With a priority to identify smokers with depression, this proof-of-concept study explores the feasibility, efficiency, precision, and equality of a planned implementation of universal screening for depressive symptoms within the ethnically diverse population of smokers seeking cessation services from CSH, and smokers seeking primary medical care services within a large network of family physicians.
Despite persistent tobacco control efforts, the prevalence of smoking among those reporting symptoms of depression has not declined in step with non-depressed smokers. US public health surveillance has generated critical documentation of the high concentration of tobacco users among depressed persons and lower rates of successful smoking cessation among smokers with depression. More than 30% of California residents with depression smoke cigarettes (1.15 million smokers). Smokers in California with depression are 2.5 times more likely to be current heavy smokers and are 50% less likely to have quit successfully than non-depressed smokers. It is unclear what mechanisms drive these differences. Smokers with depression report a similar desire to quit, similar rates of recent quit attempts, and similar rates of using quitting aids as non-depressed smokers. Public health efforts to decrease smoking in this high-risk population will require improved screening of depression within typical points of contact for cessation services. Once screening and identification of these high-risk smokers is improved then design and promotion of efficient clinical interventions targeting smokers with depression can proceed.
Improved screening for depression is critical given the potential for improved outcomes for depressed smokers receiving specialized cognitive behavioral treatment. Recent meta-analyses focusing on the comparative effectiveness of specialized behavioral cessation treatments for smokers with depression support a significant advantage of mood management interventions. This investigative team has completed a NIDA-funded behavioral therapy development project designed specifically to add mood management intervention components to the CSH protocol and a brief motivational intervention, with established efficacy, to engage depressed smokers in cessation treatments. While we are pursuing NIH funding to confirm results within fully powered trials, feasibility and effectiveness of universal screening for depression remain.
Challenges in universal screening dictate selection of brief and valid instruments that are feasible to administer to the high volume of smokers screened by CSH and primary care providers. Instruments need to provide sufficient precision to allocate valuable resources equitably to meet the needs of smokers with depression. The Patient Health Questionnaire (PHQ) for depression has been used widely in US and California epidemiological surveillance and is one of the most common clinical screening instruments for depression. Although the PHQ questions were developed empirically, have national and statewide representative norms, and support for diagnostic efficiency when validated against clinical and survey-based DSM-IV criteria-based diagnoses, it is critical that the psychometric characteristics of these screens be evaluated in practice given evidence that PHQ items perform differently across African American, Hispanic, and White subgroups. Contextual demands, clinical characteristics, and demographic concentrations of smokers seeking behavioral phone counseling or primary care services may further impact responses to PHQ items. Efforts to implement universal brief screening protocols will need to be informed by the psychometric characteristics, accuracy of selected thresholds for case identification. Potential biases in this instrument may suggest adjustments are needed when applied to smokers from diverse ethnic and cultural backgrounds seeking services from the CSH and primary care settings in California.