Recognizing and Managing Depression in Primary Care A Standardized Patient Study

,

Original Research

Recognizing and Managing Depression in Primary Care A Standardized Patient Study

J Fam Pract. 1999 December;48(12):965-972

References

1. Barrett JE, Barrett JA, Oxman TE, Gerber PD. The prevalence of psychiatric disorders in a primary care practice. Arch Gen Psychiatry 1998;45:1100-6.

2. Katon W. Epidemiology of depression in medical care. Int J Psychiatry Med 1987;17:93-112.

3. Coyne JC, Fechner-Bates S, Schwenk TL. The prevalence, nature and co-morbidity of depressive disorders in primary care. Gen Hosp Psychiatry 1994;16:267-76.

4. Spitzer RL, Williams BW, Kroenke K, Linzer M DeGruy FV, III, Hahn SR. Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. JAMA 1994;272:1749-56.

5. Feldman EL, Jaffe A, Galambos N, Robbins A, Kelly RB, Froom J. Clinical practice guidelines on depression: awareness, attitudes and content knowledge among family physicians in New York. Arch Fam Med 1998;7:58-62.

6. Fortney J, Rost K, Zhang M. A joint choice model of the decision to seek depression treatment and choice of provider sector. Med Care 1998;36:307-20.

7. Mourilhe P, Stokes PE. Risks and benefits of selective serononin reuptake inhibitors in the treatment of depression. Drug Safety 1998;18:57-82.

8. Katon W, Schulberg H. Epidemiology of depression in primary care. Gen Hosp Psychiatry 1992;41:237-47.

9. Wells KB, Hays RD, Burnam A, Rogers W, Greenfield S, Ware JE. Detection of depressive disorder for patients receiving prepaid or fee-for-service care: results from the Medical Outcomes Study. JAMA 1989;262:3298-302.

10. Higgens ES. A review of unrecognized mental illness in primary care: prevalence, natural history, and efforts to change the course. Arch Fam Med 1994;3:908-17.

11. Simon GE, von Korff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med 1995;4:99-105.

12. Klinkman MS, Schwenk TL, Coyne JC. Depression in primary care—more like asthma than appendicitis: the Michigan Depression Project. Canadian J Psychiatry 1997;42:966-73.

13. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression: two questions are as good as many. J Gen Int Med 1997;12:439-45.

14. Ronalds C, Creed F, Stone K, Webb S, Tomenson B. Outcome of anxiety and depressive disorders in primary care. Br J Psychiatry 1997;171:427-33.

15. Furukawa T, Hirai T, Kitamura T, Takahashi K. Application of the Center for Epidemiologic Studies Depression Scale among first-visit psychiatric patients: a new approach to improve its performance. J Affect Dis 1997;46:1-13.

16. Schade CP, Jones ER, Jr, Wittlin BJ. A ten year review of the validity and clinical utility of depression screening. Psychiatr Serv 1998;49:55-61.

17. Klinkman MS, Coyne JC, Gallo S, Schwenk TL. Can case-finding instruments be used to improve physician detection of depression in primary care? Arch Fam Med 1997;6:567-73.

18. Upadhyaya AK, Stanley I. Detection of depression in primary care: comparison of two self-administered scales. Int J Geriatric Psychiatry 1997;12:35-7.

19. Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER. The economic burden of depression in 1990. J Clin Psychiatry 1993;54:405-18.

20. Hirschfeld RMA, Keller MB, Panico S, et al. The national depressive and manic-depressive association consensus statement on the undertreatment of depression. 1997;277:333-40.

21. McFarland BH. Cost effectiveness considertaions for managed care systems: treating depression in primary care. Am J Med 1994;57:115-32.

22. Klinkman MS. Competing demands in psychosocial care: a model for the identification and treatment of depressive disorders in primary care. Gen Hosp Psychiatry 1997;19:79-81.

23. Agency for Health Care Policy and Research Clinical practice guideline—depression in primary care: detection, diagnosis, and treatment. Agency for Health Care Policy and Research; 1993.

24. Hays RD, Wells KB, Sherbourne CD, Rogers W, Spritzer K. Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses. AHCPR Publication No. 93-0552. Arch Gen Psych 1995;52:11-9.

25. Carney PA, Rhodes LA, Eliassen MS, et al. Variations in approaching the diagnosis of depression: a guided focus group study. J Fam Pract 1998;46:73-82.

26. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Revised. Washington, DC: American Psychiatric Press; 1987.

27. Badger LW, Berbaum M, Carney PA, Dietrich AJ, Owen M, Stem JT. Physician-patient gender and the recognition and treatment of depression in primary care. J Soc Serv Res. In press.

28. Brody DS, Hahn SR, Spitzer RL, et al. Identifying depressed patients in the primary care setting: a more efficient method. Arch Intern Med 1998;158:2469-75.

Questioning about anhedonia exceeded questioning about depressed mood in both presentations but did not differ significantly between them. Debriefings of physicians assigned to scenario A who did not ask about mood indicated that depressed mood was so obvious that it did not require a direct question. Debriefings of physicians assigned to scenario B who did not ask about mood indicated that the presentation did not suggest to them that the patient had a depressed mood.

Table 3 outlines physicians’ exploration of other information relevant to depression. Exploration of work and home life was more likely to occur for patients enacting scenario A. For scenario B, the work situation was less often addressed. The patient’s social network was explored in both scenarios by approximately 40% of the physicians.

Table 4 shows the DSM criteria explored when depression was not diagnosed. Exploring weight gain and sleep pattern occurred in about half of the encounters, while most other criteria were explored by only a few physicians or not at all. We found that only 7% of scenario B patients who did not receive a diagnosis of depression were asked about their social network; more than 40% of patients given a diagnosis of depression in either scenario A or B, however, were asked about their social network (Table 2).

Management of Depression

Table 5 shows the management strategies used by physicians who diagnosed depression (n = 133). This includes all 72 assigned to scenario A and 61 of those assigned to scenario B.

Physicians visited by scenario A patients often followed AHCPR guidelines for the management of depression. They prescribed selective serotonin reuptake inhibitors (SSRIs) more often than counseling. Forty-four of the 72 patients were treated with both counseling and SSRIs by the end of the second visit. Patients acting out scenario A were more likely to receive education on the causes of depression, treatment options, and prognosis, and to be provided with written material about depression than those presenting with scenario B.

Patients enacting scenario B often received recommendations for over-the-counter (OTC) analgesic medications appropriate for treatment of headache and were told to exercise. The OTC medication recommendations were more likely to occur at the first visit (22 of 38, 58%), while recommendations for exercise were more likely at the second visit (23 of 39, 59%). When SSRIs were prescribed for the patient in scenario B, this occurred more often at the second visit (68%).

Referrals for ongoing mental health counseling were more likely to be made for patients enacting scenario B than scenario A. Follow-up was almost equally recommended for patients portraying either scenario, but the time interval for follow-up was significantly shorter for scenario A patients than for those of scenario B. Sixty percent of the physicians recommended follow-up within 2 weeks for patients portraying scenario A, and an additional 34% recommended follow-up to occur between 2 and 4 weeks after the first visit. After the second visit in scenario A, follow-up was recommended to occur within 2 weeks in 13% of encounters, between 2 to 4 weeks in 52%, and in 35% it was recommended to occur more than a month later. For patients portraying scenario B, follow-up was recommended within 2 weeks for 42% after the first visit, and an additional 45% recommended it occur between 2 and 4 weeks. Follow-up after the second visit was recommended to occur within 2 weeks for 21% of patients, with an additional 48% recommended between 2 and 4 weeks.

For patients enacting scenario B where depression was not diagnosed, 64% received a recommendation for an over-the-counter nonsteroidal anti-inflammatory, acetaminophen, or aspirin. Twenty-one percent received a prescription drug for migraine headache; 7% received a prescription for a muscle relaxant; 7% received a prescription for a b blocker; and 7% received a recommendation for exercise only.

Patients spent 12.2 to 24.5 minutes in the waiting room. No statistical differences were noted by region or by first versus second visits. Physicians spent 13.4 to 28.4 minutes with patients. Time spent with patients did not vary by region. Second visits were half as long as first visits (12.7 minutes vs 23.0, P = .001). For scenario A patients, the mean number of minutes spent with physicians was 19.4 (SD = 11.7), and it was 16.6 (SD = 9.3) for scenario B patients (P = .01). Charges for visits ranged from $43.75 to $70.30, with a mean of $56.44 (SD = $26.46). First visits were more expensive than second visits ($69.96 vs $43.19, P <.001), but did not differ by number of depressive symptoms ($59.17 for scenario A, $54.86 for scenario B; P = .10). Pearson’s correlation coefficient between time spent with the physician and charges was 0.399 (P <.01).