Leonard Egede explains why PHQ-9 screening belongs in every cardio-kidney-metabolic (CKM) syndrome risk assessment—and how community pharmacists can reach patients the formal system misses.
In an interview with Pharmacy Times, Leonard E. Egede, MD, MS, FACP, chair of the Department of Medicine at the University at Buffalo Jacobs School of Medicine and Biomedical Sciences, discussed the clinical implications of a JAMA Network Open study he authored examining how social risk factors drive advanced cardiovascular-kidney-metabolic (CKM) syndrome across different racial, ethnic, and sex subgroups.1
Egede explained that while social risk factors such as economic instability, food insecurity, and limited education each independently elevated the odds of advanced CKM syndrome, their associations varied considerably depending on a patient's demographic background—making subgroup-specific screening approaches essential. He emphasized that poverty and economic instability had the strongest associations among non-Hispanic Black and White adults, while food insecurity was most significant among non-Hispanic Black and other race and ethnicity populations.
One of the study's most clinically actionable findings, Egede noted, was that poor social or community context—measured through depressive symptoms via the Patient Health Questionnaire-9 (PHQ-9)—was the only social risk factor significantly associated with advanced CKM syndrome across all racial and ethnic groups, with odds ratios ranging from 1.40 in non-Hispanic Black adults to 1.72 among Hispanic adults. He argued this makes routine depression screening a universal priority in CKM syndrome risk assessment, not an optional add-on.1
Egede also addressed the counterintuitive finding that lacking health insurance appeared inversely associated with advanced CKM syndrome, cautioning that this almost certainly reflects underdiagnosis rather than protection. Uninsured individuals interact less with the health system and are less likely to have conditions detected and staged appropriately.
On reaching these underserved patients, Egede pointed to community pharmacies as a critical touchpoint. Pharmacist-led screening for hypertension, blood glucose, and kidney function at community health fairs, federally qualified health centers, and Women, Infants, and Children (WIC) clinics could surface undetected advanced CKM syndrome in populations currently invisible to the formal health system—without requiring insurance as a prerequisite for engagement.
Pharmacy Times: The study found that poor social or community context was the only social risk factor significantly associated with advanced CKM syndrome across all racial and ethnic groups. What explains that consistency when other risk factors varied so much by subgroup?
Leonard E. Egede, MD, MS, FACP: The consistency of poor social and community context measured through depressive symptoms likely reflects the fact that social isolation and psychological distress are not confined to any single socioeconomic or structural circumstance. Other social risks, such as economic instability or limited education, tend to cluster differently across racial and ethnic groups due to structural and historical inequities, which is why their associations with advanced CKM syndrome vary by subgroup. Poor social and/or community context, by contrast, was associated with greater odds of advanced CKM syndrome across all groups, with the highest odds among Hispanic adults (odds ratio, 1.72; 95% CI, 1.43–2.08), but with elevated risk also observed among non-Hispanic White, non-Hispanic Black, and other race and ethnicity groups.
Depressive symptoms, as a proxy for weakened social and emotional support, affect physiological stress pathways, treatment adherence, and health-seeking behavior regardless of race or ethnicity. This makes them a particularly universal amplifier of CKM syndrome risk. The study used the PHQ-9 to capture depressive symptoms as a proxy for social and emotional support challenges, and its consistent signal across all subgroups underscores the need to routinely screen for behavioral and emotional health as part of CKM syndrome risk assessment, not as an afterthought but as a core clinical priority.
Pharmacy Times: The unexpected inverse association between lacking health insurance and advanced CKM syndrome points to a real underdiagnosis problem. From a clinical standpoint, what’s the most practical way to reach uninsured patients who may have undetected advanced CKM syndrome?
Egede: The inverse association is striking but not surprising once you account for the underlying mechanism. Individuals without health insurance were typically younger and had a lower prevalence of diagnosed comorbidities such as cancer, chronic obstructive pulmonary disorder, and asthma. Because these individuals interact less frequently with the health system, they are less likely to have underlying conditions detected or classified as advanced CKM syndrome. This pattern may also reflect well-described phenomena such as the healthy worker effect or healthy immigrant effect, in which relatively healthier individuals are overrepresented among uninsured populations. In short, the data are almost certainly capturing underdiagnosis, not genuine protection.
From a practical standpoint, reaching these patients requires moving care outside traditional clinical settings. The study suggests that place-based strategies to improve neighborhood environments such as mobile health units may better serve non-Hispanic Black and other race populations, and this logic extends directly to the uninsured. Community pharmacies are particularly well-positioned here: they are accessible, trusted, and often the first point of health contact for uninsured individuals. Pharmacist-led screening for hypertension, blood glucose, and kidney function markers at no cost, integrated into community health fairs, federally qualified health centers, and WIC clinics, could surface undetected advanced CKM syndrome in populations currently invisible to the formal health system. The priority should be low-barrier, high-visibility touchpoints that do not require insurance as a prerequisite for engagement.
Pharmacy Times: What is the single most actionable takeaway for pharmacists and clinicians managing patients at risk for CKM syndrome progression day-to-day?
Egede: Screen for social risk and do it in a way that is subgroup-specific, not generic. The study highlights the clinical importance of incorporating routine social risk screening into the management of patients at risk for CKM syndrome progression, noting that identifying factors such as economic instability, poor neighborhood environment, limited education, and weak social or community support may help clinicians better stratify risk and connect patients to appropriate resources, including community health workers, social services, or behavioral health support.
For day-to-day practice, the most immediate implication is that a PHQ-9 or equivalent depression screen should be a standard component of CKM syndrome risk assessment for every patient, every time, because poor social and/or community context was the only social risk factor consistently associated with advanced CKM syndrome across all racial and ethnic groups and both sexes. Beyond that, clinicians should tailor which additional social risks they probe based on who is in front of them. Medical-financial navigation, including linkage to food or housing assistance, may be particularly impactful for non-Hispanic Black and White adults, given the association between economic instability and advanced CKM syndrome. The evidence is clear that a one-size-fits-all social risk tool will miss meaningful variation. Stratified, targeted screening is not a nice-to-have; it is what the data support.
