Study Identifies Depression Treatment Gaps by Ethnicity, Age, Suicidal Risk

Maria E. Garcia, MD

Credit: University of California, San Francisco

Patients with suicidal ideation, Black or Asian ethnicity, or older age face a greater risk of undertreatment for depression, a new study discovered.¹

“We found that 38% of patients received USPSTF-recommended initial treatment (antidepressant, referral) at the screening visit,” wrote investigators, led by Maria E. Garcia, MD, from the University of California, San Francisco.

After the 2016 United States Preventive Services Task Force (USPSTF) revision, primary care practices expanded depression screening. At the University of California, San Francisco, 6 facilities increased screening rates by 48% in 2 years and eliminated disparities across demographics.² Other systems reported similar screening increases but lacked consistent data on patient characteristics.

Although the expansion of depression screenings reduced screening disparities in University of California, San Francisco facilities, it is not known how the increase in depression screenings may impact treatment rates among certain groups, such as by ethnicity and age. Investigators sought to investigate the factors linked to initial treatment among patients who screened positive for depression or suicidal ideation.¹

The primary outcome of their cohort study was the order of antidepressants or mental health referrals at screening. Secondary outcomes included antidepressants or mental health referrals or follow-up visits within 8 weeks.

The team leveraged 2017 – 2021 electronic health record data from the University of California, San Francisco Health, collecting patient characteristics of gender, age, preferred language, and race and ethnicity. Participants had increased depressive symptoms, determined by a Patient Health Questionnaire-9 score ≥ 10, or suicidal ideation. The study excluded patients with baseline depression, bipolar disorder, schizophrenia, schizoaffective disorder, or dementia.

Investigators analyzed the data from December 30, 2022, to February 17, 2024. Among the 60,062 patients screened, 3980 (7%) reported increased depressive symptoms or suicidal ideation. The sample had a mean age of 46.5 years, included 68.1% women, and had a race/ethnicity distribution of 36.9% White, 24.8% Asian, 14.6% Latino/Latina/Latinx, 12.4% African American or Black, 9% other/unknown, 1.5% Pacific Islander, and 0.8% American Indian or Alaska Native. A low percentage of the sample (5.6%) preferred a non-English language.

Less than half of the participants who screened positive for depression (38%) and suicidal ideation (44%) received antidepressants or mental health referrals. By 8 weeks, 70% and 75% of participants screened positive for depression and suicidal ideation, respectively, received antidepressants or mental health referrals.

Multivariable logistic regression models adjusted for site and clustered on primary care physicians showed no statistically significant differences in the primary outcome by gender, preferred language, or health insurance. However, there were differences when it came to race and ethnicity.

The study found African American/Black (34%; 95% confidence interval [CI], 28.4 – 39.6%) and Asian (35.4%; 95% CI, 31.5% - 39.4%) patients had a lower estimated likelihood of receiving treatment after screening positive for depression or suicidal ideation, compared with White patients (40.5%; 95% CI, 37.4 – 43.5%). Furthermore, the likelihood of treatment reduced with increasing age, decreasing from 46.4% at ages 18 – 30 years (95% CI, 41.2% - 51.5%) to 17.5% at ages≥ 75 years (95% CI, 12.1% - 22.9%).

Patients with suicidal ideation (43.5%; 95% CI, 39.9% - 47.1%) had a greater likelihood of treatment than those without suicidal ideation (35.2%; 95% CI, 33.0% - 37.5%). Despite this, participants with suicidal ideation still had an overall low treatment rate.

The study also revealed there were no statistically significant differences in follow-up visits for African American/ Black and Asian patients compared with White patients.

Investigators lacked data on patients who declined or did not initiate treatment and those clinically evaluated for depression after a positive screen. Without proper assessment and diagnosis, individuals risk overtreatment of mild or self-remitting symptoms.

The investigators concluded by emphasizing the need for medical institutions to intensify efforts to address systemic racism and expand access to culturally appropriate treatments to improve treatment rates among African American and Asian populations.

Additionally, the team added how using patient portals as a tool for population-based depression screening may not be effective. This study found portal screenings were linked to lower odds of clinical action.

“Our findings highlight that patient portal screening should not be used in isolation,” investigators wrote. “Steps must be taken to allocate sufficient resources to ensure accountability and to proactively establish appropriate workflows for follow-up of positive screen results.”

References

1. ^{Garcia ME, Ochoa-Frongia L, Neuhaus J, Hong JC, Hinton L, Livaudais-Toman J, Feldman MD, Mangurian C, Appelle N, Karliner LS. Depression Treatment After a Positive Depression Screen Result. JAMA Intern Med. 2024 Dec 9. doi: 10.1001/jamainternmed.2024.6211. Epub ahead of print. PMID: 39652335.}
2. ^{Garcia ME, Hinton L, Neuhaus J, Feldman M, Livaudais-Toman J, Karliner LS. Equitability of Depression Screening After Implementation of General Adult Screening in Primary Care. JAMA Netw Open. 2022;5(8):e2227658. doi:10.1001/jamanetworkopen.2022.27658}