Routine depression screening in primary care reduces disparities
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Key takeaways
- Barriers to depression screening in primary care include patients underreporting symptoms and stigma concerns, but implementing routine screening may address these challenges.
- Just 2 years after implementing a routine screening policy, depression screening rates in a California health system’s primary care practices jumped from 40.5% to 88.8%.
- By the end of 2019, the researchers found that screening rates by sex were similar, but men continued to face lower odds of being screened (adjusted OR = 0.87; 95% CI, 0.81-0.93).
Implementing routine depression screening in primary care substantially increased screening rates, particularly among those at risk for undertreatment, according to a study published in JAMA Network Open.
Specifically, a routine screening policy improved screening disparities for older patients, those who are Black and those with language barriers. However, disparities for men still were present, according to researchers.
“Depression screening is necessary, but not sufficient, to decrease depression care disparities,” they wrote. “Screening may help with poor physician recognition of depressive symptoms, but screening must be followed by clinical action.”
With low depression screening rates in primary care settings and recent pushes for behavioral health integration, Maria E. Garcia, MD, MPH, MAS, a clinician investigator and assistant professor of medicine at the University of California, San Francisco, and colleagues conducted the cohort study to better understand if implementing routine depression screening in primary care practices is associated with better screening rates for people who are at risk.
The researchers analyzed health record data from 52,944 adults at six University of California, San Francisco, primary care facilities who were seen from September 2017 through December 2019. They evaluated the likelihood of being screened with annual logistic regression models, and assessed comorbidities, race, ethnicity, language, sex and age for multivariable analysis.
Medical assistants conducted the screening by giving patients the Patient Health Questionnaire-2 — “a well-validated and widely used measure to screen for current depressive symptoms,” Garcia and colleagues wrote. If the results were positive for depression, the patients were asked to complete a more in-depth survey, the PHQ-9. When appropriate, clinicians could then arrange follow-up visits, initiate medication or refer the patient to a behavioral health team, social worker or psychiatrist.
In the rollout period before the intervention — from September 2017 to December 2017 — 40.5% of eligible patients were screened. In the following years, the screening rate jumped to 71.4% in 2018 (24,684 of 34,555 patients; 95% CI, 71-71.9) and 88.8% in 2019 (32,848 of 36,974 patients; 95% CI, 88.5-89.1). When the screening was fully implemented in the primary care settings, “the substantial disparities in depression screening observed early in the rollout period, which were consistent with disparities reported in prior studies, were greatly reduced,” Garcia and colleagues wrote.
During the first full year of screening for depression in 2018, the researchers wrote that “there were statistically significant differences in screening by sex, age, language-race-ethnicity group, and health insurance type.”
Compared with white, English-speaking patients, the researchers found that patients who preferred Chinese language had lower odds of being screened for depression (adjusted OR = 0.59; 95% CI, 0.51-0.67). Further, patients who spoke languages other than English, Chinese or Spanish were least likely to receive depression screening (aOR = 0.55; 95% CI, 0.47-0.64), but “screening was lower for all groups with non-English language preference compared with language-race-ethnicity groups with English language preference,” the researchers wrote.
The next year, however, the researchers found “a steady decrease in screening differences” in the secondary analysis evaluating age, sex, language-race-ethnicity and more, “resulting in resolution or near resolution of disparities by the last two quarters of 2019.” The screening rose for every group studied, “regardless of sex, language-race-ethnicity group, age, or health insurance type,” Garcia and colleagues wrote. By the end of 2019, the researchers found that screening rates by sex “were nearly identical,” but men continued to face lower odds of being screened (aOR = 0.87; 95% CI, 0.81-0.93).
The disparities for people with non-English language preferences were also “no longer significantly different than among patients with English preference” in 2019, according to the researchers.
“Through implementation of adult depression screening in primary care, a large academic health system achieved high rates of depression screening among all patients, including groups at risk for underrecognition and undertreatment of depression,” they wrote.
There are multifactorial barriers to depression screening in primary care, according to Garcia and colleagues. These include time pressures, competing demands, patients underreporting symptoms and stigma concerns. Implementing routine screening eased some of these barriers, though, the researchers wrote.
“Several factors may have contributed to achieving high, more equitable screening rates in this health system,” the researchers wrote.
For example, the health care system in the study was able to provide the primary care practices with the support and resources they needed for the program. Depression screening was a priority for the system due to “a larger focus on quality improvement metrics implemented across safety net systems in California that are tied to state funds,” Garcia and colleagues wrote. The practices also benefited from a task force that the health system convened that focused specifically on identifying screening disparities and making adjustments.
Further, according to the researchers, the seamless alignment of depression screening with established clinical workflows in 2018 “likely contributed to increasing screening rates” the following year. Having access to professional interpreters and the fact that the screening tool was available in multiple languages “may have facilitated implementation,” they added.
“This alignment of local quality improvement efforts, health system priorities, reimbursement policies, and a health equity lens for improvement efforts created a favorable environment to implement and improve adult depression screening in these primary care practices,” the researchers wrote.
In all, the researchers concluded that with the well-documented disparities in depression care for underrepresented populations, “a focus on implementing depression screening and initial depression treatment in primary care may help to improve depression recognition and appropriate treatment for all patients.”
Perspective
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We are currently in the midst of a mental health crisis in the United States, and we must take every opportunity to identify when our patients are experiencing symptoms of depression.
This study highlights how instituting clinical practice changes to routinely screen for depression in primary care using the PHQ-2 questionnaire, regardless of a patient’s reason for the clinical encounter, decreased racial and ethnic disparities in screening for depression, which represents an important first step.
However, in order to truly understand how effective this strategy is in addressing existing health inequities, it is imperative to take the next step in the analysis and determine if increased screening for depression resulted in increased linkage to care and treatment of depression among those reporting symptoms of depression for all the population groups included, or if disparities in access to treatment and care emerged among the diverse populations studied.
This is particularly important, since access to mental health services is often dictated by quality of health insurance, availability of in-network mental health clinicians, insurance copays, coinsurance, deductibles and annual visit limits, personal finances, and ability to take time away from work and family responsibilities, all of which can result in inequitable access to mental health treatment.
The COVID-19 pandemic and opioid epidemic have compounded our nation’s mental health crisis. While this study only examined changes in depression screening rates prior to the COVID-19 pandemic, during the pandemic, as we have shifted to new models of care, such as telehealth, it is important that we continue certain routine processes, including screening for depression, even if other clinical intake processes for patients may change when performing virtual clinical visits. This will ensure that all patients continue to receive screening for depression in the primary care setting, so that we may identify patients with symptoms of depression as early as possible and provide them with the care they need.
Due to the rising incidence and prevalence of depression during the pandemic, particularly among those with lower incomes and multiple stressors associated with COVID-19, it is critical that we adopt systems to ensure every person diagnosed with depression receives the care they need to reduce inequitable outcomes.
One approach to improving access to behavioral health services for patients with symptoms of depression is to adopt a model of behavioral health integration in primary care. While many models of behavioral health integration exist, models with the highest degree of integration, where behavioral health clinicians and primary care clinicians share a clinical space and provide warm handoffs of patients needing behavioral health services with same day access to and/or joint behavioral health and primary care appointments, help facilitate and streamline patients’ prompt access to behavioral health services if they are found to have symptoms of depression during routine screening during their primary care appointment.
While behavioral health integration in primary care has the potential to decrease barriers to treatment access and reduce existing inequities, we must ensure policies and structures are in place to optimally support fully integrated models of care.
For example, if patients have limited annually allowed behavioral health visits and restrictions on whether primary care and behavioral health clinicians can bill for services provided on the same day, these patients may not have access to integrated behavioral health services due to the associated out-of-pocket costs for services not covered by insurance. In addition, if interprofessional teams are not appropriately supported through traditional fee-for-service models, practices may be less likely to provide integrated behavioral health services to their patients.
Further, if behavioral health services are not available in a patient’s preferred language or not provided in a culturally competent way, it can limit patients’ access to these services. It is, therefore, important to implement novel strategies and adaptive policies to support innovative models of care that are designed to end existing disparities.
As we continue to address our nation’s mental health crisis, it is vital that we not only screen each of our patients for depression in primary care, but that we ensure appropriate linkage to care and optimize our patients’ health by developing policies and systems capable of delivering high quality, affordable, accessible, and timely behavioral health services to reduce inequities and improve health outcomes.
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