Primary Care Physician Recognition and Documentation of Depressive Symptoms Among Chinese and Latinx Patients During Routine Visits: A Cross-Sectional Study

Bring It Up: An Adapted Collaborative Care Model for Depression in a Safety-Net Primary Care Clinic

Objective

Over 90 clinical trials demonstrate the efficacy of the collaborative care model (CoCM) to treat depression in primary care but there is significant variability in real-world CoCM implementation and scalability. This study aimed to determine the feasibility and effectiveness of an adapted CoCM in a safety-net primary care setting.

Methods

Bring It Up! (BIU) is a pilot trial comparing an adapted CoCM (intervention group) to usual care (historical controls) for primary care safety-net clinic patients with depression. Inclusion criteria: (1) age ≥18; (2) Patient Health Questionnaire-9 (PHQ-9) score ≥10; and (3) major depressive disorder diagnosis. Patients who completed ≥6 months of treatment upon rolling enrollment (April 1, 2018-October 31, 2019) were included. Historical controls completed ≥6 months of usual care in 2017. BIU included all aspects of CoCM except accountable care and leveraged existing staff rather than a dedicated care manager. The primary outcome was depression remission (PHQ-9 <5) within 6 months. Secondary outcomes included depression response, adherence to treatment guidelines and care coordination process. Data were extracted from the electronic health record.

Results

Thirty-six patients received the intervention; 41 controls received usual care. Depression remission was achieved in 33.3% of intervention patients and 0% of controls (p = 0.001). Of intervention patients, 44.4% achieved ≥50% reduction in PHQ-9 compared to 4.9% of controls (p = 0.003). Further, 66.7% of intervention patients had guideline-recommended antidepressant medication titration compared to 26.9% of controls (p = 0.003); 94.4% of intervention patients had PHQ-9 repeated compared to 53.7% of controls (p < 0.001).

Conclusions

An adapted CoCM was feasible and improved depression care in a safety-net clinic.

Correlation of event-related potentials N170 with dysfunctional attitudes in patients with major depressive disorder

BACKGROUND

Cognitive impairment frequently accompanies first-episode major depressive disorder (MDD) in patients. Early detection and intervention for cognitive impairment can enhance the quality of life for individuals with depressive disorders. Impaired emotion recognition may serve as an initial manifestation of cognitive impairment in these patients. This study examines the characteristics of event-related potentials N170 and dysfunctional attitudinal questionnaire total scores, as well as each factor and their correlation, revealing characteristic electroencephalogram (EEG) changes associated with cognitive impairment in first-episode MDD patients.

METHOD

A total of 88 patients experiencing first-episode MDD and 29 healthy volunteers from the same period participated in the study. They underwent event-related potential N170 measures to assess mood recognition function, the 17-item Hamilton depression scale (HAMD-17) to evaluate the severity of depressive disorder, and the Dysfunctional Attitudes Scales(DAS) to appraise cognitive function.

RESULT

The dysfunctional attitude questionnaire's total score and each factor score were higher in the MDD group compared to the healthy control (HC) group. The MDD group exhibited lower amplitudes than the HC group at CZ, PZ, POZ, P7, PO7, P8, and PO8 electrode points. A correlation was identified between the P7 and PO7 electrode points of the event-related potential N170 and cognitive function.

LIMITATION

This study solely considered neutral face emotional stimuli and did not account for depressive disorder subtypes.

CONCLUSION

Differences were observed between the MDD and HC groups in cognitive function and N170 amplitude in the central brain region (CZ, PZ, POZ), left posterior temporal region (P7), left occipitotemporal region (PO7), right posterior temporal region (P8), and right occipitotemporal region (PO8). Additionally, a correlation was found between N170 latency in the left posterior temporal region of the brain (P7) and the left occipitotemporal region (PO7) with cognitive function.

Validity of the Spanish-Language Patient Health Questionnaires 2 and 9: A Systematic Review and Meta-Analysis

Importance

Reliable screening for major depressive disorder (MDD) relies on valid and accurate screening tools.

Objective

To examine the validity, accuracy, and reliability of the Spanish-language Patient Health Questionnaires 2 and 9 (PHQ-2 and PHQ-9) to screen for MDD.

Data Sources

PubMed, Web of Science, Embase, and PsycINFO from data initiation through February 27, 2023.

Study Selection

English- and Spanish-language studies evaluating the validity of the Spanish-language PHQ-2 or PHQ-9 in screening adults for MDD compared with a standardized clinical interview (gold standard). Search terms included PHQ-2, PHQ-9, depression, and Spanish.

Data Extraction and Synthesis

Two reviewers performed abstract and full-text reviews, data extraction, and quality assessment. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Random-effects meta-analyses of sensitivity, specificity, and area under the curve (AUC) were performed. Internal consistency was evaluated using Cronbach α and McDonald ψ.

Main Outcomes and Measures

Test accuracy and internal consistency. The PHQ-2 is composed of the first 2 questions of the PHQ-9 (targeting core depression symptoms of depressed mood and anhedonia; a score of 3 or higher (score range, 0-6) is generally considered a positive depression screen. If a patient screens positive with the PHQ-2, a follow-up assessment with the PHQ-9 and a clinical diagnostic evaluation are recommended. Once depression is diagnosed, a PHQ-9 score of 10 or higher (score range, 0-27) is often considered an acceptable threshold for treating depression.

Results

Ten cross-sectional studies involving 5164 Spanish-speaking adults (mean age range, 34.1-71.8 years) were included; most studies (n = 8) were in primary care settings. One study evaluated the PHQ-2, 7 evaluated the PHQ-9, and 2 evaluated both the PHQ-2 and PHQ-9. For the PHQ-2, optimal cutoff scores ranged from greater than or equal to 1 to greater than or equal to 2, with an overall pooled sensitivity of 0.89 (95% CI, 0.81-0.95), overall pooled specificity of 0.89 (95% CI, 0.81-0.95), and overall pooled AUC of 0.87 (95% CI, 0.83-0.90); Cronbach α was 0.71 to 0.75, and McDonald ψ was 0.71. For the PHQ-9, optimal cutoff scores ranged from greater than or equal to 5 to greater than or equal to 12, with an overall pooled sensitivity of 0.86 (95% CI, 0.82-0.90), overall pooled specificity of 0.80 (95% CI, 0.75-0.85), and overall pooled AUC of 0.88 (95% CI, 0.87-0.90); Cronbach α was 0.78 to 0.90, and McDonald ψ was 0.79 to 0.90. Four studies were considered to have low risk of bias; 6 studies had indeterminate risk of bias due to a lack of blinding information.

Conclusions and Relevance

In this systematic review and meta-analysis, limited available evidence supported the use of the Spanish-language PHQ-2 and PHQ-9 in screening for MDD, but optimal cutoff scores varied greatly across studies, and few studies reported on blinding schemes. These results suggest that MDD should be considered in Spanish-speaking individuals with lower test scores. Given the widespread clinical use of the tools and the heterogeneity of existing evidence, further investigation is needed.

"How's your mood": Recorded physician mental health conversations with Chinese and Latino patients in routine primary care visits

OBJECTIVE

Patient-physician communication patterns may influence discussions around depressive symptoms and contribute to engagement in depression care among racial/ethnic minority adults. We examined patient-physician communication about depressive symptoms during routine primary care visits with Chinese and Latino patients with and without language barriers.

METHODS

We examined 17 audio-recorded conversations between primary care physicians and Chinese (N = 7) and Latino (N = 10) patients who discussed mental health during their visit and reported depressive symptoms on a post-visit survey. Conversations (in English, Cantonese, Mandarin, Hoisan-wa, Spanish) were transcribed and translated by bilingual/bicultural research assistants and analyzed using inductive and deductive thematic and discourse analysis.

RESULTS

Patients initiated mental health discussion in eleven visits. Physicians demonstrated care in word choice and sometimes avoided openly mentioning depression; this could contribute to miscommunication around symptoms and treatment goals. Interpreters had difficulty finding single words to convey terms used by either patients or physicians.

CONCLUSION

Patients and doctors appeared willing to discuss mental health; however, variability in terminology presented challenges in mental health discussions in this culturally and linguistically diverse sample.

PRACTICE IMPLICATIONS

Further understanding patient preferred terminology about mental health symptoms and interpreter training in these terms could improve patient-physician communication about depressive symptoms and treatment preferences.

Validity of the Chinese Language Patient Health Questionnaire 2 and 9: A Systematic Review

Introduction

Chinese Americans with limited English proficiency have higher mental health needs than English speakers but are more likely to be undiagnosed and undertreated for depression. Increasing anti-Asian hate crimes during the COVID-19 pandemic has increased the urgency to accurately detect depressive symptoms in this community. This systematic review examines the validity of the Patient Health Questionnaire (PHQ)-2/9 for depression screening in Chinese-speaking populations.

Methods

We queried PubMed, Web of Science, Embase, and PsycINFO databases, examining studies through September 2021. Studies were included if they evaluated the Chinese language PHQ-2 or PHQ-9 and diagnosed depression using a clinical interview. Two investigators independently extracted study data and assessed quality using the QUADAS-2. Study sensitivities and specificities were combined in random effects meta-analyses.

Results

Of 513 articles, 20 met inclusion criteria. All examined the PHQ-9; seven also examined the PHQ-2. Studies were conducted in Mainland China (17), Hong Kong (1), Taiwan (1), and the United States (1). Fourteen studies were published in English; six in Chinese. Studies were diverse in setting, participant age, and comorbidities. For the Chinese language PHQ-9, Cronbach's alpha ranged from 0.765 to 0.938 for included studies (optimal cutoff scores ranged from 6 to 11). For the PHQ-2, Cronbach's alpha ranged from 0.727 to 0.785 (optimal cutoff scores 1-3). Overall, the PHQ-9 pooled sensitivity was 0.88 (95% CI 0.86-0.90), and pooled specificity was 0.87 (95% CI 0.83-0.91). Similarly, the pooled PHQ-2 sensitivity was 0.84 (95% CI 0.80-0.87), and pooled specificity was 0.87 (95% CI 0.78-0.93). The overall risk of bias was low (12 studies) or indeterminate (8 studies).

Discussion

While limited by missing study information, the Chinese language PHQ-9 appears to be a valid depression screening tool among Chinese-speaking populations across geographic and clinical settings. Further research should explore optimal cutoff scores for this population for routine depression screening and the validity of the tool to measure response to depression treatment.

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.

Communication methods between outpatients with limited-English proficiency and ancillary staff: LASI study results

OBJECTIVE

Describe communication methods between primary care ancillary staff, including front desk administrative staff and medical assistants (MAs), and patients with limited-English proficiency (LEP).

METHODS

Patients with LEP completed a telephone survey after a primary care visit including questions about communication with ancillary staff (n = 1029). To inform practice improvements and lend qualitative perspective to these quantitative data, we subsequently conducted semi-structured interviews with ancillary staff and physicians.

RESULTS

Professional interpreter use was minimal with ancillary staff (<4%). Among patients who did not use their preferred language with bilingual staff, about one-third reported using English to communicate, despite most (≥ 80%) speaking English 'not well' or 'not at all.' In semi-structured interviews, ancillary staff felt basic English sufficient for most patient communication. However, physicians reported taking on extra visit tasks to compensate for the communication barriers between ancillary staff and patients with LEP.

CONCLUSIONS

Use of professional interpretation by front desk staff and MAs was minimal. This led many patients with LEP to 'get by' with limited English when communicating with ancillary staff, in turn increasing burden on the physician visit.

PRACTICE IMPLICATIONS

Future interventions should focus on increasing use of professional interpretation by outpatient ancillary staff when communicating with LEP patients.