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
Second, we used standardized patients instead of actual patients to assess physicians’ behaviors. We had 2 reasons for using this approach. First, we wanted to control for patient case-mix, the variability in depressed patients across practices. Standardized patients provided us with known and consistent patient presentations and consistent assessments of specific skills taught in the workshop.59-61 Second, we wanted to limit the complexity and cost of the study. Since this was the first step in evaluating the Depression Education Program, we wanted evidence that the program would have an effect on physicians’ behaviors before we asked busy practices to allow us to study patient outcomes.
Finally, the effect of the workshop was more apparent with the female patient than with the male patient. There may be several explanations for this difference. Physicians are more likely to diagnosis depression in women than men.46,64 More important, Boyd Kelly had a potentially life-threatening complaint (chest pain) and more medical problems than Louise Williams. Compared with control physicians, intervention physicians were more likely to schedule Mr. Kelly for a follow-up visit within 2 weeks (82% and 38%, respectively). Intervention physicians may have saved the full exploration of depressive symptoms and discussion of depression for the second visit. Scheduling a return visit within 2 weeks was one strategy suggested in the workshop for dealing with patients who are medically and psychosocially complex. This strategy also addressed the concerns some workshop participants had about discussing depression with a patient they had just met. However, we could not assess this explanation since our study design did not allow for return visits.
Conclusions
The Depression Education Program may be a useful intervention for improving the diagnosis and management of depressed patients in primary care practices. Although a variety of interventions have been evaluated previously, they did not include explicit goals related to improving physicians’ communication skills and educational strategies likely to change behavior. Further research is needed to determine the impact of the Depression Education Program on patient outcomes and to assess the durability of the skills and need for reenforcement of those skills.67 Few studies of educational programs have evaluated the durability of their effects on physicians’ behaviors.20,25,29,67 Lin and colleagues did the most rigorous evaluation of durability of a program’s effects as a follow-up to the multifaceted Collaborative Care Program.25 They found no enduring effects of the physician education component of the program on physician behavior once the restructured services (eg, lengthened initial visit, on-site consultation with a psychiatrist) were removed. However, the physician education component of the Collaborative Care Program focused on knowledge about the diagnosis and management of depression and not on communication skills.
In primary care, the most powerful and enduring intervention to improve the care of depressed patients is likely to be one that includes effective physician education and structural changes in a practice (eg, routine use and feedback to physicians of patients’ scores on a depression screening instrument, surveillance of medication adherence through automatic pharmacy data).65 This approach would enhance and reinforce the role of the primary care physician in the care of patients with depression, an outcome desired by most patients.13 By improving physicians’ communication behaviors with depressed patients, the Depression Education Program can be a key component in these broader interventions.
Acknowledgments
Grant support was provided by the John D. and Catherine T. MacArthur Foundation’s Initiative on Depression in Primary Care.
The authors thank the 49 physicians who took time from their busy practices to participate in the study; Dale Kraemer, PhD, for statistical support; and Chris Kelleher, Kelly Redfield, and Alicia Ahn for their work on the project.
