Aetna has begun depression screening in primary care settings for health
plan enrollees who have certain high-risk, chronic medical conditions.
The insurer will reimburse primary care physicians to use the nine-item
Patient Health Questionnaire, or PHQ-9, to screen patients who have diabetes,
coronary artery disease, or other chronic medical conditions that are known to
accompany depression frequently, according to Hyong Un, M.D., national medical
director for behavioral health at Aetna.
The PHQ-9, developed at Columbia University and the Regenstrief Institute
at Indiana University, screens for the presence of depression and provides an
assessment of severity (Psychiatric News, June 3, 2005).
Aetna's screening program is being piloted in the District of Columbia and
six states: New Jersey, Pennsylvania, Maryland, Virginia, Texas, and Oklahoma.
If successful, it will be extended nationwide.
The move by Aetna to screen high-risk patients in primary care settings is
a first among large health insurers. It is regarded as a sign of widening
recognition of employers of the toll that depression takes in the workplace
and by health plans of the comorbidity of depression with general medical
"Since family physicians and other primary care doctors write an
estimated two-thirds of prescriptions for antidepressants in the United States
and are often the gatekeepers for referral to psychiatrists and mental health
professionals, this Aetna program, which will be carefully evaluated, is an
important breakthrough in providing financial support for depression
treatment," wrote APA President Steven Sharfstein, M.D., in his
president's column in the January 6 Psychiatric News.
"With nearly half of lost productivity in the United States
attributed to major depression, with an estimated cost of $44 billion
annually, this Aetna program will be carefully reviewed by other major payers,
HMOs, and employer groups, as well as professional organizations such as
APA," Sharfstein wrote.
Un told Psychiatric News that the depression-screening plan is
part of Aetna's effort to integrate general medical and mental health care, an
effort that includes the termination of "carveout" care for
enrollees who have mental health benefits with Aetna. As of January 1,
coverage of mental health under Magellan Behavioral Healthcare—the
carveout company contracted with Aetna—will cease, and enrollees will
have their claims paid for by Aetna.
"We want to integrate behavioral health care with the rest of medical
care," Un said. "If you want to do that, you can't talk about two
different data systems and two different care processes. You have to look at
Un emphasized that, contrary to some reports, Aetna was not undertaking
general population screening of all of its enrollees. "What we are
trying to do is assess members at risk," he said. "That means
people with medical comorbidity—diabetes, coronary artery disease, or
back pain, for instance. We know the prevalence of depression is higher in
Aetna's initiative encompasses three components: training of primary care
physicians and office staff to use the PHQ-9, a care-management system to
support patients and primary care physicians in managing depression, and
access to mental health specialists.
"This program is focused on collaboration with specialists," he
told Psychiatric News. "It is not meant to divert patients away
from psychiatrists. We are committed to working with APA to make sure
psychiatrists are involved in this process. Based on our data, most of our
patients are getting treated by primary care physicians, but we want to get
those patients who need to see a psychiatrist an appropriate
The Aetna initiative also expands the use of the PHQ-9 as a quantitative
measure for assessing depression. In New York City, primary care doctors began
using the instrument last year to screen for depression in primary care
settings (Psychiatric News, May 20, 2005).
"The Aetna initiative can potentially provide greater access to
treatment for depression at the primary care site," said Darrell Regier,
M.D., M.P.H., executive director of the American Psychiatric Institute for
Education and Research and director of APA's Division of Research. "We
are very interested in how this is going to work for Aetna, and we are looking
at how the PHQ-9 could be used eventually as a quality indictor in other
quality improvement efforts."
Regier said a large number of studies have shown that "if primary
care physicians will use the PHQ-9 to quantify severity and treatment
response, and if they will have a care manager to follow up with the patient
after the patient has started treatment, there will be a major improvement in
quality of care and outcome for these patients."
He added, however, that while the instrument has proven highly successful
in test conditions, physicians tend to neglect use of the instrument, when the
study is over. For that reason, APA has been collaborating with the American
Academy of Family Physicians and the American College of Physicians to examine
the barriers and obstacles to adoption of the instrument.
"The main problems are logistical, involving staff support and
tracking of patients," he said. "To make efficient use of this
instrument, you may need support staff who can monitor patients. If you don't
have the support staff, then you need a mechanism for tracking patients to
make sure they have periodic assessments of treatment effectiveness—to
guide treatment changes as needed."
More information about the screening initiative is posted on Aetna's
Web site at<www.aetna.com/news/2005/pr_20051102.htm>.▪