The Effect of Patient and Visit Characteristics on Diagnosis of Depression in Primary Care

,

Original Research

The Effect of Patient and Visit Characteristics on Diagnosis of Depression in Primary Care

J Fam Pract. 2001 December;50(12):1068

By

Jeffrey S. Harman, PhD

References

1. Unutzer J, Katon W, Sullivan M, Miranda J. Treating depressed older adults in primary care: narrowing the gap between efficacy and effectiveness. Milbank Q 1999;77:225-56.

2. Penninx W, Penninx H, Guralnik J, et al. Depressive symptoms and physical decline in community dwelling older persons. JAMA 1998;279:1720-26.

3. Penninx B, Geerlings S, Deeg D, van Eijk J, van Tilburg W, Beekman A. Minor and major depression and the risk of death in older persons. Arch Gen Psychiatry 1999;56:889-95.

4. Rovner B, German P, Brant L, Clark R, Burton L, Folstein M. Depression and mortality in nursing homes. JAMA 1991;265:993-96.

5. US Department of Health and Human Services. Mental health: a report of the surgeon general. Rockville, Md: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institutes of Mental Health.; 1999.

6. Kroenke K, Taylor-Vaisey A, Dietrich AJ, Oxman TE. Interventions to improve provider diagnosis and treatment of mental disorders in primary care: a critical review of the literature. Psychosomatics 2000;41:39-52.

7. Klinkman M, Coyne J, Gallo S, Schwenk T. False positives, false negatives, and the validity of the diagnosis of major depression in primary care. Arch Fam Med 1998;7:451-61.

8. Rost Kea. The deliberate misdiagnosis of major depression in primary care. Arch Fam Med 1994;3:333-37.

9. Eaton W, Anthony J, Gallo J, et al. National history of Diagnostic Interview Schedule/DSM-IV major depression: the Baltimore Epidemiologic Catchment Area Follow-up. Arch Gen Psychiatry 1997;54:993-99.

10. Williams JW, Rost K, Dietrich AJ, Ciotti MC, Zyzanski SJ, Cornell J. Primary care physicians’ approach to depressive disorders: effects of physician specialty and practice structure. Arch Fam Med 1999;8:58-67.

11. Caine E, Lyness J, King D, Connors L. Clinical and etiological heterogeneity of mood disorders in elderly patients. In: Schneider L, Reynolds C, Lebowitz B, Friedhoff A, eds. Diagnosis and treatment of depression in late life: results of the NIH Consensus Development Conference. Washington, DC: American Psychiatric Association; 1994;21-54.

12. Gallo J, Rabins P, Anthony J. Sadness in older persons: 13-year follow-up of a community sample in Baltimore, Maryland. Psychol Med 1999;29:341-50.

13. Gallo J, Royall D, Anthony J. Risk factors for the onset of major depression in middle age and late life. Soc Psychiatry Psych Epidemiol 1993;28:101-08.

14. Kessler R, McGonagle K, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994;51:8-19.

15. Gallo J, Cooper-Patrick L, Lesikar S. Depressive symptoms of whites and African Americans aged 60 years and older. J Gerontol: Psychol Sci 1998;53B:277-86.

16. Cooper-Patrick L, Gallo J, Gonzalez J, et al. Race, gender, and partnership in the patient-physician relationship. JAMA 1999;37:1034-45.

17. Rost K, Nutting P, Smith J, Coyne JC, Cooper-Patrick L, Rubenstein L. The role of competing demands in the treatment provided primary care patients with major depression. Arch Fam Med 2000;9:150-54.

18. Bryant E, Shimizu I. Sampling design, sampling variance, and estimation procedures for the National Ambulatory Medical Care Survey. Vital Health Stat 2 1988;108:1-39.

19. Woodwell DA. National Ambulatory Medical Care Survey: 1998 summary. Advance data from vital and health statistics. Hyattsville, Md: National Center for Health Statistics; 2000.

20. Potthoff R, Woodbury M, Manton K. ‘Equivalent sample size’ and ’equivalent degrees of freedom’ refinements for inference using survey weights under superpopulation models. J Am Stat Assoc 1992;87:383-96.

21. Leaf P, Myers J, McEvoy L. Procedures used in the epidemiologic catchment area study. In: Robins L, Regier D, eds. Psychiatric Disorders of America: The Epidemiologic Catchment Area Study. New York, NY: The Free Press; 1991.

22. Brown C, Shulberg HC. Diagnosis and treatment of depression in primary medical care practice: the application of research findings to clinical practice. J Clin Psychol 1998;54:303-14.

23. Olfson M, Shea S, Feder A, et al. Prevalence of anxiety, depression, and substance use disorders in an urban general medicine practice. Arch Fam Med 2000;9:876-83.

24. Sullivan M, Cole S, Gordon G, Hahn S, Kathol R. Psychiatric training in medicine residencies: current needs, practices and satisfaction. Gen Hosp Psychiatry 1996;18:95-101.

25. Solberg L, Korsen N, Oxman T, Fischer L, Bartels S. The need for a system in the care of depression. J Fam Pract 1999;48:973-79.

OBJECTIVES: The purpose of our study was to determine if factors other than the patient’s clinical presentation were associated with the likelihood of depression being recognized during a physician office visit.

STUDY DESIGN: We used a cross-sectional design.

POPULATION: Data from the 1997 and 1998 National Ambulatory Medical Care Surveys were examined.

OUTCOMES MEASURED: We assessed the association of factors such as age, sex, race, physician specialty, type of insurance, and visit duration with a recorded depression diagnosis during office visits to primary care physicians.

RESULTS: After controlling for symptom presentation, primary care physicians were 56% less likely to record a diagnosis of depression during visits made by elderly patients, 37% less likely to do so during visits by African Americans, and 35% less likely to do so during visits by Medicaid patients. Visits with a depression diagnosis were, on average, 2.9 minutes longer in duration (16.4 vs 19.3) than visits without a depression diagnosis. Family practice and general practice physicians were 65% more likely to record a diagnosis of depression than internists.

CONCLUSIONS: Many factors were associated with making and recording a depression diagnosis beyond the patient’s reported symptoms. If rates of diagnosis are to improve, interventions that go beyond getting physicians to recognize the symptoms of depression are needed.

KEY POINTS FOR CLINICIANS

Receipt of a recorded depression diagnosis during office visits to primary care physicians is dependent on patient age, race, and type of insurance.
Family practice and general practice physicians are more likely than internists to record a depression diagnosis during office visits.
Many factors beyond the patient’s reported symptoms are associated with making and recording a depression diagnosis.

Characteristics and Depression Diagnosis

Depression is a common disorder that significantly affects quality of life, functioning, and even mortality.^1-4 However, as indicated in the Surgeon General’s Report on Mental Health, depression remains under-recognized and underdiagnosed.⁵ Most studies examining recognition of depression have focused on the role of symptom presentation, the use of screening tools, and physician educational interventions designed to improve symptom recognition.⁶ However, factors other than clinical presentation may be associated with the likelihood that depression is recognized during a physician visit.^7,8 For example, patient age and race, type of insurance, and duration of the visit may increase or decrease the rate at which a depression diagnosis is recorded. Also, diagnostic rates may differ between family or general practice physicians and internists. If differences in diagnostic rates indeed occur because of extraclinical factors and current interventions continue to focus primarily on recognition of patients’ symptoms, certain patient groups will continue to be underdiagnosed and undertreated.

Given this concern about the range of factors possibly associated with receiving a depression diagnosis, we examined data from a nationally representative sample of office visits to physicians, the National Ambulatory Medical Care Survey. More specifically, we examined the independent role of factors such as age, sex, race, type of insurance, and duration of the visit on the probability that depression would be diagnosed during a patient’s visit to a primary care physician. Although the prevalence of depression is greater in women, there should not be a large difference in the likelihood that a depression diagnosis is recorded during an office visit after controlling for the patient’s reason for encounter. Similarly, if primary care physicians are recording diagnoses of depression based solely on the patient’s reasons for encounter, the likelihood that a depression diagnosis is recorded should be similar by age, even though there is a reported lower prevalence of major depression in elderly persons (minor depression is believed to occur more frequently in the elderly).⁹ Admittedly, however, some of the somatic symptoms associated with depression (eg, fatigue) are more likely to be due to a physical illness rather than depression in elderly patients. Thus, rates of diagnoses can should be slightly lower among elderly persons. However, because of primary care providers’ lack of confidence in assessing and diagnosing adults with depression^1,10 and the tendency for older persons to present depressive symptoms in terms of somatic complaints,^11,12 depression diagnoses are expected to be recorded much less frequently during visits by elderly persons, even after controlling for the patient’s reasons for the visit. Also, although African American patients have a lower reported prevalence and incidence rate of depression,^13,14 one would expect depression diagnoses to be recorded at rates similar to those for other races after controlling for patient presentation of symptoms. Nevertheless, cultural stereotypes among providers may lead to depression diagnoses being recorded less frequently during these visits.^15,16

With regard to practice factors affecting accurate diagnosis, since primary care physicians tend to schedule short patient visits and have many conditions to treat during those visits, we expected that the probability of a depression diagnosis being recorded would increase as the duration of the visit increased. Given competing demands for the physician’s awareness, depression often gets less attention during visits where the patient has a recent medical problem or even several of them.¹⁷ Finally, we expected family and general practice physicians to diagnose depression more often than internists. Family practice physicians express more responsibility for treating depression, tend to have more complete knowledge of available treatments, and are more confident in managing a mood disorder.¹⁰