Limitations of the Study
The study included a small sample of patients in only one medical facility. The population in this area is not diverse and consists of 86.1% white patients as of 2016 in an area of above average income for the state of Texas.14 Results may differ in a low-income area with reduced access to healthy food, gym membership, and regular healthcare.
The project was conducted between early October and late December. This can be a more stressful time because of the holiday season and could have triggered more positive depression screenings than might occur at other times of the year.
Patients who were advised to follow up with their treating physician for re-evaluation of their depression therapy were not contacted to confirm follow-up. Patients who were referred to psychiatry or a nutritionist were not contacted to confirm follow-up and the outcome of the visit. A longer project duration could have facilitated more time for follow-up with patients and to repeat depression screenings.
Some of the findings from the project were not supported by previous studies. Research by Pratt and Brody found depression and obesity to be directly related.3 A trend in the data showed that patients who took the PHQ-9 had a higher BMI than those who screened negative for depression. However, the authors’ quality improvement project did not find a statistically significant relationship between BMI and a positive screening for depression in its study sample.
No major obstacles were encountered during project implementation. The PHQ-9 screening and discussion were time-consuming, but only 24.7% of participating patients required this additional screening. Having patients answer the questionnaire while in the waiting room or during triage could decrease some of the time necessary for the visit.
The potential negative outcomes for patients with obesity and undiagnosed depression make continuing this screening important. It is clear from this project that even patients with obesity who are currently on antidepressants have continued issues with depression that may be underreported and should be closely monitored. Adding a referral to a support group may help patients establish new coping strategies and improve stress management.15 Support groups may teach patients new skills to deter the overeating response to stressful emotions. In the authors’ project, 82.2% of the patients with obesity seen in the clinic were female. This is consistent with data from the National Institute of Diabetes and Digestive and Kidney Diseases in which obesity and extreme obesity were found to be higher in women than in men.16
Unintended consequences during the project implementation included patient complaints about unwanted advice and questions regarding weight. The approach to discussing weight loss and depression was modified to reduce negative feelings from the patient about the discussion. Patients were asked to participate in the project prior to questioning them about weight loss or depression, which eliminated patient complaints.
Three statistically significant findings were discovered during data analysis. First, results showed that 54.8% of patients in both PHQ-2 and PHQ-9 groups reported no history of depression. In contrast, 88.9% of patients who reported a history of depression screened positive for depression and were given the PHQ-9. The results suggest that patients with a history of depression are likely to have current/ongoing issues with depression.
Second, results show that 67.1% of patients in both PHQ groups were not already on antidepressants. However, 66.7% of the patients who were taking an antidepressant screened positive for depression (PHQ-9). Therefore, patients who were on antidepressants were more likely to screen positive for depression than those not on antidepressants.
Third, results showed that 93.2% of patients in both PHQ groups declined a psychiatry referral. However, 100% of the patients who agreed to the psychiatry referral screened positive for depression (PHQ-9). Most of the patients who did not agree to the psychiatry referral screened negative for depression (PHQ-2). Findings indicate that patients with depression were more likely to accept a referral to a psychiatrist than patients without depression.
As noted, no significant differences were found between sex, BMI, or age in those who screened negative for depression and those who screened positive for depression. No significant difference was found with acceptance of a nutritionist referral or likelihood to follow up for weight loss management between patients screening positive or negative for depression.
However, we noted a trend suggesting that patients with depression have a higher average BMI than those who do not have depression. In the authors’ project, patients with depression were more likely to return for weight loss management than those without depression. Trends also suggest that patients with depression are more likely to accept a referral to a nutritionist.