Depression Screening Rates during COVID-19 Low Among Telehealth Appointments

Maria E. Garcia, MD, MPH

Credit: University of California

Video and phone telehealth appointments, non-English speakers, older adults > 75 years old, and patients on Medicaid were less likely to have depression screenings during COVID-19 than in-person visits, English speakers, patients aged 18 – 30 years, and patients with private insurance, a new study found.¹

Although depressive symptoms increased during the COVID-19 pandemic, investigators, led by Maria E. Garcia, MD, MPH, from Mount Zion Division of General Internal Medicine, sought to assess the likelihood of people having depression screenings by visit format and patient characteristics during the early pandemic.

“Depression screening workflows and protocols were initially developed for in-person visits,” investigators wrote. “Due to the abrupt transition to telemedicine early in the pandemic and the urgency of the pandemic response, team-based workflows for depression screening lagged for telemedicine encounters.”

Garcia and colleagues conducted a cohort study evaluating depression screenings in 6 primary care practices at the University of California, San Francisco, from June 1, 2020 – September 30, 2021. They obtained depression screenings through electronic health record data.

The team considered a depression screening as patients who completed Patient Health Questionnaire 2 (PHQ-2) during an eligible visit. They excluded patients if they had been screened in the previous 12 months, had a baseline diagnosis of depression, bipolar disorder, schizophrenia, schizoaffective disorder, or dementia, or had a new diagnosis of depression during the study.

Visit types, determined through billing information, were either in person, via video, or by telephone. Other than visit types, the team examined the covariates of self-reported race and ethnicity, preferred language, sex, age, baseline Elixhauser comorbidity count, and primary insurance type. All these covariates had been linked with depression screening disparities.

Investigators measured monthly depression screening rates by visit type and used a mixed-effects logistic regression model with random patient effects to evaluate the odds of depression screening at a visit. Data was analyzed from December 2021 – June 2023.

In total, the study examined 57,301 eligible visits with 37,250 patients. More than half were female (60%), and the mean age was 52.3 years. The study included 42% White, 30% Asian, 10% Hispanic or Latinx, 8% African American or Black, 8% other or unknown, 1% Native Hawaiian or Pacific Islander, and 0.3% American Indian or Alaska Native.

Most patients preferred to speak English, but for 7%, language preference was non-English—either Chinese, Spanish, or other.

Despite not observing differences in screening by sex or race and ethnicity, the team found patients who preferred speaking English had greater odds of depression screening than patients who preferred speaking Chinese (adjusted odds ratio [AOR], 0.70; 95% confidence interval [CI], 0.59 – 0.82), Spanish (AOR, 0.59; 95% CI, 0.43 – 0.80), and other (AOR, 0.69; 95% CI, 0.57 – 0.82).

Moreover, patients had lower odds of being screened via video (AOR, 0.28; 0.27 – 0.30) and phone (AOR, 0.24; 95% CI, 0.20 – 0.27) visits compared with in-person visits. Patients > 75 years had lower odds of being screened than patients aged 18 – 30 years. Additionally, patients with Medicaid (AOR, 0.80; 95% CI, 0.73 – 0.88) had lower odds of being screened compared to patients with private insurance.

Limitations the investigators pointed out were the single site, not being able to observe patients refusing screening, and the visit-level vs individual-level analysis.

Even with the pandemic over, mental health video visits persist, and the number of mental health virtual visits has increased in the past year, according to a new study published this past January.2 In August 2023, 34.5% of mental health visits took place via video.

“Although disparities in screening had been eliminated before the study period for older adults and patients with non–English language preference, multiple comorbidities, and Medicaid, these disparities recurred and persisted during the study period for all visit types,” investigators wrote.1 “Health systems must be vigilant and proactive in addressing emerging disparities by race and ethnicity, language, or age, particularly in the telemedicine setting.”

^References

1. ^{Garcia, M, Neuhaus, J, Livaudais-Tomain, J. Telemedicine and Depression Screening After the Start of the COVID-19 Pandemic. JAMA Network Open. 2024;7(2):e2355830. doi:10.1001/jamanetworkopen.2023.55830}
2. ^{Derman, C. Telemedicine Reduced After COVID-19 Peak, Mental Health Video Visits on Rise. HCPLive. January 24, 2024. https://www.hcplive.com/view/telemedicine-reduced-after-covid-19-peak-mental-health-video-visits-rise. Accessed February 12, 2024.}