BACKGROUND: The relationship between physician communication patterns and the successful recognition of depression is poorly understood.
METHODS: We used unannounced visits by actors playing standardized patients to evaluate verbal communication between primary care physicians and a patient presenting with a minor depression scenario. Participants (n = 77) were assigned to receive 2 visits from a man or woman portraying a 26-year-old patient with chronic headaches who meets the criteria for minor depression. The standardized patients carried hidden audiotape recorders and high-fidelity microphones to document the encounters. The audiotapes were coded at 2-second intervals. These data were linked to information gathered from standardized patient checklists, medical records, and debriefing telephone calls with participants.
RESULTS: We obtained complete data on 59 (77%) of the physician-patient encounters; of those, 43 (73%) of the physicians recognized depression. Physicians who recognized depression asked twice as many questions about feelings and affect compared with those who did not (for feelings: 1.9% of total physician activity vs 0.9%, P = .017; for affect: composite score of 2.7% of total physician activity vs 1.3%, P = .003). We found no differences in the proportion or timing of broad to narrow questioning between those who did and did not recognize depression. Physicians who successfully recognized depression later in the interview showed an increase in questions about feelings in the quartile just before recognition occurred.
CONCLUSIONS: Physicians who recognized depression differed significantly in the percentage of questions about feeling and affect, and an increase in questions about feelings may precede a diagnosis of depression, though more research is needed to establish this as an important finding.
Despite findings that the prevalence of depression symptomatology in general medical practice is comparable with hypertension and arthritis,1 several studies have found that primary care clinicians identify only half of the patients who meet the criteria for a depressive disorder.2-8 The barriers contributing to underrecognition of depression have been well documented and include the knowledge and attitudes of patients,9,10 inadequate physician training,11-13 physician attitudes,14,15 reimbursement issues,16,17 and insufficient time or other health care system factors that lead to inadequate diagnostic interviews.18-22 One area that has received relatively little attention is how physician-patient communication influences recognition of depression in primary care practice.
Communication is a core component of the physician-patient relationship. Good communication is associated with increased patient satisfaction,23 better diagnostic performance by physicians, greater patient compliance, improved health status of patients,24-26 and lower rates of malpractice litigation.27,28 Few studies have explored how physician-patient communication may influence the successful diagnosis of depression. One study29 found 2 communication behaviors that predicted successful recognition of depression, including the proportion of the interview devoted to affective interview behaviors (eg, accepting and eliciting feelings) and the use of broad open-ended psychosocial questions by the physician. Another study30 found that success in diagnosing somatiform disorders was associated with effective interdependent communication between physicians and patients. More research is needed, however, to understand how the timing of specific communication behaviors contributes to the success or failure of recognizing depression.
We conducted an exploratory study using actors portraying standardized patients to evaluate how physician communication contributes to a diagnosis of depression in primary care. We specifically explored whether successfully recognizing depression was associated with the timing and respective proportion of broad (open-ended) to narrow (close-ended) and medical to psychosocial questioning by the physicians or with the timing of questions about affect and mood. Primary care physicians are in a unique position to identify and treat the 1% to 25% of their patients with depression (of whom 5% to 9% have major depression).31-33 To identify how best to assist primary care physicians in overcoming the complicated obstacles that hinder recognizing depression, the communication process must be better understood.
Methods
Study methods for participant recruitment, scenario development, standardized patient recruitment, training and testing are described in detail elsewhere.34 In 1997, 3 study centers were selected to represent a range of primary care geographic settings. These included one center in northern New England; one in the region around Seattle, Washington; and one in northwest Alabama. Physician recruitment involved peer-to-peer contact. All study procedures were approved by the institutional review boards at the 3 study centers. Participants were informed that they would be visited twice by a standardized patient at some point during a 1-year period and that the encounters would be audiotaped to evaluate scenario replication and the accuracy of the standardized patients’ assessments of physician performance. The tapes would also be used to analyze communication patterns between the physicians and the standarized patients. Physicians were blinded to the specific study topic of depression, the dates of the visits, and the standarized patient’s age, sex, and specific clinical presentations.