Routine Depression Screening in Primary Care Reduces Disparities in Screening

Routine screening for depression in primary care can help reduce disparities in screening and therefore improve treatment for all patients with depression, according to a study published in JAMA Network Open.

While there are effective treatments for depression, they only work for patients whose depression is recognized and treated. Depression is often treated in the primary care setting, but more than half of people who have symptoms of depression go undiagnosed and untreated, according to the authors.

“Underrecognition of presenting symptoms occurs more frequently among men, racial and ethnic minority individuals, individuals with language barriers, and older adults,” they explained. “Furthermore, these populations are less likely to receive adequate depression care and may be at higher risk for adverse outcomes as a result of undertreatment.”

The US Preventive Serves Task Force recommends depression screening in the general adult population. The researchers sought to evaluate if implementing depression screening as recommended by the task force resulted in equitable screening rates. They calculated a screening rate for the rollout period (September 1, 2017, to December 31, 2017) and the following 2 calendar years to identify the percentage of patients who had a visit and were screened at least once for depression using the Patient Health Questionnaire-2 (PHQ-2).

Overall, there were 52,944 eligible patients with 1 or more visits to the 7 primary care practices of the University of California, San Francisco, Health. during the study period. The majority were female (50%) and the mean age was 48.9 years. During the rollout period, 40.5% of patients who were eligible were screened, which increased to 71.4% in 2018 and to 88.8% in 2019.

The health system used a variety of implemented strategies, such as making adjustments to address identified disparities. These adjustments included making questionnaires available in non-English languages and training of medical assistants to conduct the screening.

The researchers found that there were statistically significant differences in screening by sex, age, language-race-ethnicity, group, and health insurance type in 2018, which was the first full year of implementation. They found:

• Men were less likely to be screened than women
• Screening rates decreased as age increased
• Patients whose language preference was not English had lower screening rates than patients with a preference for English
• Patients with private insurance had higher screening rates than patients with public insurance, Medicare, or Medi-Cal

In 2019, the rates of depression screening increased across all groups. For most English-speaking racial and ethnic groups, the odds of being screened were higher compared with English-speaking White patients, and preferring a non-English language was no longer associated with a significant difference compared with patients who preferred English. Similarly, the screening rates by age and insurance were no longer significantly different.

Overall, the researchers determined that the implementation of depression screening in primary care led to high rates of screening for all patients, including those who were previously at risk for undertreatment of depression. “The substantial disparities in depression screening observed early in the rollout period, which were consistent with disparities reported in prior studies, were greatly reduced once screening was fully implemented in primary care,” they wrote.

The system-based screening program that had the screening conducted in a routine manner helped to alleviate barriers to depression screening in primary care.

The authors suggested future evaluations to understand if screening results in diagnosis, treatment, follow-up, and remission from symptoms. “It is unclear whether improving equity in depression screening will translate into equal benefit from depression care,” they wrote.

One of the limitations the authors noted was that during the time of the study, they were not able to assess screening rates among gender minority groups because the data were not collected until 2019.

Reference

Garcia ME, Hinton L, Neuhaus J, et al. Equitability of depression screening after implementation of general adult screening in primary care. JAMA Netw Open. 2022;5(8):e2227658. doi:10.1001/jamanetworkopen.2022.27658