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.

Keywords: Patient Health Questionnaire-9; effective clinical intervention; measures of health and disease.

Fig. 1

Factors associated with PHQ-9 score in linear model. SES was in the top six predictors of PHQ-9 score, significantly predicting higher PHQ-9 after adjusting for demographics, behavior, medical conditions, symptoms, and physical function (p<0.001). LASSO, least absolute shrinkage and selection operator; PHQ-9, Patient Health Questionnaire-9; SES, socioeconomic status.

Fig. 2

Network depicting relationship of PHQ-9 and SES with selected variables. This figure demonstrates the relationships among PHQ-9, SES, and other key measures in a partial correlation network. The length of the edges is inversely proportional to the magnitude of the correlation, and hence, highly related nodes appear closer together, with thicker edges indicating stronger correlations. PHQ-9, Patient Health Questionnaire-9; SES, socioeconomic status.