BACKGROUND: Many problems have been identified in the usual care of patients with depression, including lack of identification, overreliance on medications, and inadequate treatment and follow-up. Most of these problems can be attributed to an absence of depression care systems in primary care practice. We collected information from a group of practices to assess the need for and acceptability of such systems.
METHODS: We conducted 4 focus groups with primary care physicians and their staffs to identify attitudes and perceived behaviors for depression problems and to determine the participants’ level of acceptance of alternative systematic approaches. We also surveyed clinicians and a sample of patients who recently visited their practices.
RESULTS: Systematic screening was viewed unfavorably, and many barriers were identified with collaborative care with mental health clinicians. Participants did support involvement of other office staff and more systematic follow-up for patients with depression. The patient survey suggested that some patients with depressive symptoms were unrecognized and undertreated, but the key finding was considerable variation in care among practices.
CONCLUSIONS: These findings suggest that a more systematic approach could improve the problems associated with treatment of patients with depression in primary care and would be acceptable to physicians if introduced appropriately. There are at least 2 promising approaches to introducing such changes. One involves external feedback of data about their care to the practices, followed by offering a variety of systems concepts and tools. The other involves an internal change process in which a multiclinic improvement team collects its own data and develops its own systematic solutions using rapid-cycle testing.
Many studies have documented that patients with depressive symptoms or disorders are frequently unrecognized, untreated, or receive suboptimal care.1-7 Subthreshold depression is especially likely to go unrecognized, even though it is frequently associated with somatization and high health care utilization and costs.8-11 To reduce these problems, the focus of change must be on the primary care setting, where most patients with depression appear with various manifestations of the disease and where many will receive their care.
Although many factors contribute to these care delivery problems, the main barriers are probably the same as those that interfere with the delivery of clinical preventive services and with optimal care for any chronic condition. These barriers are time pressures, orientation of both clinicians and patients to presenting symptoms and acute problems, and the lack of well-organized support systems for clinicians and patients in most primary care settings.12 Clinicians continue to care for depression as if it were an acute illness, even though there is considerable reason to see it as a relapsing, recurrent, or even chronic disease.2,13-16
During the early stages of depression care, most of the identified problems with current care patterns (recognition and compliance with appropriate treatment) are of the type that would benefit from a more systematic approach.17 And since nearly 40% of treated cases have a relapse within 1 year and 75% have had at least 2 previous episodes of depression,15 the suggestion of Simon and Von Korff18 to redirect treatment toward more intensive follow-up and relapse prevention may make systems imperative. Nolan17 defines a system as “a collection of interdependent elements that interact to achieve a common purpose.” However, it might be easier for clinicians to think of a system as an organized set of processes created to ensure that a patient care action occurs more consistently than would be likely if it were necessary to depend entirely on the attitudes, memory, and clinical situations of individual clinicians. The integrated multidisciplinary steps necessary to ensure that a surgical procedure is carried out efficiently and safely represent a familiar clinical example of a system.
There are no well-documented models of effective ongoing comprehensive depression care systems in typical primary care settings in the United States. Also, there have been no good examples of a practical (ie, nonresearch) change process for facilitating the implementation or dissemination of the partial systems tested in controlled trials. We know that traditional educational interventions and distribution of materials or toolboxes have little if any effect on clinician behavior.19-21 We need a demonstration of replicable change processes that can help primary care physicians produce a sustainable model of systematic improved care for depression.
The MacArthur Foundation Initiative on Depression and Primary Care sponsored 2 projects to test methods for introducing new care models that emphasize practice systems. Located in distant parts of the country (New England and Minnesota) and in different types of care systems, those 2 projects have used different approaches that provide more comprehensive information about the potential to introduce systems improvements. We report the results of preliminary studies from the New England project designed to verify the need for new systems in these settings and to identify barriers to their introduction. We also describe 2 alternative approaches to introducing change in primary care settings.