Universal Mental Health Screening in Primary Care Closes Care Gaps

Primary care clinics can effectively close the care gap for depression assessments by employing universal mental health screenings, according to researchers from the University of California San Francisco Health.

The data, published in JAMA Network Open, showed that universal depression screening—or screening that happens during every primary care encounter—closed care gaps almost entirely. Particularly, screening rates increased from around 40 percent in 2017 to nearly 90 percent by 2019.

These findings come as the US healthcare system works to get a handle on its mental health crisis. Depression is the second-leading cause of disability, a problem only made worse by the COVID-19 pandemic. And although depression is extremely treatable, those treatments only come if the patient is screened and referred to treatment, and mental health screenings have been woefully low for a while.

Primary care is a key setting for mental healthcare, the UCSF researchers said. Around 60 percent of patients receive depression care in primary care settings and 79 percent of all antidepressants are written by folks who do not work in mental healthcare.

By extension, primary care is also a good place to administer mental health screening, the researchers found. In an assessment of nearly 53,000 adults receiving primary care in one of six settings in a California health system, the researchers found that universal mental health screening was able to almost entirely close care gaps and reduce health disparities.

Universal mental health screening essentially meant that all patients would complete the screening during their primary care appointments. Primary care providers were to exclude folks who already had a baseline diagnosis of depression, bipolar disorder, schizophrenia, schizoaffective disorder, or dementia.

The program was a success, the researchers concluded, with overall screening rates increasing from 40.5 percent in 2017 to 88.8 percent by 2019. That progress was in part fueled by a statewide push for quality improvement metrics in California federally qualified health centers (FQHCs), meaning the clinics had the resources necessary to broadly implement universal mental health screening.

Particularly, clinics were able to employ multilingual screening administrators or offer the screenings in multiple languages. The health system also had the resources to convene experts from each of the six clinics at which the universal mental health screening was rolled out, meaning system leaders had access to granular insights into the disparities affecting mental health screening.

Ultimately, those insights allowed the UCSF to chip away at mental health screening disparities seen across age, race, and language preference.

Prior to the universal screenings, surveys were completed more often by younger patients who spoke English. But by study’s end, those disparities got smaller for older adults, folks with limited English proficiency (LEP), and Black and Hispanic people.

Gender-based health disparities remained, the researchers noted, with 87 men being screened for every 100 women.

Even still, these results are promising for a healthcare industry focused on addressing mental health. During the COVID-19 pandemic, mental health and challenges like social isolation got worse.

Having an effective strategy to make sure everyone completes a mental health screening will be essential for referral and treatment, according to Maria E. Garcia, MD, MPH, MAS, the study’s first author.

“Our study is the largest since 2016, when the U.S. Preventive Services Task Force recommended that adult patients be screened for depression, and the first to investigate patient predictors of screening,” Garcia, who is also professor in the UCSF Division of General Internal Medicine and the Department of Epidemiology and Biostatistics, said in a statement.

“Because depression impacts so many other chronic diseases, implementation of routine depression screening could also improve patient outcomes for complications from other conditions,” Garcia added.

That said, it will be key for primary care providers to close the loop on that screening. Referral to mental healthcare providers and access to medication are essential to addressing the mental health crisis the US faces, Garcia noted.

“Depression screening is necessary, but not sufficient, to decrease care disparities,” she concluded. “Screening may help with poor physician recognition of depressive symptoms, but it must be followed by clinical action.”