Depression Treatment After a Positive Depression Screen Result.

Abstract

Importance: As primary care practices increase depression screening, it is unknown whether screening is associated with appropriate and equitable treatment.

Objective: To investigate factors associated with initial treatment among patients who screen positive for depression and/or suicidal ideation (SI).

Design, setting, and participants: Cohort study using electronic health record data from September 2017 to September 2021, from a large US academic health system. Participants were adult primary care patients with elevated depressive symptoms (Patient Health Questionnaire-9 score ≥10) and/or SI, excluding patients with baseline depression, bipolar disorder, schizophrenia, schizoaffective disorder, or dementia. Data were analyzed from December 30, 2022, to February 17, 2024.

Exposure: Patient characteristics including gender, age, preferred language, and race and ethnicity.

Main outcomes and measures: Primary outcome was antidepressant or mental health referral ordered at screening. Secondary outcomes were antidepressant/referral and antidepressant/referral or follow-up visit within 8 weeks.

Results: Of 60 062 patients screened, 3980 (7%) reported elevated depressive symptoms or SI. The cohort was 68.1% women (2711), and the mean (SD) age was 46.5 (17.6) years; 0.8% were 12.4% African American or Black (493), American Indian or Alaska Native (30), 24.8% Asian (988), 14.6% Latino/Latina/Latinx (582), 1.5% Pacific Islander (58), and 36.9% White (1470), and 9.0% other/unknown (359); 5.6% preferred a non-English language (223). Approximately 38% (1518) received antidepressants/referrals when screened (including 44% of 461 patients [203] with SI). By 8 weeks, 2785 patients (70%) received antidepressant/referral and/or follow-up (including 75% of 783 patients with SI). In multivariable logistic regression models adjusting for site and clustered on primary care physician, there were no statistically significant differences in the primary outcome by gender, preferred language, or health insurance. African American or Black and Asian patients had lower estimated probabilities of treatment ordered when screened (34.0% [95% CI, 28.4%-39.6%] for Black patients and 35.4% [95% CI, 31.5%-39.4%] for Asian patients) than White patients (40.5% [95% CI 37.4%-43.5%]). Estimated treatment decreased with increasing age (46.4% [95% CI, 41.2%-51.5%] for patients aged 18-30 years and 17.5% [95% CI, 12.1%-22.9%] for patients aged ≥75 years). Patients with SI had greater estimated treatment than those without SI (43.5% [95% CI, 39.9%-47.1%] vs 35.2% [95% CI, 33.0%-37.5%]), although treatment was overall low for this high-risk group. Secondary outcomes were consistent, although there were no statistically significant differences in follow-up visits for African American or Black and Asian patients compared with White patients.

Conclusions and relevance: In this cohort study, moderate rates of initial treatment among patients with elevated depressive symptoms and/or SI were found. Targeted interventions are needed for patients at risk of undertreatment, including patients with SI, African American or Black and Asian patients, and older adults.