Importance of Social Determinants in Screening for Depression

Abstract

Importance The most common screening tool for depression is the Patient Health Questionnaire-9 (PHQ-9). Despite extensive research on the clinical and behavioral implications of the PHQ-9, data are limited on the relationship between PHQ-9 scores and social determinants of health and disease. Objective To assess the relationship between the PHQ-9 at intake and other measurements intended to assess social determinants of health. Design, Setting, and Participants Cross-sectional analyses of 2502 participants from the Baseline Health Study (BHS), a prospective cohort of adults selected to represent major demographic groups in the US; participants underwent deep phenotyping on demographic, socioeconomic, clinical, laboratory, functional, and imaging findings. Interventions None. Main Outcomes and Measures Cross-sectional measures of clinical and socioeconomic status (SES). Results In addition to a host of clinical and biological factors, higher PHQ-9 scores were associated with female sex, younger participants, people of color, and Hispanic ethnicity. Multiple measures of low SES, including less education, being unmarried, not currently working, and lack of insurance, were also associated with higher PHQ-9 scores across the entire spectrum of PHQ-9 scores. A summative score of SES, which was the 6th most predictive factor, was associated with higher PHQ-9 score after adjusting for 150 clinical, lab testing, and symptomatic characteristics. Conclusions and Relevance Our findings underscore that depression should be considered a comorbidity when social determinants of health are addressed, and both elements should be considered when designing appropriate interventions.

Association of Depression With 10-Year and Lifetime Cardiovascular Disease Risk Among US Adults, National Health and Nutrition Examination Survey, 2005–2018

“…More broadly, depression is a general CVD risk marker because it predicts pathologically diverse CVD subtypes ( 34 ) and is robust to adjustment for many traditional CVD risk factors ( 4 , 5 ). Beyond traditional risk factors, social determinants of health are strongly predictive of depression ( 35 ) and CVD ( 36 ) and may represent an important “upstream” cause of both conditions.…”

Biological and clinical correlates of the patient health questionnaire-9: exploratory cross-sectional analyses of the baseline health study

“…Our study reinforces previous observations regarding the relationship between PHQ-9 and measures of chronic disease and poor physical performance in addition to the critical importance of social factors and psychological distress, previously published. 12 While these findings are not surprising, they highlight how PHQ-9 is an entree into a variety of individual-level and population-level concerns that demand more attention. Contextual awareness is critically important when the PHQ-9 is used in clinical practice 18 as recommended by the USA Preventive Services Task Force 19 for screening within a health system or for public health assessment.…”

“…The Baseline Health Study BHS methods have been previously described, [11][12][13] including entry and exclusion criteria, the institutional review board and participant consent procedures, the data collection scheme and key components of study procedures.…”

“…Additional details of the effects of social determinants on health in the BHS study have been previously reported. 12 BHS is enrolling a large number of participants, beginning with intensive measurement of the first 2502 people (the deeply phenotyped cohort) in whom a large volume of multimodal data are collected. Four clinical BHS sites in the USA have begun enrolment.…”

“…The statistical methods used in this manuscript have been described previously. 12 Distributional measures; medians and 25th, 75th percentiles for continuous variables; and counts and percentages for categorical variables were computed and summarised across each of 5 PHQ-9 severity groups 6 (0, 1–4, 5–9, 10–14, >14), divided by convention to be consistent with prior studies. The Cochran-Armitage trend test for binomial variables, 13 14 and the Spearman rank correlation test for continuous variables 15 or categorical variables that are ordinal in nature (eg, education and income), were used to test for linear trend across severity group.…”