Martha S. Gerrity, MD, PhD Steven A. Cole, MD Allen J. Dietrich, MD James E. Barrett, MD Portland, Oregon; New Hyde Park, New York; and Hanover, New Hampshire Submitted, revised, September 9, 1999. From the Department of Medicine, Oregon Health Sciences University and the Portland Veterans Administration Medical Center, Portland (M.S.G.); the Department of Psychiatry, Long Island Jewish Medical Center and Care Management Group of Greater New York, Inc, New Hyde Park (S.A.C.); and the departments of Community and Family Medicine, Dartmouth Medical School, Hanover (A.J.D., J.E.B.). Reprint requests should be addressed to Martha S. Gerrity, MD, PhD, Department of Medicine, OP30, Oregon Health Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR 97201. E-mail: gerritym@OHSU.edu
References
BACKGROUND: Many patients who visit primary care physicians suffer from depression, but physicians may miss the diagnosis or undertreat these patients. Improving physicians’ communication skills pertaining to diagnosing and managing depression may lead to better outcomes.
METHODS: We performed a randomized controlled trial involving 49 primary care physicians to determine the effect of the Depression Education Program on their knowledge of depression and their behavior toward depressed patients. After randomization, physicians in the intervention group completed the Depression Education Program, which consists of 24-hour interactive workshops that combine lectures, discussion, audiotape review, and role-playing. Between sessions, physicians audiotaped an interview with one of their patients.
RESULTS: For both standardized patients, more intervention physicians than control physicians asked about stresses at home, and they also scored higher on the Participatory Decision-Making scale. During the office visits of one of the standardized patients, more intervention physicians asked about at least 5 criteria for major depression (82% and 38%, P = .006), discussed the possibility of depression (96% and 65%, P = .049), scheduled a return visit within 2 weeks (67% and 33%, P = .004), and scored higher than control physicians on the Patient Satisfaction scale (40.3 and 35.5, P = .014).
CONCLUSIONS: The Depression Education Program changed physicians’ behavior and may be an important component in the efforts to improve the care of depressed patients.
Depression is a common illness that has a significant impact on patients and society. The World Health Organization estimated that depression is responsible for approximately 25% of all visits to health care centers worldwide.1 In primary care practices, 5% to 10% of adult patients suffer from major depression.2,3 Depressed patients have increased disability, health care utilization, and mortality rates, as well as reduced quality of life and productivity.3-10 Although many individuals with depression want help from primary care physicians,11-13 these physicians may fail to recognize depression or may undertreat it when recognized.14-17
A variety of interventions has been developed to improve the diagnosis and management of depression by primary care physicians.18-20 A recent systematic review of the literature20 identified 7 well-designed studies with physicians’ behaviors (eg, diagnosis of depression, antidepressant prescription) or patient outcomes as end points.21-32 These studies included the evaluation of providing patients’ scores on depression screening instruments to physicians;21,22 psychiatric consultation before and during the primary care physician visit (ie, collaborative care);23 20 hours of lecture and videos;27-30 academic detailing visits;31 and multiple interventions, including didactic sessions with physicians.24-26,32 Many of these interventions in these studies would be difficult to implement in most primary care settings, and none focused on changing physicians’ communication skills as a means to alter their behavior toward depressed patients.
Physicians’ communication skills may be a critical component of improving the care of depressed patients. Physicians who ask about psychosocial issues, use open-ended questions, and allow more time for the patient to talk are more likely to recognize depression.33-35 In a recent national survey of primary care physicians, 30% to 50% of physicians reported that patients’ reluctance to accept the diagnosis, begin treatment with medications, or accept referral to a mental health specialist were major barriers to their care of patients with depression.36 Overcoming patient reluctance and negotiating an appropriate treatment plan require good communication skills. Finally, studies have demonstrated that improving physicians’ communication skills lessens patients’ emotional distress and improves health outcomes.37-40
The Depression Education Program was developed to fill the gap in current interventions by focusing on primary care physicians’ knowledge of depression and the communication skills they use with patients with the disease. The primary objective of our study was to determine to what extent the Depression Education Program would improve physicians’ knowledge and behaviors toward patients with depression, including their assessment of psychosocial stressors and criteria for major depression,41 discussions of depression, and scheduling of return visits within 2 weeks.
Methods
Study Design and Sample
We used mailing lists from the state medical society to obtain names and addresses and sent recruitment letters to all primary care physicians in Portland, Oregon. Of the 166 physicians who responded, 56 (34%) met inclusion criteria and gave informed consent. Inclusion criteria were: practicing primary care exclusively, practicing at least 50% of the time, able to attend both sessions of the workshop, practice open to new patients, and agreement to see 2 standardized patients in the office.
Physicians were stratified by sex, then randomly assigned to the intervention group (n = 27) or the control group (n = 29). We stratified by sex because men and women vary in their communication and practice styles.42-46 After randomization, 7 physicians (4 intervention and 3 control) withdrew from the study because of scheduling conflicts (2), unwillingness to participate (2), serious illness (1), a practice that would not allow standardized patients (1), and an obstetricsgynecology primary specialty (1). All 49 participating physicians completed a preintervention questionnaire; then physicians in the intervention group participated in the Depression Education Program.
