Garcia Maria E, Ochoa-Frongia Lisa, Neuhaus John, Hong Julian C, Hinton Ladson, Livaudais-Toman Jennifer, Feldman Mitchell D, Mangurian Christina, Appelle Nicole, Karliner Leah S
Division of General Internal Medicine, Department of Medicine, University of California, San Francisco.
Center for Aging in Diverse Communities, University of California, San Francisco.
JAMA Intern Med. 2025 Feb 1;185(2):221-229. doi: 10.1001/jamainternmed.2024.6211.
As primary care practices increase depression screening, it is unknown whether screening is associated with appropriate and equitable treatment.
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.
Patient characteristics including gender, age, preferred language, and race and ethnicity.
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.
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.
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.
随着基层医疗实践中抑郁症筛查的增加，尚不清楚筛查是否与适当且公平的治疗相关。
调查抑郁症和/或自杀意念（SI）筛查呈阳性的患者初始治疗的相关因素。
设计、地点和参与者：队列研究，使用来自美国一个大型学术医疗系统2017年9月至2021年9月的电子健康记录数据。参与者为成年基层医疗患者，其抑郁症状加重（患者健康问卷-9评分≥10）和/或有自杀意念，排除有基线抑郁症、双相情感障碍、精神分裂症、分裂情感性障碍或痴呆症的患者。数据于2022年12月30日至2024年2月17日进行分析。
患者特征，包括性别、年龄、首选语言以及种族和民族。
主要结局是筛查时开具的抗抑郁药或心理健康转诊。次要结局是抗抑郁药/转诊以及8周内的抗抑郁药/转诊或随访就诊。
在60062名接受筛查的患者中，3980名（7%）报告有抑郁症状加重或自杀意念。该队列中68.1%为女性（2711名），平均（标准差）年龄为46.5（17.6）岁；0.8%为非裔美国人或黑人（493名），12.4%为美洲印第安人或阿拉斯加原住民（30名），24.8%为亚洲人（988名），14.6%为拉丁裔/拉丁美洲人/拉丁裔（582名），1.5%为太平洋岛民（58名），36.9%为白人（1470名），9.0%为其他/不明（359名）；5.6%首选非英语语言（223名）。筛查时约38%（1518名）接受了抗抑郁药/转诊（包括461名有自杀意念患者中的44%[203名]）。到8周时，2785名患者（70%）接受了抗抑郁药/转诊和/或随访（包括783名有自杀意念患者中的75%）。在调整了地点并以基层医疗医生为聚类的多变量逻辑回归模型中，主要结局在性别、首选语言或医疗保险方面无统计学显著差异。非裔美国人或黑人以及亚洲患者筛查时开具治疗的估计概率低于白人患者（黑人患者为34.0%[95%置信区间，28.4%-39.6%]，亚洲患者为35.4%[95%置信区间，31.5%-39.4%]），白人患者为40.5%[95%置信区间37.4%-43.5%]）。估计治疗率随年龄增长而降低（18至30岁患者为46.4%[95%置信区间，41.2%-51.5%]，75岁及以上患者为17.5%[95%置信区间，12.1%-22.9%]）。有自杀意念的患者比无自杀意念的患者有更高的估计治疗率（43.5%[95%置信区间，39.9%-47.1%]对35.2%[95%置信区间，33.0%-37.5%]），尽管该高危组的总体治疗率较低。次要结局一致，尽管非裔美国人或黑人以及亚洲患者与白人患者相比，随访就诊无统计学显著差异。
在这项队列研究中，发现抑郁症状加重和/或有自杀意念的患者初始治疗率中等。对于治疗不足风险较高的患者，包括有自杀意念的患者、非裔美国人或黑人以及亚洲患者和老年人，需要有针对性的干预措施。
