Improving mental and physical health outcomes in general healthcare settings: a Gedenkschrift in honor of Wayne Katon, MD (1950-2015)

Equitability of Depression Screening After Implementation of General Adult Screening in Primary Care

IMPORTANCE

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.

OBJECTIVE

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.

EXPOSURES

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.

RESULTS

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.

Collaborative Care for Depression among Patients with Limited English Proficiency: a Systematic Review

BACKGROUND

Patients with limited English proficiency (LEP) have high rates of depression, yet face challenges accessing effective care in outpatient settings. We undertook a systematic review to investigate the effectiveness of the collaborative care model for depression for LEP patients in primary care.

METHODS

We queried online PubMed, PsycINFO, CINAHL and EMBASE databases (January 1, 2000, to June 10, 2017) for quantitative studies comparing collaborative care to usual care to treat depression in adults with LEP in primary care. We evaluated the impact of collaborative care on depressive symptoms or on depression treatment. Two reviewers independently extracted key data from the studies and assessed risk of bias using the Cochrane bias and quality assessment tool (RCTs) and the Newcastle-Ottawa Quality Assessment Scale (non-RCTs).

RESULTS

Of 86 titles identified, 15 were included (representing 9 studies: 5 RCTs, 3 cohort studies, and 1 case-control study). Studies included 4859 participants; 2679 (55%) reported LEP. The majority spoke Spanish (93%). The wide variability in study design and outcome definitions precluded performing a meta-analysis. Follow-up ranged from 3 months to 2 years. Three of four high-quality RCTs reported that 13-25% more patients had improved depressive symptoms when treated with culturally tailored collaborative care compared to usual care; the last had high treatment in the control arm and found equal improvement. Two non-RCT studies suggest that Spanish-speaking patients may benefit as much as, if not more than, English-speaking patients treated with collaborative care. The remaining studies reported increased receipt of preferred depression treatment (therapy vs. antidepressants) in the intervention groups. Eight of nine studies used bilingual providers to deliver the intervention.

DISCUSSION

While limited by the number and variability of studies, the available research suggests that collaborative care for depression delivered by bilingual providers may be more effective than usual care among patients with LEP. Implementation studies of collaborative care, particularly among Asian and non-Spanish-speakers, are needed.

Diabetes Mellitus as a Risk Factor for Development of Depressive Symptoms in a Population-Based Cohort of Older Mexican Americans

OBJECTIVES

To determine whether diabetes mellitus increases depressive symptoms in older Latinos in a population-based cohort.

DESIGN

Prospective cohort study.

PARTICIPANTS

Individuals from the Sacramento Latino Study on Aging aged 60 and older in 1998-99 and followed annually until 2008 (N = 1,586).

MEASUREMENTS

Diabetes mellitus was defined according to self-report, fasting blood glucose of 126 mg/dL or greater, glycosylated hemoglobin of 6.5% or greater, or diabetic medication use. Depressive symptoms were defined as Center for Epidemiologic Studies Depression Scale (CES-D) score of 16 or greater or use of antidepressant medication. Multistate Markov modeling was used to assess the effects of time-dependent diabetes mellitus on transitions between three states over time: low CES-D score (normal), high CES-D score or treated (depressed), and death. Bivariate analyses identified covariates significantly associated with any transition, including sex and baseline measures of age, education, body mass index, hypertension, and stroke.

RESULTS

In a fully adjusted model, participants with diabetes mellitus had a 35% higher rate of developing depressive symptoms or starting treatment with an antidepressant (hazard ratio (HR) = 1.35, 95% confidence interval (CI) = 1.13-1.62). Time-dependent diabetes mellitus was associated with a lower rate of regression from depressed to normal (HR = 0.72, 95% CI = 0.59-0.88) and a 2.3 greater rate pf progression from depressed to death (HR = 2.31, 95% CI = 1.57-3.40).

CONCLUSION

Diabetes mellitus increased the risk of developing depressive symptoms in older Mexican Americans. Older Latinos with diabetes mellitus should be screened for depressive symptoms and prioritized for close follow-up, potentially through greater reliance on team-based models of care.