Disparities Shrink With Aggressive Depression Screening

Mary Chris Jaklevic

April 11, 2022

An analysis at a large academic health system suggests that universal screening might help to reduce problematic disparities in depression treatment.  

The study began soon after the US Preventive Services Task Force recommended depression screening for all adults in 2016. The task force based this recommendation on evidence that people who are screened and treated experience fewer debilitating symptoms.

In the new research, the investigators analyzed electronic health record data following a rollout of a universal depression screening program at the University of California San Francisco (UCSF). The researchers found that the overall rate of depression screening doubled at six primary care practices over a little more than 2 years, reaching nearly 90%. The investigators presented the data April 9 at the Society of General Internal Medicine 2022 Annual Meeting in Orlando, Florida.

Meanwhile, screening disparities diminished for men, older individuals, racial and ethnic minorities, and people with language barriers — all groups that are undertreated for depression.

"It shows that if a health system is really invested, it can achieve really high depression screening," primary investigator Maria Garcia, MD, MPH, co-director of UCSF's Multiethnic Health Equity Research Center, told Medscape Medical News.

Methods for Identifying Depression

Dr Maria Garcia

The health system assigned medical assistants to administer annual screening using a validated tool, the Patient Health Questionnaire-2 (PHQ-2). A "yes" response to either of its two questions triggered a longer questionnaire, the PHQ-9, used to diagnose and guide treatment.

Screening forms were available in multiple languages. Medical assistants received training on the importance of identifying depression in undertreated groups, and a banner was inserted in the electronic health record to indicate a screening was due, Garcia said.

During the rollout, a committee was assigned to monitor screening rates and adjust strategies to target disparities.

Garcia and fellow researchers calculated the likelihood of a patient being screened starting in September 2017 — when a field for depression screening status was added to the system's electronic health record — until the rollout was completed on December 31, 2019.

Screening Disparities Narrowed for All Groups Studied

The screening rate for patients who had a primary care visit increased from 40.5% to 88.8%. Early on, patients with language barriers were less likely to be screened than English-speaking White individuals (odds ratios [OR], 0.55 - 0.59). Men were less likely to be screened than women (OR, 0.82; 95% CI, 0.78 - 0.86), and the likelihood of being screened decreased as people got older. By 2019, screening disparities had narrowed for all groups and were only statistically significant for men (OR, 0.87; 95% CI, 0.81 - 0.93).

Dr Ian Kronish

Ian Kronish, MD, MPH, a general internist and associate professor of medicine at Columbia University in New York City, called the increases "impressive," adding that the data show universal depression screening is possible in a system that serves a diverse population.

Kronish, who was not involved in this study, noted that other research indicates screening does not result in a significant reduction in depressive symptoms in the overall population. He found this to be the case in a trial he led, which focused on patients with recent cardiac events, for example.

"Given all the effort that is going into depression screening and the inclusion of depression screening as a quality metric, we need definitive randomized clinical trials testing whether depression screening leads to increased treatment uptake and, importantly, improved depressive symptoms and quality of life," he said.

Garcia acknowledged more work needs to be done to address treatment barriers, such as language and lack of insurance, and assess whether greater recognition of depressive symptoms in underserved groups can lead to effective treatment. "But this is an important step to know that universal depression screening narrowed disparities in screening over time," she added.

Garcia and Kronish have disclosed no relevant financial relationships.

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