Comorbid Chronic Illness and the Diagnosis and Treatment of Depression in Safety Net Primary Care Settings

Chizobam Ani; Mohsen Bazargan; David Hindman; Douglas Bell; Michael Rodriguez; Richard S. Baker

doi:10.3122/jabfm.2009.02.080035

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Table 1.

Characteristics of the Study Sample (n = 315)

Variables	Frequency (n [%])
Gender
Male	72 (22.9)
Female	243 (77.1)
Age (years)
18–44	94 (29.8)
45–54	104 (33.0)
≥55	117 (37.1)
Mean age (SD)	49.85 (10.80)
Ethnicity
Latino/Hispanic	192 (61.0)
Black/African-American	71 (22.5)
Other^*	52 (16.5)
Health insurance status
No health insurance coverage	160 (50.7)
Some source of health insurance	155 (49.3)
Medical visits during past 12 months (n)
1	177 (56.2)
2–3	58 (18.4)
≥4	80 (25.4)
Depression and chronic physical conditions
Depression no chronic physical condition (CCI score = 0)	86 (27.3)
Depression and chronic physical condition (moderate CCI score = 1–2)	106 (33.7)
Depression and chronic physical Condition (severe CCI score ≥3)	123 (39.0)
Depression severity
Moderate	103 (32.7)
Moderately severe	131 (41.6)
Severe	81 (25.7)
Physician depression diagnosis
Not diagnosed	207 (67.4)
Diagnosed	100 (32.6)
Depression treatment^‡
Non–guideline-concordant	212 (67.3)
Guideline-Concordant	103 (32.7)^†
Depression follow-up care^‡
Non–guideline-concordant	236 (83.7)
Guideline concordant	46 (16.3)

↵* “Others” here refer to whites, Asian-Americans, and all other ethnicities.
↵† Included 3 patients without a documented diagnosis of depression.
↵‡ Among all participants regardless of diagnosis status.
CCI, Charlson Comorbidity Index.

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Table 2.

Bivariate Analysis Outcome and Independent Variable in Patients with Depression with No Chronic Physical Condition Vs Patients with Moderate Charlson Comorbidity Index (CCI) Score of 1 to 2 and Depression Vs Patients with a Severe Charlson Comorbidity Index Score of ≥3 and Depression

Variables	Depression with No Chronic Condition (n [%])	Depression with Chronic Condition(s)^* (n [%])	Depression with Chronic Condition(s)^† (n [%])	χ² (P)
Physician depression diagnosis				0.130 (.937)
Not diagnosed	60 (27.9)	72 (33.5)	83 (38.6)
Diagnosed	26 (26.0)	34 (34.0)	40 (40.0)
Depression treatment				2.194 (.334)
Non-guideline concordant	25 (25.0)	30 (30.0)	45 (45.0)
Guideline concordant	61 (28.4)	76 (35.3)	78 (36.3)
Depression follow-up care				3.577 (.167)
Non-guideline concordant	54 (22.9)	88 (37.3)	94 (39.8)
Guideline concordant	15 (32.6)	11 (23.9)	20 (43.5)
Depression everity				2.562 (.634)
Moderate	33 (32.0)	34 (33.0)	36 (35.0)
Moderately severe	31 (23.7)	47 (35.9)	53 (40.5)
Severe	22 (27.2)	25 (30.9)	34 (42.0)
Medical visits during past 12 months (n)				7.239 (.124)
1	58 (32.8)	58 (32.8)	61 (34.5)
2–3	13 (12.4)	21 (36.2)	24 (41.4)
≥4	15 (18.8)	27 (33.8)	38 (47.5)
Age (years)				102.852^‡ (<.001)
18–44	44 (46.8)	41 (43.6)	9 (9.6)
45–54	25 (24.0)	50 (48.1)	29 (27.9)
≥55	17 (14.5)	15 (12.8)	85 (72.6)
Ethnicity				14.368^§ (.006)
Latino/Hispanic	45 (23.4)	66 (34.4)	81 (42.2)
Black/African-American	16 (22.5)	25 (35.2)	50 (42.3)
Other	25 (48.1)	15 (28.8)	12 (23.1)
Gender				0.646 (.724)
Male	19 (26.4)	27 (37.5)	26 (36.1)
Female	67 (27.6)	79 (32.5)	97 (39.9)

↵* Moderate CCI score = 1–2.
↵† Severe CCI score = ≥3.
↵‡ P <.050 is significant.
↵§ P <.001 is significant.

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Table 3.

Bivariate Analysis Outcome and Independent Variable in Patents with Depression with No Chronic Physical Condition vs Paitents with Chronic Physical Conditions (Charlson Comorbidity Index score ≥1) with Depression

Variables	Depression with No Chronic Condition (n [%])	Depression with Chronic Condition(s)^* (n [%])	χ² (P)
Physician dpression dagnosis			0.125 (.724)
Not dagnosed	60 (69.8)	155 (67.7)
Diagnosed	26 (30.2)	74 (32.3)
Deression treatment			0.391 (.532)
Non-guideline concordant	61 (70.9)	154 (67.2)
Guideline concordant	25 (29.1)	75 (32.8)
Depression follow-up care			1.971 (.160)
Non-guideline concordant	54 (78.3)	182 (85.4)
Guideline concordant	15 (21.7)	31 (14.6)
Depression severity			2.039 (.361)
Moderate	33 (38.4)	70 (30.6)
Moderately severe	31 (36.0)	100 (43.7)
Severe	22 (25.6)	59 (25.8)
Medical visits during past 12 months (n)			6.311 (.043)^†
1	58 (67.4)	119 (52.0)
2–3	13 (15.1)	45 (19.7)
≥4	15 (17.4)	65 (28.4)
Age (years)			28.195 (<.001)^‡
18–44	44 (51.2)	50 (21.8)
45–54	25 (29.1)	79 (34.5)
≥55	17 (19.8)	100 (43.7)
Ethnicity			13.56 (.001)^†
Latino/Hispanic	45 (53.3)	147 (64.2)
Black/African-American	16 (18.6)	55 (24.0)
Other	25 (29.1)	27 (11.8)
Gender			0.039 (.843)
Male	19 (22.1)	53 (23.1)
Female	67 (77.9)	176 (22.9)

↵* Charlson Comorbidity Index score ≥1.
↵† P <.050 is significant.
↵‡ P <.001 is significant.

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Table 4.

Binary Logistic Regression: Physician Depression Diagnosis vs Independent Variables

Variables	P^*	Unadjusted OR (95% CI)	P^†	Adjusted OR (95% CI)
Chronic medical condition
No chronic medical condition; depression only (Ref)	N/A	1.00 (–)	N/A	1.00 (–)
Depression with moderate CCI score of 1–2	.784	1.09 (0.59–2.02)	.48	1.26 (0.66–2.45)
Depression with severe CCI score of ≥3	.726	1.11 (0.61–2.02)	.24	1.56 (0.74–3.31)
Depression severity
Moderate (Ref)	N/A	1.00 (–)	N/A	1.00 (–)
Moderately severe	.44	1.26 (0.70–2.25)	.492	1.23 (0.68–2.22)
Severe	.01	2.25^* (1.21–4.21)	.02	2.10^* (1.11–3.98)
Medical visits during past 12 months (n)
1 (Ref)	N/A	1.00 (–)	N/A	1.00 (–)
2–3	.99	1.01 (0.53–1.88)	.90	0.98 (0.51–1.89)
≥4	.52	0.83 (0.47–1.47)	.47	0.82 (0.42–1.48)
Age (years)
18–44 (Ref)	N/A	1.00 (–)	N/A	1.00 (–)
45–54	.52	1.21 (0.68–2.16)	.44	0.78 (0.41–1.47)
≥55	.77	1.09 (0.62–1.93)	.23	0.63 (0.3–1.34)
Gender
Male (Ref)	N/A	1.00 (–)	N/A	1.00 (–)
Female	.16	1.53 (0.84–2.77)	.22	1.465 (0.793–2.706)
Ethnicity
Latino/Hispanic (Ref)	N/A	1.00 (–)	N/A	1.000 (–)
African-American	.22	0.67 (0.36–1.26)	.47	0.79 (0.42–1.49)
Non–African-American and Others)	.11	0.54 (0.25–1.16)	.16	1.65 (0.83–3.29)
−2 likelihood of final model = 380.6
Nagelkerke R₂ = 0.057

↵* P <.050 is significant.
↵† P <.001 is significant.
OR, odds ratio; CCI, Charlson Comorbidity Index; Ref, reference category.

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Table 5.

Binary Logistic Regression: Guideline-Concordant Depression Care Vs Independent Variables^*

Variables	P^†	Unadjusted OR (95% CI)	P^‡	Adjusted OR (95% CI)
Chronic medical condition
No chronic medical condition; depression only (Ref)	N/A	1.00 (–)	N/A	1.000 (–)
Depression with moderate CCI score of 1–2	.26	0.50 (0.15–1.67)	.56	0.65 (0.16–2.73)
Depression with severe CCI score of ≥3	.59	0.71 (0.21–2.40)	.41	0.54 (0.13–2.32)
Depression Severity
Moderate (Ref)	N/A	1.00 (–)	N/A	1.00 (–)
Moderately severe	.17	0.41 (0.12–1.45)	.13	0.34 (0.08–1.36)
Severe	.23	0.46 (0.13–1.66)	.18	0.38 (0.09–1.57)
Total Number of Medical visits in past 12 months
1 (Ref)	N/A	1.00 (–)	N/A	1.00 (–)
2–3	.26	0.50 (0.15–1.67)	.33	1.99 (0.50–7.85)
≥4	.59	0.71 (0.21–2.40)	.96	0.97 (0.298–3.18)
Age (years)
18–44 (Ref)	N/A	1.00 (–)	N/A	1.00 (–)
45–54	.93	1.05 (0.37–3.00)	.90	0.93 (0.29–2.95)
≥55	.18	2.20 (0.69–6.97)	.26	2.36 (0.53–10.58)
Gender
Male (Ref)	N/A	1.00 (–)	N/A	1.00 (–)
Female	.17	2.11 (0.72–6.20)	.10	2.82 (0.82–9.75)
Ethnicity
Latino/Hispanic (Ref)	N/A	1.00 (–)	N/A	1.00 (–)
African-American	.79	0.87 (0.28–2.62)	.78	0.83 (0.23–3.04)
Non–African-American and Others	.21	2.37 (0.62–9.11)	.42	1.82 (0.43–7.83)
−2 log likelihood of final model = 0.146
Nagelkerke R₂ = 104.1

↵* Participants with a physician diagnosis of depression = 100.
↵† P <.050 is significant.
↵‡ P <.001 is significant.
OR, odds ratio; Ref, reference category; CCI, Charlson Comorbidity Index.

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Table 6.

Binary Logistic Regression: Guideline-Concordant Depression Follow-up Care vs Independent Variables^*

Variables	P^†	Unadjusted OR (95% CI)	P^‡	Adjusted OR (95% CI)
Chronic medical condition
No chronic medical condition; depression only (Ref)	N/A	1.00 (–)	N/A	1.00 (–)
Depression with chronic conditions (CCI score ≥1)	.16	0.41 (0.12–1.14)	.15	0.29 (0.06–1.49)
Depression severity
Moderate (Ref)	N/A	1.00 (–)	N/A	1.00 (–)
Moderately severe	.01	0.14^* (0.03–0.60)	.01	0.11^* (0.02–0.55)
Severe	.01	0.50^* (0.01–0.42)	.01	0.04^* (0.01–0.41)
Age (years)
18–44 (Ref)	N/A	1.00 (–)	N/A	1.00 (–)
45–54	.34	0.43 (0.08–2.43)	.46	0.44 (0.05–3.90)
≥55	.78	1.20 (0.33–4.41)	.48	1.90 (0.31–10.93)
Gender
Male (Ref)	N/A	1.00 (–)	N/A	1.00 (–)
Female	.23	0.44 (0.12–1.66)	.56	0.60 (0.11–3.31)
Ethnicity
Latino/Hispanic (Ref)	N/A	1.00 (–)	N/A	1.00 (–)
African-American	.11	2.92 (0.79–10.81)	.35	2.22 (0.42–11.77)
Non–African-American and Others	.39	0.39 (0.05–3.39)	.15	0.16 (0.01–1.90)
−2 log likelihood of final model = 51.0
Nagelkerke R₂ = 0.411