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Pendo K, Knight J, Samuels M, Baig S, Stumbar S. Managing depression at a free clinic: a pilot study using a provider survey. HPHR. 2023;62. DOI: 10.54111/0001/JJJ12
Community-based free clinics face unique challenges in treating depression. This research letter presents initial findings from an exploratory, in-progress study aimed at understanding barriers to depression care at a free clinic in South Florida.
A survey was distributed to primary care providers at the clinic that assessed barriers to depression care and ways to mitigate them.
Nine of twelve providers responded. Providers felt confident using screening tools for depression but did not feel as confident about screening workflows. Providers felt more comfortable managing patients’ existing antidepressants versus prescribing new antidepressants. The most significant barriers providers faced in managing depression were (1) Patients’ social determinants of health, (2) Lack of outside referral options, and (3) Lack of in-house mental health resources. They indicated the most helpful improvement the clinic could make for depression services would be having an in-house social worker/licensed clinical therapist.
Initial findings show that providers at this free clinic are confident in their ability to screen and treat depression, but factors including unclear workflows, inconsistent patient follow-up, and lack of referral options make it challenging to manage depression in this setting.
Initial findings of this pilot study suggest that procedural and situational barriers, not provider knowledge or willingness, limit the treatment of depression in this free clinic. An ongoing second phase of this study is surveying clinic patients to understand patient-facing barriers to mental health care in this setting.
Community-based free clinics face unique challenges in treating depression due to limited resources and inconsistent continuity of care, among other reasons.1-5 This research letter presents initial findings from an exploratory, in-progress study aimed at understanding barriers to depression care at a free clinic in the underserved community of Miami Gardens, FL.
An anonymous survey of Likert-type and short-answer questions was emailed to the clinic’s primary care providers. The survey assessed providers’ knowledge and comfort with depression treatment, perceived needs regarding depression resources and clinic workflows, and barriers to depression treatment. Descriptive statistics consisting of basic demographic data and Likert averages were tabulated (1-Strongly Disagree to 5-Strongly Agree). IRB approval was obtained.
Nine of twelve (75%) providers completed the survey. Providers felt confident using the PHQ screening tools for depression (mean rating: 4.33/5), but they did not feel as confident locating these tools in the EMR (2.56/5) and did not have a clear understanding of the clinic’s screening workflow (2.44/5). Providers felt more comfortable managing patients’ existing antidepressants compared to starting patients on medication (4.22/5 and 3.39/5, respectively). Providers reported their most significant barriers to managing depression were (1) Patient’s social determinants of health (3.78/5), (2) Lack of external referral options for mental health care (3.44/5), and (3) Lack of in-house mental health resources (2.89/5). They indicated an in-house social worker/licensed clinical therapist would be the most helpful step for improving depression services (4.33/5).
Table 1: Depression Care at UHI
Question | Number of Responses | Mean Rating | ||||
Strongly Disagree (1) | Disagree (2) | Neither Agree nor Disagree (3) | Agree (4) | Strongly Agree (5) | ||
Depression is a significant issue for UHI’s patient population | 0 | 0 | 0 | 7 | 2 | 4.22 |
I feel confident screening adult patients for depression using the PHQ2/PHQ9 | 0 | 0 | 1 | 4 | 4 | 4.33 |
I feel confident interpreting the results of the PHQ2/PHQ9 | 0 | 0 | 1 | 4 | 4 | 4.33 |
I know where to locate the PHQ2/PHQ9 in the Athena EMR | 1 | 5 | 1 | 1 | 1 | 2.56 |
I have a clear understanding of the workflow we use at UHI for depression screening with the PHQ2/PHQ9 (from intake through the patient visit) | 1 | 6 | 0 | 1 | 1 | 2.44 |
I feel confident starting a patient on an antidepressant medication | 0 | 0 | 3 | 4 | 2 | 3.89 |
I feel confident managing an antidepressant medication for a patient who is already taking one | 0 | 0 | 1 | 5 | 3 | 4.22 |
I feel that depression is adequately addressed in most patients at UHI | 0 | 2 | 5 | 2 | 0 | 3.00 |
I feel that there is a need for more robust services to manage depression at UHI | 0 | 0 | 1 | 5 | 3 | 4.22 |
Table 2: Barriers to Depression Care at UHI
Question | Number of Responses | Mean Rating | ||||
Never a Barrier (1) | Rarely a Barrier (2) | Sometimes a Barrier (3) | Often a Barrier (4) | Always a Barrier (5) | ||
Lack of time during patient visits | 1 | 2 | 5 | 1 | 0 | 2.67 |
Language barriers | 1 | 2 | 4 | 2 | 0 | 2.78 |
Difficulty discussing depression due to different cultural beliefs about mental health | 1 | 2 | 6 | 0 | 0 | 2.56 |
My own confidence talking about depression with patients | 6 | 2 | 1 | 0 | 0 | 1.44 |
My own confidence prescribing medications to my patients for depression | 2 | 4 | 2 | 1 | 0 | 2.22 |
Lack of in-house mental health resources at UHI | 2 | 1 | 2 | 4 | 0 | 2.89 |
Lack of referral options for mental health care outside of UHI | 0 | 1 | 3 | 5 | 0 | 3.44 |
Patient’s social determinants of health (i.e., immigration status makes outside referrals difficult, affording medications, etc.) | 0 | 0 | 2 | 7 | 0 | 3.78 |
Table 3: Solutions to Improve Depression Services at UHI
Question | Number of Responses | Mean Rating | ||||
Not at all helpful (1) | Slightly helpful (2) | Somewhat helpful (3) | Very helpful (4) | Extremely Helpful (5) | ||
Additional training on management of depression including diagnosis and medications | 1 | 2 | 4 | 2 | 0 | 2.78 |
In-house social worker/licensed clinical therapist at UHI | 0 | 0 | 2 | 2 | 5 | 4.33 |
Improved clarity on psychiatry/therapy referral options and other work flows following a positive PHQ2/PHQ9 screening | 0 | 1 | 3 | 4 | 1 | 3.56 |
The initial findings from the first phase of this study suggest that the providers at this free clinic are confident in screening and treating depression. Still, procedural and situational challenges, such as unclear workflows and lack of referral options, make it hard for them to do so. Existing literature shows that despite the proven benefits of collaborative care models for mental health in the community setting, the majority of primary care settings in the US do not employ any dedicated behavioral health staff.6,7 Hiring an in-house social worker or clinical therapist may provide an effective way for free clinics to improve their depression services. This individual could help mitigate several of the clinic’s current challenges. Specific tasks for this employee could include streamlining screening, coordinating and tracking follow-up appointments, and aggregating referral options in the community. There are several limitations to these preliminary findings. First, challenges to depression care likely vary across different free clinics due to differences in staffing, location, and patient populations. Secondly, the sample size of this study is small. A more extensive study across multiple free clinics would enhance the generalizability of this data. Additionally, this survey did not elicit patients’ perspectives; an ongoing second phase of the study is doing just that.
Initial findings of this pilot study suggest that procedural and situational barriers, not provider knowledge or willingness, limit the treatment of depression in this free clinic. Staffing a social worker or therapist could improve depression care for patients. Ongoing data collection on patient-facing barriers to mental health care in this free clinic will provide additional insights into structural and process-related changes that may improve mental health care.
We would like to acknowledge the UHI Community Care Clinic for their tremendous support and cooperation throughout this project.
The author(s) have no relevant financial disclosures or conflicts of interest.
Kevin Pendo is a medical student at Florida International University Herbert Wertheim College of Medicine. His research interests include community mental health, neuroimaging, and body-focused repetitive behaviors. He received his bachelor’s degree in Neuroscience at Princeton University.
Dr. Jennifer Knight, MD. MPH, is a resident physician in Obstetrics & Gynecology at the University of Alabama. Her research areas include community mental health, gun violence, and medical education. She received her medical degree at Florida International University Herbert Wertheim College of Medicine and her MPH at Brown University.
Marquita Samuels, MBA, is coordinator and administrator in the Department of Humanities, Health, and Society at Florida International University Herbert Wertheim College of Medicine. Her research areas include medical education and narrative medicine.
Syeda Baig, BS, is a former program manager at the UHI Community Care Clinic. Her research areas include grant administration for underserved populations.
Dr. Sarah Stumbar, MD, MPH, is the Assistant Dean for Clinician Education and an Associate Professor at the Florida International University Herbert Wertheim College of Medicine. Her research areas include medical education, narrative medicine, and public health. She received her bachelor’s in History of Medicine from Yale University, her MPH from Columbia University, and her medical degree from Stony Brook University. She completed her training in Family Medicine at Montefiore Medical Center in the Bronx, NY.
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