were the only option, some folks may not want that,” said Leung. “But if you make options available, you can engage folks in treatment.”

While experts said the study is an important step, it also comes with several caveats, including that it had an overwhelmingly male population and excluded patients who didn’t return to the system for primary care after screening positive. Christina Mangurian, professor of clinical psychiatry at the University of California, San Francisco, also noted that the research didn’t detail “whether the people who had minimal treatment actually recovered from their depression.”

To Rubenstein, this study gives a thousand-foot view of what managing depression at the population level looks like. “Depression is going to affect today’s children of war. It’s going to affect people who have fought in wars like the vets. It confounds so many other aspects of how society and people function,” said Rubenstein. “It’s hard to think of something more fundamental.”

Correction: A previous version of this story misidentified the current role of Ayana Jordan. 

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