Public Outreach Depression Screening: collaboration between medical education and integrative primary care.

To the Editor: Depression in the primary care setting is often under-treated and under-recognized, especially within the public health sector. Because depression is associated with medical illness, poverty, and minority status, a group of Tulane medical students recognized the need for a public health depression-screening program in New Orleans. With the help of the Louisiana State Department of Mental Health, we, the authors, designed, implemented and managed a barrier-sensitive depression-screening program in an inner-city public health clinic. Primary care physicians already serving this community offered antidepressant medication and third year Tulane students offered supervised supportive psychotherapy to patients whose scores on the Beck Depression Inventory II (BDI-II) indicated evidence of depression. BDI-II scores range from 0 (not depressed) to 63 (severely depressed) with a score of 14 indicating mild depression. Our Public Outreach Depression Screening (PODS) program embodied educational opportunities for medical students, primary care physicians and clinic staff, in addition to clinical services tailored to the needs of depressed patients.

Before participation inpatient screening, volunteer first- and second-year medical students completed a training program that addressed the prevalence, impact, signs, symptoms and treatment of depression, as well as techniques for orally administering the 21-item BDI-II and a supplemental questionnaire. Physicians providing care in the clinic received additional CME training on aspects of depression. Physicians gave qualifying patients the option of psychopharmacotherapy and supportive psychotherapy, both free of charge. Tulane's Institutional Review Board approved the study protocol proposed by the program's leadership. Patient consent for participation in the study, which included follow up, was obtained after screening, which was also voluntary. Data were collected over an 18-month period.

Data were analyzed using SPSS version 11.5 (SPSS, Inc., 2002). (1) Pearson [chi square] tests were used to examine relationships between outcome groups (depressed and nondepressed, adherent and nonadherent) and gender, ethnicity, public assistance and employment. Independent sample t tests were used to compare outcome groups on variables that were measured on a continuous scale. Inferences were made at 0.05 level of significance.

Of the 238 patients screened (80% female, 95% African-American, 44% unemployed, 35.5% on public assistance, and mean age 37.5), 65 were evaluated as clinically depressed (27.3%). Depressed patients were more likely to be female, unemployed and on public assistance. They had fewer friends as social support. Twelve patients were referred to psychiatrists because of severe depression or other mental or physical uncontrolled comorbidities. Of the 53 patients offered treatment, 40 (75.5%) accepted antidepressant medication and/or supportive psychotherapy. Of the 34 patients available for follow up, 24 (71.0%) were re-assessed an average of 8.3 months after the initial evaluation. Nineteen of

the 24 patients took antidepressant medications alone; four chose both forms of treatment; and one received psychotherapy alone. Nine of the 24 re-assessed patients (37.5%) reported full adherence with medications and/or attendance at psychotherapy sessions. The average BDI-II score of the 24 patients decreased by 10 points from their initial screening. For the nine fully adherent patients, the mean decrease was 17.9 points.

The rate of depression among patients in this study (27.3%) is roughly three times the national average and 50% higher than the prevalence of depression among primary care patients identified in earlier studies (18.0%). (2) The results are consistent with prior studies that point to female gender, unemployment, the receipt of public assistance, a low education level and low social support as predisposing, precipitating and perpetuating factors for depression. (3) Among the many known factors affecting adherence in this population, difficulties in arranging follow-up assessments to monitor patient progress probably contributed to the low adherence rate of our follow-up patients (38%), which compares unfavorably to the NIMH collaborative treatment of depression study rate of 68%. (4)

Screening initiatives have been shown to increase the recognition of depression by a factor of 2 to 3. (5) Integrating mental healthcare into primary care settings is effective in detecting depression, and treating depression in a primary care setting can allow improved treatment acceptance. The development of effective strategies to improve patient monitoring, which in turn might improve treatment adherence, remains a challenge, however. The integration of screening and treatment for depression into this New Orleans public health clinic demonstrates significant potential for comprehensive care, treatment acceptance, and patient response. The unique involvement of medical students at various levels of the comprehensive care offered in this study accomplished important clinical exposure with credit in exchange for cost-free staffing.

Pooja Sukhwani, BA

Medical and Public Health Student

Tulane University School of Medicine 

New Orleans, LA

Rahul P. Prasankumar, BS

Fasih A. Hameed, BA

Kyle L. Widmer, BA

Medical Student

Tulane University School of Medicine

New Orleans, LA

Keith L. Winfrey, MD, MPH

Clinical Instructor, Department of Internal Medicine

Tulane University School of Medicine and Clinical Director,

St. Bernard Family Health Clinic

New Orleans, LA

Paul Rodenhauser, MD

Professor Emeritus of Psychiatry

Tulane University School of Medicine

References

1. SPSS, Inc. Statistical Package for Social Sciences. Release 11.5 ed. Chicago, IL, SPSS, 2002.

2. Schulberg HC, Saul M, McClelland M, et al. Assessing depression in primary medical and psychiatric practices. Arch Gen Psychiatry 1985;42:1164-1170.

3. Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289:3095-3105.

4. Krupnick JL, Sotsky SM, Simmens S, et al. The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. J Consulting & Clinical Psychology 1996;64:532-539.

5. Pignone MP, Gaynes BN, Rushton JL, et al. Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;136:765-776.