Using a sample of participants who received care at an IBH facility, the present study examined which variables best predict patient’s experiences with depression, explored how discrimination is associated with depression, and examined how demographics (i.e., age, sex, race, and income) are connected to patients’ experience with depression. Overall, our findings suggest that there is a combination of variables that predict a patient’s experiences with depression. Specifically, those variables are anxiety, perceived stress, self-esteem, experiences with discrimination, and demographic variables, such as race, gender, and income level. In this study, patients’ depression levels increased when their levels of anxiety, perceived stress, and experiences with discrimination increased. We discuss the significance of these findings below.
In this study, White participants scored significantly higher than Black participants on measures of anxiety, depression, and perceived stress, whereas Black participants scored significantly higher on measures of self-esteem and experiences with discrimination. These findings are consistent with previous research 37–40. Our findings also confirm prior research showing that higher levels of depression are correlated significantly with higher levels of anxiety 41,42, higher levels of perceived stress 43–45, higher levels of discrimination 29,46,47, and lower levels of self-esteem 28,48,49. For IBH facilities, identifying contextual factors, such as a patient’s experience with discrimination, would help the provider know which factors are facilitators or barriers to health. Thus, it is important to know which contextual factors correlate with (and predict) levels of depression within IBH settings.
Depression and Anxiety
Our findings show that higher levels of anxiety were predictive of higher levels of depression. Research suggests that anxiety and depression are highly comorbid conditions (Kalin, 2020). At the bivariate level, it was also clear that there were racial differences in the presentation of depression, anxiety, and perceived stress. IBH providers, therefore, need to be aware of the nuances of how race and discrimination may play a role in the manifestation of anxiety and depression. Further, understanding mitigating factors such as self-esteem is important for identifying how to assess and intervene with depression and anxiety.
In IBH facilities, workflows are often employed to assess depression with the Patient Health Questionnaire (PHQ-9), but depression is often treated without identifying psychological states associated with the presence of depression. For example, though anxiety frequently co-occurs with depression, it is not always considered 50. In addition, differences in self-report and conceptualization of depression regarding race are rarely utilized while screening for depression in IBH settings. We suggest that IBH settings implement the PHQ-9 and the Generalized Anxiety Disorder (GAD-7) screening assessments, in addition to a screening assessment on race and the contextual dynamics that may contribute to the patients’ symptomatology. This whole-person approach could increase the quality of care provided by integrated healthcare teams.
Perceived Stress and Anxiety
Previous research shows that stress and depression are positively associated 51–53 and our findings confirm this. Health providers should understand that there may be differences in how stress is internalized depending on the race of the patient. Currently, there are no structured screening pathways in IBH that assess the presence of stress or stress-related incidents that may contribute to a patient’s symptomatology 5,26,43,53,54. Because IBH systems aim to understand and address contextual factors that impact the patient's quality of life 55–58, there is a need for more comprehensive tools that assess stress. More research is needed that examines which tools are best at not only assessing stress but also assessing racial dynamics that contribute to stress. We suggest that the 10-item perceived stress scale used in this study could be a viable instrument for IBH systems 27,59.
Discrimination and Depression
Discrimination contributes to an individual’s level of stress. Our findings indicate that higher levels of experiences with discrimination predicted higher levels of depression. Previous research shows that perceived discrimination is a greater predictor of levels of stress and depression for Black individuals compared to White individuals 14,26,37,60,61. By contrast, our study shows that the association between experiences with discrimination and depression was not moderated by race. Extant literature demonstrates Black individuals may internalize depressive symptoms more when compared to White identifying individuals 62–64. Thus, the differences between White and Black participants within the current study may speak to the weight of stigma and how this may create challenges for Black patients to self-report experiences of depression. Integrated care providers are the first line of treatment for health and mental health conditions. Being aware of the variance in how depression is self-reported is important for screening and assessing depressive symptoms for Black patients.
Further, this finding underscores the importance of identifying the connection between discrimination and health. Systematic methods of screening and treating discrimination as a facilitator of health are pivotal to ensuring the health of individuals and communities. Rather than manifesting as depression, discrimination may be internalized. Contextualizing assessment and screening for Black patients may be pivotal for acquiring accurate data regarding the influence of stress and discrimination on health. Nevertheless, there are currently no standard screening tools to assess experiences with discrimination in IBH settings 29,46,54,63,65,66. The Everyday Discrimination Scale is a valid, efficient screening tool that could be utilized within primary care settings. Future research should further examine the role that discrimination screening assessment tools play in enhancing the whole-person approach to treatment in IBH settings.
Study Limitations
Our findings add to the knowledge base on depression and IBH care. However, this study is not without limitations. Foremost, this study used a cross-sectional design, which restricts causal interpretations. Second, this study was conducted at one large IBH care facility, which precludes our ability to generalize broadly to other populations. Future research should sample multiple facilities to better understand the predictors of depression. Finally, we used widely accepted and validated measures in this study. However, there are several measures for anxiety, depression, and perceived stress. Thus, it could be that our findings may, in part, be influenced by the specific measures that we used. It is important to note that the measures used in this study all had good internal consistency reliability. Nevertheless, future studies could employ different measures of anxiety, depression, and perceived stress to corroborate this. Despite these limitations, our study yields novel information, thus adding to the literature base on this topic.