Summary: Routine depression screening in primary care can improve diagnosis and reduce disparities in who receives care, a UC San Francisco study finds.
Source: UCSF
Screening for depression in primary care substantially increases the likelihood that adults who are traditionally undertreated—racial and ethnic minorities, older adults, people with limited English proficiency and men—will be identified and steered toward treatment, according to a study led by University of California, San Francisco.
Depression is one of the leading causes of disability worldwide, second only to cardiovascular disease, and remains underrecognized. Research shows that more than half of primary care patients with depressive symptoms go undetected, even though primary care settings deliver an estimated 60% of all depression care.
The investigators examined electronic health record data from 52,944 adult patients who visited six UCSF primary care clinics between September 2017 and December 2019. After the system implemented a routine depression-screening policy, screening rates rose from 40.5% during the policy rollout in 2017 to 88.8% by 2019, the team reported in JAMA Network Open on Aug. 18, 2022.
Early in the rollout, disparities persisted. In 2018, for example, clinics were more likely to screen younger adults than older patients: for every 100 patients ages 18 to 30 screened, only 75 patients aged 75 and older were screened. Language and race gaps also appeared: for every 100 English-speaking white patients screened, only 59 Chinese-preferring patients and 55 patients who preferred other non-English languages were screened.
By 2019, many of those differences had narrowed substantially. Disparities for older adults, Black/African American patients, other English-speaking groups and people with limited English proficiency were no longer statistically significant after full implementation. Screening among men remained lower than among women: in 2019, for every 100 women screened, 87 men were screened, an improvement from 82 men per 100 women before the policy but still lagging behind.
“This is the largest study since the U.S. Preventive Services Task Force recommended routine adult depression screening in 2016, and the first to examine which patient characteristics predict whether someone is screened,” said Maria E. Garcia, MD, assistant professor in UCSF’s Division of General Internal Medicine and the Department of Epidemiology and Biostatistics, and the study’s first author.
“Because depression affects outcomes across many chronic conditions, systematic screening in primary care has the potential not only to identify untreated depression but also to improve care for patients who have other medical problems.”
The study population had a mean age of 49; 59% were female. Racial and language breakdown included 42.9% English-speaking White, 25.0% English-speaking Asian, 9.0% English-speaking Latino/Latina/Latinx, 6.8% English-speaking Black/African American, 1.4% Pacific Islander, 0.3% American Indian/Alaska Native, and 5.5% patients preferring a non-English language. Race and ethnicity were missing or unknown for about 9% of English-speaking patients.
Leah S. Karliner, MD, professor in the UCSF Division of General Internal Medicine and the study’s senior author, said the findings show how a systems-based approach can expand screening and reduce disparities. Several coordinated actions helped drive the improvement: leadership prioritization of depression screening as a quality metric, dedicated resources across safety-net clinics, a multidisciplinary task force to monitor disparities, availability of multilingual staff and interpreters, and screening tools offered in multiple languages.
The authors emphasize that screening alone is not enough. “Screening is necessary to overcome under-recognition by clinicians, but it must be linked to effective clinical follow-up, diagnosis, treatment and monitoring to reduce care gaps,” Garcia said.
Future work from the team will assess whether higher screening rates translate into more diagnoses, increased treatment, better follow-up and higher remission rates for depression.
About this depression research news
Author: Press Office
Source: UCSF
Contact: Press Office – UCSF
Image: The image is in the public domain
Original Research: Open access. “Equitability of Depression Screening After Implementation of General Adult Screening in Primary Care” by Maria E. Garcia et al., JAMA Network Open.
Abstract
Equitability of Depression Screening After Implementation of General Adult Screening in Primary Care
Importance
Depression is a disabling, costly condition that is frequently undertreated. Certain groups—including men, racial and ethnic minorities, older adults, and people with limited English proficiency—face higher risk of undertreatment, and unequal screening may contribute to those disparities.
Objective
To evaluate depression screening rates among groups at risk for undertreatment during and after a primary care rollout of universal adult screening.
Design, Setting, and Participants
This cohort study analyzed electronic health record data from 52,944 adult patients across six UCSF primary care clinics between September 1, 2017, and December 31, 2019. Patients with baseline diagnoses of depression, bipolar disorder, schizophrenia, schizoaffective disorder, or dementia were excluded.
Exposures
Screening year: rollout period (September–December 2017) and subsequent full calendar years (2018 and 2019).
Main Outcomes and Measures
The primary outcome was completion of depression screening using the two-question Patient Health Questionnaire-2 administered by medical assistants. The study evaluated screening by age, sex, race and ethnicity, and language preference (English versus non-English), using combined language-race-ethnicity categories for analysis and adjusting for clinic site and comorbidities in multivariable logistic regression models.
Results
Overall screening rose from 40.5% at rollout to 88.8% by 2019. In 2018, older age and non-English language preference (other than Spanish) were associated with lower odds of screening compared with young adults and English-speaking White patients. By 2019, screening had increased across most at-risk groups and many disparities were no longer significant; men remained less likely than women to be screened.
Conclusions and Relevance
Implementing routine depression screening across a large academic primary care system was associated with a substantial increase in screening rates and a reduction in disparities for most groups at risk of undertreatment. These findings suggest that universal screening in primary care can improve detection and create opportunities for equitable diagnosis and treatment of depression.