Summary: Routine screenings for depression given by primary care providers could help better diagnose those who are traditionally undertreated, a new study reports.
Screening for depression at the primary care level could dramatically increase the likelihood of treatment for those who are traditionally undertreated—racial and ethnic minority individuals, older adults, those with limited English proficiency and men—according to a new study led by UC San Francisco.
Second only to cardiovascular disease as a leading cause of disability, depression goes unrecognized in more than half of patients presenting with symptoms in primary care, where an estimated 60% of patients receive depression care, studies have shown.
The researchers tracked electronic health data of 52,944 adult patients seen at six UCSF primary care facilities over a two-year period. After a routine screening policy was implemented, depression screening rates more than doubled—from 40.5% in 2017 to 88.8% in 2019, the researchers reported in their study, publishing in JAMA Network Open on Aug.18, 2022.
In 2018, they found that for every 100 patients ages 18 to 30 screened for depression, 75 patients ages 75 and older were likely to be screened for depression. For every 100 English-speaking white patients screened for depression, there were 59 Chinese-language patients and 55 other non-English language patients likely to be screened for depression.
By 2019, statistically significant disparities virtually disappeared for older patients, Black/African Americans, other English-speaking patients and patients with language barriers. However, screening for men remained relatively low: for every 100 women screened for depression, 87 men were likely to be screened for depression, compared to 82 men before the policy was implemented.
“Our study is the largest since 2016, when the U.S. Preventive Services Task Force recommended that adult patients be screened for depression, and the first to investigate patient predictors of screening,” said first author Maria E. Garcia, MD, assistant professor in the UCSF Division of General Internal Medicine and the Department of Epidemiology and Biostatistics.
“Because depression impacts so many other chronic diseases, implementation of routine depression screening could also improve patient outcomes for complications from other conditions.”
Additionally, the health care system convened a task force with representation from all primary care practices focused on identifying screening disparities in clinical settings. Image is in the public domain
The average age of the patients was 49, 59% of the patients were female, 43% English-speaking whites, 25% English-speaking Asians, 9% Latino, 7% Black, 1.4% Pacific Islander, 0.3% American Indian/Alaskan Native and 5.5% were patients with language barriers. Race and ethnicity data were missing or unknown for 9% of English-speaking patients.
“Our study shows that a systems-based approach can increase depression screening and address screening disparities,” said senior author Leah S. Karliner, MD, professor in the UCSF Division of General Internal Medicine.
Several factors contributed to achieving high, more equitable screening rates, the authors stated. During the study period, depression screening was a priority as part of a larger focus on quality improvement metrics across safety net systems in California tied to state funds; this provided primary care practices with resources.
Additionally, the health care system convened a task force with representation from all primary care practices focused on identifying screening disparities in clinical settings. Multilingual primary care staff, interpreters and screening tools in multiple languages were made available.
“Depression screening is necessary, but not sufficient, to decrease care disparities. Screening may help with poor physician recognition of depressive symptoms, but it must be followed by clinical action,” Garcia said.
Future evaluations will center on whether screening is associated with increases in depression diagnosis, treatment, follow-up and remission, she added.
Equitability of Depression Screening After Implementation of General Adult Screening in Primary Care
Depression is a debilitating and costly medical condition that is often undertreated. Men, racial and ethnic minority individuals, older adults, and those with language barriers are at increased risk for undertreatment of depression. Disparities in screening may contribute to undertreatment.
To examine depression screening rates among populations at risk for undertreatment of depression during and after rollout of general screening.
Design, Setting, and Participants
This cohort study from September 1, 2017, to December 31, 2019, of electronic health record data from 52 944 adult patients at 6 University of California, San Francisco, primary care facilities assessed depression screening rates after implementation of a general screening policy. Patients were excluded if they had a baseline diagnosis of depression, bipolar disorder, schizophrenia, schizoaffective disorder, or dementia.
Screening year, including rollout (September 1, 2017, to December 31, 2017) and each subsequent calendar year (January 1 to December 31, 2018, and January 1 to December 31, 2019).
Main Outcomes and Measures
Rates of depression screening performed by medical assistants using the Patient Health Questionnaire-2. Data collected included age, sex, race and ethnicity, and language preference (English vs non-English); to compare English and non-English language preference groups and also assess depression screening by race and ethnicity within the English-speaking group, a single language-race-ethnicity variable with non–English language preference and English language preference categories was created. In multivariable analyses, the likelihood of being screened was evaluated using annual logistic regression models for 2018 and 2019, examining sex, age, language-race-ethnicity, and comorbidities, with adjustment for primary care site.
There were 52 944 unique, eligible patients with 1 or more visits in one of the 6 primary care practices during the entire study period (59% female; mean [SD] age, 48.9 [17.6] years; 178 [0.3%] American Indian/Alaska Native, 13 241 [25.0%] English-speaking Asian, 3588 [6.8%] English-speaking Black/African American, 4744 [9.0%] English-speaking Latino/Latina/Latinx, 760 [1.4%] Pacific Islander, 22 689 [42.9%] English-speaking White, 4857 [9.0%] English-speaking other [including individuals who indicated race and ethnicity as other and individuals for whom race and ethnicity data were missing or unknown], and 2887 [5.5%] with language barriers [non–English language preference]).
Depression screening increased from 40.5% at rollout (2017) to 88.8% (2019). In 2018, the likelihood of being screened decreased with increasing age (adusted odds ratio [aOR], 0.89 [95% CI, 0.82-0.98] for ages 45-54 and aOR, 0.75 [95% CI, 0.65-0.85] for ages 75 and older compared with ages 18-30); and, except for Spanish-speaking patients, patients with limited English proficiency were less likely to be screened for depression than English-speaking White patients (Chinese language preference: aOR, 0.59 [95% CI, 0.51-0.67]; other non–English language preference: aOR, 0.55 [95% CI, 0.47-0.64]). By 2019, depression screening had increased dramatically for all at-risk groups, and for most, disparities had disappeared; the odds of screening were only still significantly lower for men compared with women (aOR, 0.87 [95% CI, 0.81 to 0.93]).
Conclusions and Relevance
In this cohort study in a large academic health system, full implementation of depression screening was associated with a substantial increase in screening rates among groups at risk for undertreatment of depression. In addition, depression screening disparities narrowed over time for most groups, suggesting that routine depression screening in primary care may reduce screening disparities and improve recognition and appropriate treatment of depression for all patients.