BACKGROUND: Guidelines for recognition and management of depression in primary care provide a framework for detailed exploration of physician practice patterns.
METHODS: Our objective was to explore physician diagnosis and management approaches to depressive disorders according to type (major vs minor) and presenting complaint (difficulty sleeping and concentrating vs headache). The participants were community primary care internists and family physicians in northern New England, Washington, and Alabama (N = 149) who were randomly assigned to receive a visit from an unannounced actor portraying a standardized patient in 1 of 2 depression scenarios: (A) insomnia and poor concentration meeting Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) criteria for major depressive disorder; or (B) tension headaches meeting the criteria for minor depression.
RESULTS: All physicians who were assigned to the standardized patients presenting with scenario A recognized depression, and 49% (38 of 78) of those assigned to scenario B patients diagnosed depression. Of those recognizing depression, 72% and 42% queried patients about anhedonia and mood, respectively. For both scenarios, if fewer than 2 DSM-III-R criteria were explored, depression was not diagnosed. Management for scenario A was compatible with Agency for Health Care Policy and Research guidelines, including the prescription of an antidepressant (94%), scheduling of a follow-up visit within 2 weeks (61%), and exploration of suicidal ideation (69.4%). For scenario B, management included over-the-counter analgesics for the headache (84%), exercise (63%), prescription for an antidepressant (53%), recommendation for ongoing counseling (100%), and follow-up within 2 weeks (42%).
CONCLUSIONS: Major depression is recognized in primary care at a very high rate. Guidelines for recognizing and managing depression are often followed in primary care. Patients’ presentations of depression influence its recognition and management.
The prevalence of major depression in primary care patients ranges from 1% to 25%,1-3 with a 13% prevalence rate for subthreshold depression.4 Although more than 90% of primary care physicians report treating depression in their offices,5,6 estimates of depressed patients who are correctly identified and treated range from 5%7 to 60%,8-11 with higher rates of diagnosis associated with more severe depression.12 Research on the use of case-finding instruments13-15 to improve recognition has produced inconsistent results.16-18 Currently, the economic burden of mood disorders in the United States is $44 billion.19
Underdiagnosis and undertreatment of depression in primary care have been attributed to patients’ presentations, expectations, competing medical problems, and reimbursement issues, and clinicians’ knowledge, skills, practice characteristics, and time constraints.20-22 Guidelines for recognition and treatment of major depressive disorder have been provided by the Agency for Health Care Policy and Research (AHCPR),23 though the effectiveness of treatment for subthreshold depression is less certain. It is clear, however, that depressed patients suffer ongoing functional impairment comparable with that experienced with a chronic medical illness such as diabetes or congestive heart failure.24 By understanding typical practice patterns, areas of depression diagnosis and management could be identified and targeted for practice-enhancement strategies.
We explored physicians’ diagnostic and treatment approaches to patients with both straightforward and more subtle presentations meeting 2 levels of depression criteria: major depressive disorder and minor depression. Unannounced trained actors portraying standardized patients were used to control the variability in patient presentations and characteristics.
Methods
In 1997, 3 study centers (one each in northern New England; Seattle, Washington; and Tuscaloosa, Alabama, were selected to represent a range of primary care geographic settings. Physician recruitment involved initial peer contact followed by a letter, consent form, and fact sheet briefly describing the study. We informed participants they would be visited twice by a standardized patient at some point during a 1-year period to assess health service delivery and that the encounters would be recorded to evaluate standardized patient case replication and accuracy of physician performance. Physicians were blinded to the study topic of depression, the date of the visits, and the standardized patient’s age, sex, and clinical presentation. All study procedures were approved by the institutional review boards at the 3 study centers.
Study Participants
A sample of 149 primary care physicians serving adults from each of the 3 regions represented a specialty mix (family physicians and internists) and a sex mix. Physicians were excluded if they had been at the current practice location for less than 1 year, their panel composition was less than 50% adults, more than 50% of their clinical time was devoted to subspecialty care, their practice was based in a residency training site or was closed to new patients.
Design
Four months before the first standardized patient visits, participants were randomly assigned to 1 of 4 study groups defined by patient sex and case presentation. The standardized patients portrayed symptoms compatible with either major depressive disorder with chief complaints suggesting depression (scenario A) or minor depression with a more subtle chief complaint (scenario B). The standardized patients called each practice in the study and requested an initial visit to address their presenting complaint and to establish ongoing care, and they returned as recommended for a second visit.