Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Depression Screening Among African American Adults in the Primary Care Setting

April Chisley Randle, DNP, FNP-BC; Amy L. Spurlock, PhD, RN; Sabrina Kelley, DNP, CRNP

Abstract

Although depression is treatable with medication and psychotherapy, it is often left undiagnosed or misdiagnosed in African American communities. African American patients may experience poor outcomes when medical problems coexist with undiagnosed and untreated mental health issues, such as depression. This is a concern because depression can inhibit compliance with providers' treatment plans. A major factor in treatment of depression is assessment and recognition of the condition itself so that a proper diagnosis and treatment plan can be determined. The purpose of the current study was to examine the effects of a depression screening tool on depression diagnoses and treatment initiation in African American patients in a primary care setting. In 200 patients prior to screening implementaion, none were screened or diagnosed with depression. After routine implementation of a depression screening tool, 75 of 182 patients were diagnosed with depression. Using a routine screening tool resulted in a 41% increase in diagnoses of depression. The integration of routine depression screening in the primary care setting may improve overall health outcomes and competence in implementation of care. [Journal of Psychosocial Nursing and Mental Health Services, 57(10), 18–23.]

Abstract

Although depression is treatable with medication and psychotherapy, it is often left undiagnosed or misdiagnosed in African American communities. African American patients may experience poor outcomes when medical problems coexist with undiagnosed and untreated mental health issues, such as depression. This is a concern because depression can inhibit compliance with providers' treatment plans. A major factor in treatment of depression is assessment and recognition of the condition itself so that a proper diagnosis and treatment plan can be determined. The purpose of the current study was to examine the effects of a depression screening tool on depression diagnoses and treatment initiation in African American patients in a primary care setting. In 200 patients prior to screening implementaion, none were screened or diagnosed with depression. After routine implementation of a depression screening tool, 75 of 182 patients were diagnosed with depression. Using a routine screening tool resulted in a 41% increase in diagnoses of depression. The integration of routine depression screening in the primary care setting may improve overall health outcomes and competence in implementation of care. [Journal of Psychosocial Nursing and Mental Health Services, 57(10), 18–23.]

Depression is a serious illness that affects at least 19 million adults in the American population annually (Anthony, Johnson, & Schafer, 2015). There are few verifiable statistics related to African American individuals and depression. However, lifetime prevalence of major depressive disorder in African American individuals is predicted to be 9% to 13% (Torres, Sampselle, Neighbors, Ronis, & Gretebeck, 2015). Although depression can be treated adequately with medication and psychotherapy, depression is often left undiagnosed or misdiagnosed in African American communities. These determinants may be related to culture, such as morals and values, religion, and community support. Anthony et al. (2015) estimated 63% of African American individuals believe that depression is a personal weakness, and approximately 66% believe that prayer and faith alone are the cure. As a result, approximately 40% of the African American population prefers to use clergy as primary counsel for mental health, and only 10% receive referrals to a mental health professional. Although there is a percentage of this ethnic group who display symptoms of depression or have factors that may eventually lead to the condition, the topic remains ignored.

Information regarding depression and mental health in African American communities is conveyed negatively. For example, Watson and Hunter (2015) suggest that the “Strong Black woman” race-gender schema encourages African American women to “show strength” by dealing with stress internally and hiding vulnerabilities instead of seeking professional help. Although economic barriers may play a role, culture may also be a leading factor in the perceptions of professional psychological assistance. For example, a significant number of African American families also believe that sharing personal business outside of the family is forbidden. As a result, professional psychological health providers are considered strangers and are not an option (Watson & Hunter, 2015). For these reasons, African American individuals may be misinformed, which results in unavailability of resources for mental health in their communities.

Primary care is considered the setting of choice for patients to request mental health treatment (Jolly et al., 2016). The National Alliance on Mental Illness (2017) reports that more than 70% of visits to primary care physicians (PCPs) relate to effects of undiagnosed psychosocial issues, which may stem from home or the workplace. As a result, these patients are often treated only for the medical conditions caused by these risk factors. However, such treatment is inadequate as it may not address the core of the problem. According to Jolly et al. (2016), 56% of clients with mental illness received treatment in a primary care setting. Therefore, integration of routine depression screening in the primary care setting may expand the productivity and competence in implementation of care (Jolly et al., 2016).

McGough, Bauer, Collins, and Dugdale (2015) suggest that mental health conditions, such as depression, continue to be undertreated and under-diagnosed amongst PCPs, causing consequences for patients; mental health is often related to risky behaviors that influence physical health, such as smoking, substance use, and unhealthy eating. Depression may also heighten risks of chronic illnesses and symptoms, as well as lower the likelihood of compliance with medical management (McGough et al., 2015). Because of the number of patients who may have un-diagnosed depression in primary care, it is important that mental health is assessed in the primary care setting. This is a vital issue in treating the whole person, both physically and mentally (McGough et al., 2015).

Purpose

The purpose of the current study was to examine the effects of a depression screening tool in relation to depression diagnoses and treatment initiation in African American adults in a primary care setting. The purpose of implementing a depression screening tool in the African American primary care population is to seek outcomes. The intent is to allow patients to recognize and be aware of the possibility of stressors and depression. The next step is to make it known that resources are available that can assist them, regardless of the level of depression. Once individuals understand that depression is a serious illness that requires intervention, there may be an increase in the number of referrals, which equates to the establishment of available resources. Using available resources may eventually result in the improvement in overall health status in the African American community. Once the health status has progressed in a positive direction, there may be a gradual decrease in relative risk. Patient maintenance of depression allows for social status improvement and income increase due to the possibility of elevated self-esteem and motivation. Implementation of the depression screening tool may be a valuable start in the primary care setting, as African American individuals seek care for most conditions from their family health care provider.

Method

Design

A retrospective chart review was conducted to evaluate a practice change. The practice change was the initiation of the Patient Health Questionnaire-9 (PHQ-9) screening tool.

Sample and Setting

The sample comprised 400 electronic health records (EHRs) of African American adults, ages 19 and older, who were patients at two primary care clinics in the southern United States. One clinic was located in a rural setting and the other in an urban setting. The rural clinic was staffed by three PCPs, two medical assistants (MAs), and two licensed practical nurses. The urban clinic was staffed with one PCP and two MAs. Although both settings included patients of all ages and ethnicities, the majority were African American.

One hundred EHRs from each clinic, respectively, were reviewed prior to and after implementation of the PHQ-9 screening tool. Exclusion criteria for the current study were race/ethnicity not African American, age <19 years, and previous diagnosis with depression or any other mental health condition.

The current study involved an evaluation of a practice change at both clinics for all patients; thus, recruitment was not necessary.

Practice Change

The PHQ-9 is a multipurpose instrument created from a larger instrument, the PHQ, that assesses common mental disorders (Kroenke, Spitzer, & Williams, 2001; Spitzer, Kroenke, & Williams, 1999). The PHQ-9 is designed as a self-report measure and includes nine questions about the occurrence of certain symptoms related to depression over the previous 2 weeks. The tool assesses the frequency of the symptoms and resultant interruption of normal daily activities. This tool compresses the Diagnostic and Statistical Manual of Mental Disorders standards of evaluation for depression and other major depressive symptoms into a concise tool for use in screening and diagnosis, including primary care settings (Dietrich, Oxman, Burns, Winchell, & Chin, 2003). The PHQ-9 has also been used to screen for depression in African American populations. Hankerson et al. (2015) used the PHQ-9 to measure depression of African American men in churches.

According to Kroenke et al. (2001), the diagnostic validity of the nine-item PHQ-9 was established in studies involving eight primary care and seven obstetrical clinics. PHQ-9 scores >10 have a sensitivity of 88% and a specificity of 88% for major depressive disorder (Kroenke & Spitzer, 2002). Reliability and validity of this instrument have suggested reasonable and well-grounded psychometric characteristics. A study comprising two different patient populations produced Cronbach alphas of 0.86 and 0.89, indicating internal consistency (American Psychological Association, 2017). It was also demonstrated that individuals who scored ≥10 on the PHQ-9 were seven to 13.6 times more likely to be diagnosed with depression and those scoring ≤4 had a less than one in 25 chance of being diagnosed with depression (American Psychological Association, 2017).

In the current study, the PHQ-9 was added as a routine screening to all patients ages 19 and older for each clinic visit. Prior to the initiation of this practice change, an educational session was conducted with PCPs and staff members at both clinics. The educational session provided an explanation of the purpose, administration, and scoring of the PHQ-9 as a screening tool. Both clinics added the PHQ-9 into the EHR to permanently capture the data. During each visit, health care providers calculated the total score to determine patient level of depression (none to minimal, mild, moderate, moderately severe, or severe). The screening score provided the basis for the providers' decision of any treatment needed, which included no treatment, monitoring and follow up of the condition, counseling, psychotherapeutic medication, or a referral to a mental health specialist.

Data Collection

After Institutional Review Board approval, a data collection sheet was used to gather data from 200 randomly chosen EHRs from December 2017 to January 2018 prior to the initiation of the practice change. Variables included sex, age, insurance status, and whether the patient was screened, diagnosed, or treated with depression. In February 2018, the practice change at each clinic was initiated. Once each patient arrived at the clinic and registered, the patient completed the PHQ-9 after being guided to a private examination room. If the patient was unable to read and write, the MA assisted by reading each item of the depression screening tool to him/her. PCPs then reviewed and discussed the score with each patient and initiated treatment for depression if needed. Clinical staff entered the PHQ-9 into the EHR then shredded the survey. After the PHQ-9 was implemented in both clinics, 200 randomly chosen EHRs were again chosen for review from February to April 2018, using the same variables.

Statistical Analysis

Data were compiled into a dataset and analyzed using IBM SPSS version 22. In congruence with the inclusion criteria of the current study, all EHRs reflected data collected from African American patients. Although 200 EHRs revealed usable data before the practice change was initiated, only 182 EHRs reviewed after the practice change were usable due to missing data. Thus, the final sample comprised 382 EHRs.

Results

Table 1 describes the frequencies for gender as well as mean patient age before and after initiating the practice change. More female patients than male patients were represented in the sample during both time periods, whereas mean age was the same. Frequencies of depression screening and diagnoses, insurance status, and location setting for participants before and after the practice change are found in Table 2. There were similarities in the type of insurance held by participants in both samples. Although there were no participants screened for depression before the practice change, all participants were screened for depression after the practice change. In addition, there were no diagnoses of depression before the implementation of the PHQ-9. However, after initiating the practice change, 41.2% of patients screened were diagnosed with depression.

Sample Gender and Age Distribution Before and After the Practice Change

Table 1:

Sample Gender and Age Distribution Before and After the Practice Change

Participants' Descriptive Variables Before and After the Practice Change

Table 2:

Participants' Descriptive Variables Before and After the Practice Change

Depression level and treatment after initiating the PHQ-9 are found in Table 3. A total of 41.2% (n = 75) of participants were diagnosed with depression after screenings were conducted, including mild (20.3%, n = 37), moderate (13.2%, n = 24), moderately severe (5.5%, n = 10), and severe (2.2%, n = 4) depression. Of 72 (39.5%) patients who received treatment for depression, most were monitored (45.8%, n = 33), but treatment also included prescribed medication (16.7%, n = 12), counseling (8.3%, n = 6), or referral (4%, n = 3). Often, a combination of treatments was performed (25%, n = 18), and only three (4%) participants diagnosed with moderate depression refused treatment.

Participants' Depression Level and Treatment After the Practice Change (N = 182)

Table 3:

Participants' Depression Level and Treatment After the Practice Change (N = 182)

After initiating the PHQ-9 in practice, scores ranged from 0 to 27, with an indication of mild depression beginning at a score of 5 (mean = 4.98, SD = 6.02).

Independent samples (t tests) were conducted to examine differences in PHQ-9 total scores between male and female patients after initiating the PHQ-9 (Table 4). Although this was not a statistical difference (t[168] = 1.879, p > 0.05), the mean PHQ-9 total score for female patients (mean = 5.77, SD = 5.75) was higher than male patients (mean = 4.07, SD = 6.27). Risk indexes conducted on gender and diagnosis with depression found that women are two times more likely to be diagnosed with depression than men (odds ratio = 2.367, 95% confidence interval [1.28, 4.36]).

Analysis of Variance of PHQ-9 Total Score and Treatment Type (N = 182)

Table 4:

Analysis of Variance of PHQ-9 Total Score and Treatment Type (N = 182)

A difference was found in an analysis of variance of PHQ-9 total scores and type of treatment after initiation of the PHQ-9 (Table 4). Patients with the highest PHQ-9 mean total score received combination treatment, and patients with the lowest total score received no treatment or monitoring. Total PHQ-9 scores >10 received either medication, counseling, referral, or a combination of treatments.

Discussion

EHRs reviewed before the practice change revealed no initial diagnoses of depression. However, the EHRs reviewed after initiation of the PHQ-9 revealed 75 (41.2%) participants were diagnosed with depression. This finding is higher than the estimated 13% to 25% of primary care clients nationwide who have been diagnosed with depression (Gates, Petterson, Wingrove, Miller, & Klink, 2016). Of patients diagnosed with depression, 20% were considered mildly depressed, 13% were considered moderately depressed, and <8% were considered moderately to severely depressed. Of participants offered treatment for depression, three refused, stating treatment was unnecessary. Although the basis for their refusal is unknown, cultural beliefs or personal preferences may have been a factor (Anthony et al., 2015).

Clinical Significance

As depression is one of the leading underlying causes of disabilities in adults, a continued effort for early diagnosis and adequate treatment must be made for individuals, families, businesses, and communities. The U.S. Preventive Services Task Force recommends regular screening efforts that will lead to early and effective diagnoses, effective treatment plans, and follow up (Siu et al., 2016). According to Kato, Borsky, Zuvekas, Soni, and Ngo-Metzger (2018), compliance with clinical practice guidelines can be an important means for reducing health deficiencies, whereas lack of enacting preventive services can cause or worsen existing disparities in health outcomes. Akincigil and Matthews (2017) reported that provider visits that included African American patients were one half as likely to screen for depression compared to visits of Caucasian patients. Disparities exist in the diagnosis, initial care, and continued treatment of mental health in the African American community. Despite having fewer reported numbers of mental health issues than Caucasian individuals, socioeconomic factors prevent access to adequate care, and oftentimes, any care for this demographic (McGuire & Miranda, 2018).

Depression screenings will be fully sustained in the suburban clinic where the current study took place; the urban clinic is no longer in existence. In addition, the success of the data collection has sparked interest from other community health organizations in the region. The principal investigator has been in discussion with health care providers and community advocates to formulate a plan to implement depression screening in other primary care facilities. This work is important as it helps dispel myths and stereotypes of mental health disorders and treatment of such conditions within the African American community. Integrating depression screening into a patient's initial visit will allow quality assessments to be performed without attached negative connotations. Although the primary benefit is to the patient, there is also an incentive to the primary care facility for additional billing for services rendered. This screening will also increase inter-professional collaboration, as referrals will be made to mental health providers.

African American patients seen by a PCP may exhibit symptoms of chronic illnesses, such as hypertension and diabetes. Depression may be an underlying contributor to these coexisting diseases. Depression may also be a negative factor in patients who are non-compliant in their treatment regimen, which could lead to poor health status. African American individuals who are uninformed about depression and its impact on daily life activities may also be unaware of the available resources for treatment. The implementation of the PHQ-9 at two primary care clinics resulted in a 41% increase in depression diagnoses in patients with coexisting conditions. Most individuals who participated in the current study and were diagnosed with depression agreed to treatment once they were informed of options. Patients were more likely to improve and treat their condition when educated on the availability of resources. Outcomes of health status were not measured in the current study due to time constraints. However, there is the possibility of improved health management of coexisting conditions if the underlying cause is depression, which can be assessed and detected in primary care with the PHQ-9.

Limitations

The first limitation is the use of a retrospective chart review, which could have resulted in an under- or over-estimation of the rate of depression diagnoses. Only 100 charts per clinical site were reviewed before the practice change during a 2-month time period. This may not have included patients seen at other times who were diagnosed with depression. A second limitation may have been the sample size postintervention. The postintervention sample only comprised 100 patients at the first site and 82 patients at the second site. This group of participants may not fully represent the 1,100 patients seen monthly at the first clinic, or the 200 patients seen monthly at the second clinic. A third limitation may have been participants' perspectives on mental health, as depression and other related illnesses have been stigmatized in African American cultures. Without informed knowledge of this condition, it is possible that participants refused to be completely transparent when answering the PHQ-9, thereby manipulating scores. The PHQ-9 is a self-report measure, so response bias may be present. Therefore, the possibility exists that the actual number of patients diagnosed with depression could have been higher than results reveal. A future option to the implementation may include patient education related to depression before patients complete the PHQ-9. This option may alleviate any misconceptions of depression.

Conclusion

The current study and its results have helped raise awareness of the symptoms, effects, and resources related to depression in African American communities in the Deep South. The implementation of a depression screening tool in primary care clinics may improve outcomes for patients with coexisting conditions, such as hypertension and diabetes, by preventing under- or misdiagnosis of the underlying problem. For patients to be treated holistically, the PCP's care regimen should be patient-centered, and patient adherence to treatment suggestions is encouraged. Mental health status may impact attainment of optimal patient care goals. Therefore, mental health must be included in all initial and ongoing assessments.

References

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Sample Gender and Age Distribution Before and After the Practice Change

VariableBefore (N = 200)After (N = 182)
Gender (n, %)
  Male85 (42.5)83 (45.6)
  Female115 (57.5)99 (54.4)
Mean age (SD, range)48.02 (15.59) (20 to 92)47.24 (15.37) (20 to 84)

Participants' Descriptive Variables Before and After the Practice Change

Variablen (%)
Before (N = 200)After (N = 182)
Screened for depression
  Yes0 (0)182 (100)
  No200 (100)0 (0)
Diagnosed with depression
  Yes0 (0)75 (41.2)
  No200 (100)107 (58.8)
Insurance type
  None1 (0.5)1 (0.5)
  Preferred Provider Organization84 (42)72 (39.6)
  Health Maintenance Organization54 (27)40 (22)
  Medicare33 (16.5)23 (12.6)
  Medicaid24 (12)12 (6.6)
  Other1 (0.5)19 (10.4)
  Combination3 (1.5)15 (8.2)
Location setting
  Urban100 (50)95 (47.8)
  Suburban100 (50)87 (52.2)

Participants' Depression Level and Treatment After the Practice Change (N = 182)

Variablen (%)
Depression level
  None to minimal107 (58.8)
  Mild37 (20.3)
  Moderate24 (13.2)
  Moderately severe10 (5.5)
  Severe4 (2.2)
Treatment
  None110 (60.4)
  Monitoring33 (18.1)
  Medication12 (6.6)
  Counseling6 (3.3)
  Referral3 (1.6)
  Combination18 (9.9)

Analysis of Variance of PHQ-9 Total Score and Treatment Type (N = 182)

VariablePHQ-9 Mean Total ScoreFp Value
Treatment type81.778<0.001
  None1.30
  Monitoring6.88
  Medication12.33
  Counseling10.33
  Referral10.50
  Combination16.39
Authors

Dr. Randle is Graduate, Dr. Spurlock is Professor and DNP Coordinator, and Dr. Kelley is Assistant Professor, Troy University, Troy, Alabama.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to April Chisley Randle, DNP, FNP-BC, 609 Castlewoods Boulevard, Brandon, MS 39047; e-mail: april.randle@ymail.com.

Received: December 03, 2018
Accepted: May 09, 2019
Posted Online: July 15, 2019

10.3928/02793695-20190610-01

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