Discussion
depression, OUD, co-occurring mental health disorders, PTSD
DISORDERS
Overall, in-person screening identified a nearly three-fold higher proportion of patients (2.4%) with probable OUD and co-occurring mental health disorders compared to the EHR (0.8%). We also identified a higher proportion of each condition separately (OUD, depression, and PTSD) with the survey. To our knowledge the prevalence of OUD and co-occurring mental health disorders has not been quantified and compared using a universal screening approach in primary care clinics in other studies. It is not surprising that EHR data would underestimate these conditions as patients may not disclose symptoms or problems to providers in association with discomfort, poor help-seeking intention, trust, shame, or stigma [Our study also found large variability in treatment for OUD and co-occurring mental health disorders relative to probable diagnoses. In the universal screening sample, among those with probable OUD and co-occurring mental health disorders, almost half (46.2%) reported not receiving any treatment, and only one in five participants was receiving both medication and counseling for at least one of the conditions. Other studies have also shown low rates of treatment for OUD in PC clinics [Our results also show missed opportunities for universal screening of probable OUD and co-occurring mental health disorders in PC. Currently, the USPSTF recommends routine screening of adults for depression [This study has several potential limitations including the cross-sectional design and self-reported data obtained from universal screening. Recall and reporting bias can occur when assessing sensitive conditions, resulting in underestimation of the prevalence estimates. However, since the survey was anonymous this limitation may have been minimized. The consistency of our results showing significant differences in observed versus expected prevalence of disorders also suggests that reporting bias was low. Our sample is not likely to be representative of PC patient populations in other locations; it was limited to English and Spanish speaking patients at PC clinics in New Mexico, three of which were FQHCs. Strengths of the results include the relatively large number of patients accessed over the 2-week survey period and the use of validated screening instruments. While our research assistants reached approximately 45% of adults visiting the primary care clinics, we demonstrated acceptability of the screening questions via the high completion rate (93.9%). Assessing these conditions without anonymizing questions and providing results to the primary care provider has potential to be effective. The participating clinics in this study have a strong community presence and have a known positive, non-judgmental approach to substance use, substance use treatment, and mental health; qualities that could enhance self-reporting. One approach could be with self-administered screeners given to every patient at check-in on a regular basis. For example, the PHQ-9 is already administered to every patient at these study clinics on an annual basis.