The Role of Primary Care Physicians in Managing Depression DAVID S. BRODY, MD, DAVID B. LAR$ON, MD, MSPH
DEPRESSION is a c o m m o n and important p r o b l e m in the primary care setting. Depending on the methods and criteria used to make this diagnosis, anywhere f r o m 5% to 25% of p r i m a r y care patients are suffering f r o m depression. 1-s Even at the l o w e r prevalence rate of 5%, depression is one of the most c o m m o n disorders seen in p r i m a r y care. 6, 7 Depressed primary care patients e x p e r i e n c e considerable morbidity and dysfunction. Results f r o m the Medical O u t c o m e Study revealed that patients w i t h depressive s y m p t o m s r e p o r t e d as m u c h or m o r e pain and dysfunction than did patients w i t h any of the eight other chronic medical conditions (e.g., arthritis, coronary artery disease) studied, a Depression has also b e e n s h o w n to adversely affect the disease courses of patients with a variety of medical disorders. 9-1~ Unfortunately, depression in the p r i m a r y care setting can be persistent. Two studies have d o c u m e n t e d that at one-year followup, a p p r o x i m a t e l y half of the untreated depressed patients w e r e still suffering from that condition. 3, 12 The p r i m a r y care setting, therefore, seems to be a potentially important place for patients to receive treatment for depression. In fact, in this country at least half o f patients w h o receive any mental health care receive that care only from p r i m a r y care physicians.t3. 14 Three factors contribute to the large percentage of depressed patients w h o are treated for this condition b y their p r i m a r y care physicians. First, there simply are not enough mental health specialists available to provide p r i m a r y mental health services to all patients w h o m i g h t benefit from them. TM Second, patients may have insurance coverage for p r i m a r y care visits but not for visits to a mental health specialist. Finally, p r i m a r y care patients w i t h mental health problems frequently do not desire to see a mental health specialist. 15, 16 Unfortunately, the m a n a g e m e n t of depression in the p r i m a r y care setting appears to be far from optimal. Most studies indicate that m o r e than 50960 o f the time
Received from the Department of Medicine, Mercy Catholic Medical Center, Darby, Pennsylvania (DSB), and the National Institute of Mental Health, Rockville, Maryland (DBL). Supported in part by the HenryJ. Kaiser Family Foundation. Address correspondence and reprint requests to Dr. Brody: Department of Medicine, Mercy Catholic Medical Center, Lansdowne Avenue and Baily Road, Darby, PA 19023.
primary care physicians fail to recognize depression.~, 2, 17-19 Even w h e n depression is identified, primary care physicians frequently fail to make an accurate diagnosis or provide a p p r o p r i a t e management. 19-21 Counseling techniques a p p e a r to be underutilized, w h i l e p s y c h o t r o p i c medications are used too often or inappropriately. 22-24 Several factors have c o n t r i b u t e d to the a p p a r e n t p o o r quality of depression m a n a g e m e n t in the p r i m a r y care setting. There is no d o u b t that p r i m a r y care physicians' lack of training and available clinical time play an important role. Other factors must also be considered. The current diagnostic classification system does not adequately describe the types o f depressed patients c o m m o n l y seen in the primary care setting. 2s, 26 Mana g e m e n t strategies for specific types of depressed prim a r y care patients have not b e e n well defined. Research on the quality of depression m a n a g e m e n t has b e e n largely d e p e n d e n t on chart review. Using a chart r e v i e w for research assessment is likely to underestimate the identification and treatment of depression for at least three reasons: 1) primary care physicians may not always m e n t i o n depression in their notes for fear of stigmatizing their patients2°; 2) it is unlikely that primary care physicians chart all of the things they do to manage depression; and 3) p r i m a r y care physicians m a y not always be aware of the nature of the mental health interventions they are providing during medical visits. 27 Given the i m p o r t a n c e of depression and the problems identified with the current m a n a g e m e n t of this disorder in the p r i m a r y care setting, w e believe that the p r i m a r y care physician's role in its m a n a g e m e n t should be clarified. O n e c o u l d argue that this role should b e limited to case finding and referral. Alternatively, it m a y be a p p r o p r i a t e for p r i m a r y care physicians to app r o p r i a t e l y manage depression as well as diagnose it. The p u r p o s e of this paper, therefore, is to define better the role of p r i m a r y care physicians in the management of depression. We will r e v i e w the effectivenesses of interventions designed to i m p r o v e access to mental health specialists as w e l l as those designed to i m p r o v e p r i m a r y care physicians' m a n a g e m e n t of relevant mental health problems. We will also offer recommendations for the types of research still n e e d e d to i m p r o v e the m a n a g e m e n t of depressed p r i m a r y care patients.
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STRATEGIES TO IMPROVE THE MANAGEMENT OF DEPRESSED PRIMARY CARE PATIENTS There are two ways in w h i c h the m a n a g e m e n t o f depressed p r i m a r y care patients can be improved. First, interventions n e e d to be d e v e l o p e d to enable p r i m a r y care physicians to provide m o r e effective care to these patients. Second, the system of care can be modified to p e r m i t greater i n v o l v e m e n t of mental health specialists in their care. Several studies have focused on the m o d e l in w h i c h the p r i m a r y care physician refers patients to a mental health specialist, w h o then provides all o f the mental health care. A meta-analysis of p u b l i s h e d studies has c o n c l u d e d that the i m p a c t of the mental health c o n s u l t a t i o n - l i a i s o n m o d e l is modest. 2s Recent studies using m o r e h o m o g e n e o u s clinical p o p u l a t i o n s seen b y c o n s u l t a t i o n - l i a i s o n psychiatrists a p p e a r m o r e promising. 2934 However, c o n s u l t a t i o n - l i a i s o n care p r o v i d e d by psychologists, social workers, or nurses has not b e e n consistently s h o w n to be effective. 3s-39 Various educational a p p r o a c h e s have also b e e n e m p l o y e d to train p r i m a r y care physicians to provide m o r e effective mental health care. These have included single seminars on the recognition and treatment of anxiety and depression, 4° a series of case m a n a g e m e n t seminars, 41 role play and videotaping to teach interviewing skill, 42 m a n a g e m e n t guidelines after a psychiatric consultation, 33 and a rotation on a c o n s u l t a t i o n liaison service. 43 In all cases, the investigators have I found that the primary care physicians acquired at least i some of the k n o w l e d g e and skills that w e r e b e i n g taught. Only one study, however, evaluated the effects of training on health care outcomes. 33 In a study of patients with a somatoform disorder, Smith et al. comp a r e d the efficacy of care p r o v i d e d by primary care physicians w h o had received consultation and managem e n t guidelines w i t h care p r o v i d e d b y practitioners w h o had received consultation only. The use of management guidelines was associated w i t h a 53% reduction in average quarterly total health care charges but did not p r o d u c e significant changes in functional health status or patient satisfaction. 33 Depression mana g e m e n t guidelines may be particularly useful to primary care physicians because they can provide concrete, specific r e c o m m e n d a t i o n s for care that might otherwise a p p e a r to be m o r e nebulous. Another type of tested intervention has b e e n the use of a screening questionnaire to identify patients with mental health p r o b l e m s and provide f e e d b a c k to the p r i m a r y care physician. This a p p r o a c h seems to result in only a modest increase in physician recognition of the mental health problems, 44-46w i t h one study finding no increase in recognition of these disorders. 47 The increased recognition in other studies, however,
has b e e n limited to selected groups of physicians a5 or selected types of patients. ~s Even with feedback, Magruder-Habib et al. found that p r i m a r y care physicians n o t e d depression or its s y m p t o m s in the medical records in o n l y one-third of the cases. 44 The impact of feedback on m a n a g e m e n t of mental health p r o b l e m s is even less impressive. Several studies have found that f e e d b a c k had little effect on the treatm e n t of mental health problems. 49,s° Rand et al. found that physicians w h o w e r e told their patients had mental health p r o b l e m s used antidepressants m o r e frequently than did physicians w h o did not receive this feedback. 4s There was no evidence that feedback increased counseling or mental health referrals, however. One other study demonstrated increased mental health treatment (medications and referrals) following feedback to physicians about their patients w i t h mental health problems. 44 In this study, physicians treated the depression only 25% of the t i m e within six w e e k s of receiving feedback. Studies to date have also s h o w n that simply informing p r i m a r y care physicians that their patients a p p e a r to have mental health p r o b l e m s has modest or no effect on health outcomes. 44-~1
FUTURE RESEARCH DIRECTIONS To i m p r o v e p r i m a r y care physicians' m a n a g e m e n t of depression, research must be c o n d u c t e d to: 1) better categorize the types of clinical depression c o m m o n l y seen in the p r i m a r y care setting; 2) define the role of the p r i m a r y care physician in recognizing, referring, and treating each category of clinical depression; and 3) d e v e l o p mental health interventions that can b e realistically p r o v i d e d by p r i m a r y care physicians to patients within these categories. Primary care mental health interventions must be feasible given the limitations of p r i m a r y care physicians' time and mental health expertise. These interventions should include guidelines on w h e n to refer, to w h o m to refer, and h o w to refer patients w h o n e e d specialized mental health care. For patients w h o are referred, interventions should be d e v e l o p e d that are integrated w i t h the care provided b y the mental health specialist. Additional research is also n e e d e d to d e v e l o p methods to train p r i m a r y care physicians to provide effective mental health care to depressed patients. It is particularly important that, as m u c h as possible, the clinical e x p e r i e n c e s of students, residents, and practicing physicians should take place in p r i m a r y care settings. Individuals w h o learn to diagnose disorders and provide mental health care in a mental health setting with well-defined and highly motivated patients and f e w e r time constraints may have difficulty transferring their mental health k n o w l e d g e and skills to the real w o r l d of p r i m a r y care. Finally, research is n e e d e d to d e v e l o p m e t h o d s to
JOURNALOFGENERALINTERNALMEDICINE,Volume 7 (March/April), 1992
promote, maintain, and reward performance of effective mental health care by primary care physicians. Primary care physicians may fail to recognize and manage depression because they lack knowledge and skills. It is also possible that this failure is due to their perceptions that mental health problems are either irrelevant to their objectives for the medical visit or beyond their capacities to effectively change. When a patient with a potential mental health problem is encountered in the medical setting, the physician commonly considers some or all of the following questions: 1) How important is it for me to address this mental health problem?; 2) Is there something that I can do for the patient with this problem?; 3) How effective is the care I can provide likely to be?; and 4) Howwill I be compensated for my efforts to manage this problem? It is, therefore, critical to develop clinical approaches to: 1) increase primary care physicians' awareness of the clinical relevance of identifying and managing depression; 2) enhance perceived effectiveness in treating this problem; and 3) ensure that primary care physicians are adequately compensated for their efforts to manage depression. There are several approaches to achieving these objectives. First, educational programs should focus on the relationship between depression and somatic symptoms, physical disease and functional status. In addition, the impact of effective management of depression on patient satisfaction with the physician and the excessive utilization of health services should be emphasized. Second, primary care physicians should be taught when and how to provide effective and practical mental health interventions that are clearly defined. Third, insurance companies must be encouraged to provide compensation for the management of depression in the primary care setting. Fourth, primary care physicians should receive more feedback on both patients' initial interest in mental health care and the perceived impact of the mental health care on illness outcomes and patient satisfaction following the medical visit. A recent study demonstrated that more effective counseling was provided when a medical resident received feedback on the following: 1) the presence of a mental health problem; 2) the impact of this problem on patient functioning; 3) the situational sources of this problem; 4) the patient's desire for help with this problem; and 5) the specific types of mental health interventions the patient desired. 27 When compared with control patients who completed the same set of questionnaires, patients seen by physicians who had received this feedback reported that the counseling they received was more valuable and they were also more satisfied with their physicians. Patients in the feedback group also reported greater decreases in the amount of overall stress experienced and greater increases in their perceived control over this stress following the medical visit when compared with control
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group patients. Further research seems warranted, therefore, on the use of patient feedback to motivate and guide physicians' management of depression.
CONCLUSIONS In summary, depression is a common and important problem in the primary care setting. There is no doubt that the quality of mental health care provided by primary care physicians can and should be improved. Before this goal can be achieved, however, a revised diagnostic nomenclature must be developed and then field-tested in primary care settings. This diagnostic system must adequately identify and describe the most prevalent types of patients with depressive symptoms seen in the primary care settings; it must be easily understood by primary care physicians; and it must clinically relate to morbidity and treatment specificity. Clearly, some depressed patients will be best served by referrals to mental health specialists. The consultation-liaison model seems to be a promising approach to providing mental health care to primary care patients. Further research is needed, however, to identify those patients who should be referred as well as the role of the primary care physician in making the initial referral and facilitating the patient's continued participation in this type of mental health care. Other patients may be appropriately managed by primary care physicians. In this regard, research is needed to accomplish the following: 1) identify mental health interventions that can be adapted effectively for use in the primary care setting; 2) evaluate methods of training primary care physicians to use these techniques; and 3) develop ways of increasing the motivation of primary care physicians to provide mental health care. We recognize that primary care physicians will never have the same knowledge, skills, and time as their mental health colleagues. Thus, it would not be appropriate for them to independently manage patients with chronic or life-threatening depression. They should, however, be able to identify patients experiencing less serious depressive symptoms and to reduce their emotional distress through mental health treatments that can be adapted for use in the general medical setting. Primary care-based management of depression might include the following: 1) supportive listening; 2) reassurance; 3) problem solving; 4) recommending selfhelp materials; 5) prescribing medications; and 6) scheduling follow-up appointments. Indeed, primary care physicians have some unique advantages over mental health specialists in providing this type of mental health care to primary care patients. Primary care physicians are particularly well situated to reassure patients who manifest their emotional distress by complaining of somatic symptoms, as well as pa-
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tients w h o s e mental health s y m p t o m s are caused or exacerbated by concerns about their physical wellbeing. The continuity o f care that exists in the primary
care setting affords primary care physicians opportunities t o e s t a b l i s h t h e r a p e u t i c r e l a t i o n s h i p s w i t h t h e i r patients over time. The trust and confidence that develop in this setting make it possible for primary care physicians to effectively influence patient behavior. For example, most studies have shown a not-immodest 5 - 10% quitting rate when a physician simply commun i c a t e s a s m o k i n g c e s s a t i o n m e s s a g e t o a p a t i e n t , s2s4 Primary care physicians generally have several opportunities to modify their patients' perceptions and beh a v i o r s as t h e y f o l l o w t h e m o v e r t i m e . Prompt attention by primary care physicians to the emotional problems of patients with depressive symptoms associated with stressful life events would help reduce the dysfunction associated with their distress and decrease the likelihood of a more deteriorated functional status or a major depressive disorder. We believe, therefore, that primary care physicians can and should play a role in the management of depression. Future research aimed at improving manage depression seems indicated.
their ability to
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health services system. Arch Gen Psychiatry. 1978;35:685-93. 15. Franc RD, Weddington WW, Houpt JL. Referral of patients from primary care physicians to a community mental health center. J Nerv Ment Dis. 1978;166:594-8. 16. Orleans CT, George LK, HouptJL, et al. How primary care physicians treat psychiatric disorders: a national survey of family practitioners. AmJ Psychiatry. 1985;I42:52-7. 17. Zung WWK, Magill M, MooreJT, et al. Recognition and treatment of depression in a family medicine practice. J Clin Psychiatry. 1983;44:3. 18. Freeling P, Rao BM, Paykel ES, et al. Unrecognized depression in general practice. Br MedJ. 1985;290:1880-3. 19. P~rez-Stable EJ, Miranda J, Mufioz RF, et al. Depression in medical outpatients: underrecognition and misdiagnosis. Arch Intern Med. 1990;150:1083-8. 20. Jencks SF. Recognition of mental distress and diagnosis of mental disorder in primary care. JAMA. 1985;253:1903. 21. Andersen SM, Harthorn BH. The recognition, diagnosis, and treatment of mental disorders by primary care physicians. Med Care. 1989;27:869-86. 22. Johnson DAW. Astudy of the use of antidepressant medication in general practice. BrJ Psychiatry. 1974;125:186-92. 23. Thomas RB, Wessinger WN. A descriptive assessment of the psychiatric practice of non-psychiatric physicians in South Carolina. South MedJ. 1973;66:221-4. 24. Kamerow DB, Pincus HA, Macdonald DI. Alcohol abuse, other drug abuse, and mental disorders in medical practice: prevalence, costs, recognition, and treatment. JAMA. 1986;255: 2054-7. 25. Von Korff M, Shapior S, BurkeJD, et aI. Anxiety and depression in a primary care clinic: comparison of Diagnostic Interview Schedule, General Health Questionnaire, and practitioner assessments. Arch Gen Psychiatry. 1987;44:152-6. 26. Ford DE, Kamerow DB, Thompson JW. Who talks to physicians about mental health and substance abuse problems?J Gen Intern Med. 1988;3:363-9. 27. Brody DS, Lerman CE, Wolfson HG, et al. Improvement in physicians' counseling of patients with mental health problems. Arch Intern Med. 1990;150:993-8. 28. Balestrieri M, Williams P, Wilkinson G. Specialist mental health treatment in general practice: a meta-analysis. Psychol Med. 1988;18:711-7. 29. Ackerman AD, LyonsJS, Hammer JS, et al. The impact of coexisting depression and timing of psychiatric consultation on medical patients' length of stay. Hosp Community Psychiatry. 1988; 39:173-6. 30. McCartuey CF, Cahill P, Larson DB, et al. Effect of a psychiatric liaison program on consultation rates and on detection of minor psychiatric disorders in cancer patients. Am J Psychiatry. 1989; 146:898-901. 31. Mumford E, Schlesinger HJ, Glass GV, et al. A new look at evidence about reduced costs of medical utilization following mental health treatment. AmJ Psychiatry. 1984;141:1145-58. 32. HankinJR, Kessler LG, Goldberg ID, et al. Alongitudinal study of offset in the use of nonpsychiatric services following specialized mental health care. Med Care. 1983;21:1099-110. 33. Smith GR, Monson RA, Ray DC. Psychiatric consultation in somatization disorder: a randomized controlled study. N Engl J Med. 1986;314:1407-13. 34. Larson DB, Kessler LC, Burns BJ, et al. A research development workshop to stimulate outcome research in consultationliaison psychiatry. Hosp Community Psychiatry. 1987;38: 1106-9. 35. Marks I. Controlled trial of psychiatric nurse therapists in primary care. Br MedJ. 1985;290:1181-4. 36. Robson MH, France R, Bland M. Clinical psychologist in primary care: controlled clinical and economic evaluation. Br Med J. 1984;288:1805-8. 37. Earll L, KinceyJ. Clinical psychology in general practice: a controlled trial evaluation. J R Coll Gen Pract. 1982;32:32-7. 38. Carney RH. Social work effectiveness in the management of depressed women: a clinical trial. Psychol Med. 1981; 11:417-23. 39. Klerman GL, Budman S, Berwick D, et al. Efficacy of a brief psychosocial intervention for symptoms of stress and distress among patients in primary care. Med Care. 1987;25:1078-88.
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40. Andersen SM, Harthorn BH. Changing the psychiatric knowledge of primary care physicians: the effects of a brief intervention on clinical diagnosis and treatment. Gen Hosp Psychiatry. 1990;12:177-90. 41. Gask L, McGrath G, Goldberg D, et al. Improving the psychiatric skills of the experienced family doctor: an evaluation of a group training course. In: Seattle, WA: Mental Disorders in General Health Care Settings: A Research Conference. 1987;209-11. 42. Roter D, Cole K, Kern D, et al. The effects of training on physicians' diagnosis and management of psychosocial problems. In: Seattle, WA: Mental Disorders in General Health Care Settings: A Research Conference. 1987;215-7. 43. Cohen-Cole SA, BirdJ, BokerJ. Medical residents' knowledge and skill after psychiatric training. In: Seattle, WA: Mental Disorders in General Health Care Settings: A Research Conference, 1987;221-2. 44. Magruder-Habib K, Zung WWK, Feussner JR, et al. Management of general medical patients with symptoms of depression. Gen Hosp Psychiatry. 1989; 11:201-6. 45. Rand EH, Badger LW, Coggins DR. Recognition of mental disorders by family practice residents: the effect of GHQ feedback. In: Seattle, WA: Mental Disorders in General Health Care Settings: A Research Conference. 1987;164-6.
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46. Linn LS, YagerJ. The effect of screening, sensitization and feedback on notation of depression. J Med Educ. 1980;55:942-9. 47. Hoeper EW, Kessler LG, Nycz GR, et al. The usefulness of screening for mental illness. Lancet. 1984;i:33-5. 48. German PS, Shapiro S, Skinner EA, et al. Direction and management of mental health problems of older patients by primary care providers. JAMA. 1987;257:489-93. 49. Shapiro S, German PS, Skinner EA, et al. An experiment to change detection and management of mental morbidity in primary care. Med Care. 1987;25:327-39. 50. Linn LS, Yager J. Screening of depression in relationship to subsequent patient and physician behavior. Med Care. 1982; 20:1233-40. 51. Johnstone A, Goldberg D. Psychiatric screening in general practice: a controlled trial. Lancet. 1976;i:605-8. 52. Rnssel MAH, Wilson C, Taylor C, et al. Effect of general practitioners' advice against smoking. Br MedJ. 1979;2:231-4. 53. Wilson D, Wood G,Johnston N, et al. Randomized clinical trial of supportive follow-up for cigarette smokers in a family practice. Can MedAssoc J. 1982;126:127-9. 54. Stewart PJ, Rosser WW. The impact of routine advice on smoking cessation from family physicians. Can Med Assoc J. 1982;126:1051-4.
AMERICAN BOARD OF INTERNAL MEDICINE 1992 Certification and Recertification Examinations in Internal Medicine Registration period: N o v e m b e r 1, 1991 - F e b r u a r y 1, 1992 ( $ 3 0 0 penalty fee for applications postmarked February 1 - A p r i l 1, 1992. No application a c c e p t e d after April 1, 1992.) Examination dates: S e p t e m b e r 15 - 16, 1992
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DEPRESSION is a c o m m o n and important p r o b l e m in the primary care setting. Depending on the methods and criteria used to make this diagnosis, anywhere f r o m 5% to 25% of p r i m a r y care patients are suffering f r o m depression. 1-s Even at the l o w e r prevalence rate of 5%, depression is one of the most c o m m o n disorders seen in p r i m a r y care. 6, 7 Depressed primary care patients e x p e r i e n c e considerable morbidity and dysfunction. Results f r o m the Medical O u t c o m e Study revealed that patients w i t h depressive s y m p t o m s r e p o r t e d as m u c h or m o r e pain and dysfunction than did patients w i t h any of the eight other chronic medical conditions (e.g., arthritis, coronary artery disease) studied, a Depression has also b e e n s h o w n to adversely affect the disease courses of patients with a variety of medical disorders. 9-1~ Unfortunately, depression in the p r i m a r y care setting can be persistent. Two studies have d o c u m e n t e d that at one-year followup, a p p r o x i m a t e l y half of the untreated depressed patients w e r e still suffering from that condition. 3, 12 The p r i m a r y care setting, therefore, seems to be a potentially important place for patients to receive treatment for depression. In fact, in this country at least half o f patients w h o receive any mental health care receive that care only from p r i m a r y care physicians.t3. 14 Three factors contribute to the large percentage of depressed patients w h o are treated for this condition b y their p r i m a r y care physicians. First, there simply are not enough mental health specialists available to provide p r i m a r y mental health services to all patients w h o m i g h t benefit from them. TM Second, patients may have insurance coverage for p r i m a r y care visits but not for visits to a mental health specialist. Finally, p r i m a r y care patients w i t h mental health problems frequently do not desire to see a mental health specialist. 15, 16 Unfortunately, the m a n a g e m e n t of depression in the p r i m a r y care setting appears to be far from optimal. Most studies indicate that m o r e than 50960 o f the time
Received from the Department of Medicine, Mercy Catholic Medical Center, Darby, Pennsylvania (DSB), and the National Institute of Mental Health, Rockville, Maryland (DBL). Supported in part by the HenryJ. Kaiser Family Foundation. Address correspondence and reprint requests to Dr. Brody: Department of Medicine, Mercy Catholic Medical Center, Lansdowne Avenue and Baily Road, Darby, PA 19023.
primary care physicians fail to recognize depression.~, 2, 17-19 Even w h e n depression is identified, primary care physicians frequently fail to make an accurate diagnosis or provide a p p r o p r i a t e management. 19-21 Counseling techniques a p p e a r to be underutilized, w h i l e p s y c h o t r o p i c medications are used too often or inappropriately. 22-24 Several factors have c o n t r i b u t e d to the a p p a r e n t p o o r quality of depression m a n a g e m e n t in the p r i m a r y care setting. There is no d o u b t that p r i m a r y care physicians' lack of training and available clinical time play an important role. Other factors must also be considered. The current diagnostic classification system does not adequately describe the types o f depressed patients c o m m o n l y seen in the primary care setting. 2s, 26 Mana g e m e n t strategies for specific types of depressed prim a r y care patients have not b e e n well defined. Research on the quality of depression m a n a g e m e n t has b e e n largely d e p e n d e n t on chart review. Using a chart r e v i e w for research assessment is likely to underestimate the identification and treatment of depression for at least three reasons: 1) primary care physicians may not always m e n t i o n depression in their notes for fear of stigmatizing their patients2°; 2) it is unlikely that primary care physicians chart all of the things they do to manage depression; and 3) p r i m a r y care physicians m a y not always be aware of the nature of the mental health interventions they are providing during medical visits. 27 Given the i m p o r t a n c e of depression and the problems identified with the current m a n a g e m e n t of this disorder in the p r i m a r y care setting, w e believe that the p r i m a r y care physician's role in its m a n a g e m e n t should be clarified. O n e c o u l d argue that this role should b e limited to case finding and referral. Alternatively, it m a y be a p p r o p r i a t e for p r i m a r y care physicians to app r o p r i a t e l y manage depression as well as diagnose it. The p u r p o s e of this paper, therefore, is to define better the role of p r i m a r y care physicians in the management of depression. We will r e v i e w the effectivenesses of interventions designed to i m p r o v e access to mental health specialists as w e l l as those designed to i m p r o v e p r i m a r y care physicians' m a n a g e m e n t of relevant mental health problems. We will also offer recommendations for the types of research still n e e d e d to i m p r o v e the m a n a g e m e n t of depressed p r i m a r y care patients.
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STRATEGIES TO IMPROVE THE MANAGEMENT OF DEPRESSED PRIMARY CARE PATIENTS There are two ways in w h i c h the m a n a g e m e n t o f depressed p r i m a r y care patients can be improved. First, interventions n e e d to be d e v e l o p e d to enable p r i m a r y care physicians to provide m o r e effective care to these patients. Second, the system of care can be modified to p e r m i t greater i n v o l v e m e n t of mental health specialists in their care. Several studies have focused on the m o d e l in w h i c h the p r i m a r y care physician refers patients to a mental health specialist, w h o then provides all o f the mental health care. A meta-analysis of p u b l i s h e d studies has c o n c l u d e d that the i m p a c t of the mental health c o n s u l t a t i o n - l i a i s o n m o d e l is modest. 2s Recent studies using m o r e h o m o g e n e o u s clinical p o p u l a t i o n s seen b y c o n s u l t a t i o n - l i a i s o n psychiatrists a p p e a r m o r e promising. 2934 However, c o n s u l t a t i o n - l i a i s o n care p r o v i d e d by psychologists, social workers, or nurses has not b e e n consistently s h o w n to be effective. 3s-39 Various educational a p p r o a c h e s have also b e e n e m p l o y e d to train p r i m a r y care physicians to provide m o r e effective mental health care. These have included single seminars on the recognition and treatment of anxiety and depression, 4° a series of case m a n a g e m e n t seminars, 41 role play and videotaping to teach interviewing skill, 42 m a n a g e m e n t guidelines after a psychiatric consultation, 33 and a rotation on a c o n s u l t a t i o n liaison service. 43 In all cases, the investigators have I found that the primary care physicians acquired at least i some of the k n o w l e d g e and skills that w e r e b e i n g taught. Only one study, however, evaluated the effects of training on health care outcomes. 33 In a study of patients with a somatoform disorder, Smith et al. comp a r e d the efficacy of care p r o v i d e d by primary care physicians w h o had received consultation and managem e n t guidelines w i t h care p r o v i d e d b y practitioners w h o had received consultation only. The use of management guidelines was associated w i t h a 53% reduction in average quarterly total health care charges but did not p r o d u c e significant changes in functional health status or patient satisfaction. 33 Depression mana g e m e n t guidelines may be particularly useful to primary care physicians because they can provide concrete, specific r e c o m m e n d a t i o n s for care that might otherwise a p p e a r to be m o r e nebulous. Another type of tested intervention has b e e n the use of a screening questionnaire to identify patients with mental health p r o b l e m s and provide f e e d b a c k to the p r i m a r y care physician. This a p p r o a c h seems to result in only a modest increase in physician recognition of the mental health problems, 44-46w i t h one study finding no increase in recognition of these disorders. 47 The increased recognition in other studies, however,
has b e e n limited to selected groups of physicians a5 or selected types of patients. ~s Even with feedback, Magruder-Habib et al. found that p r i m a r y care physicians n o t e d depression or its s y m p t o m s in the medical records in o n l y one-third of the cases. 44 The impact of feedback on m a n a g e m e n t of mental health p r o b l e m s is even less impressive. Several studies have found that f e e d b a c k had little effect on the treatm e n t of mental health problems. 49,s° Rand et al. found that physicians w h o w e r e told their patients had mental health p r o b l e m s used antidepressants m o r e frequently than did physicians w h o did not receive this feedback. 4s There was no evidence that feedback increased counseling or mental health referrals, however. One other study demonstrated increased mental health treatment (medications and referrals) following feedback to physicians about their patients w i t h mental health problems. 44 In this study, physicians treated the depression only 25% of the t i m e within six w e e k s of receiving feedback. Studies to date have also s h o w n that simply informing p r i m a r y care physicians that their patients a p p e a r to have mental health p r o b l e m s has modest or no effect on health outcomes. 44-~1
FUTURE RESEARCH DIRECTIONS To i m p r o v e p r i m a r y care physicians' m a n a g e m e n t of depression, research must be c o n d u c t e d to: 1) better categorize the types of clinical depression c o m m o n l y seen in the p r i m a r y care setting; 2) define the role of the p r i m a r y care physician in recognizing, referring, and treating each category of clinical depression; and 3) d e v e l o p mental health interventions that can b e realistically p r o v i d e d by p r i m a r y care physicians to patients within these categories. Primary care mental health interventions must be feasible given the limitations of p r i m a r y care physicians' time and mental health expertise. These interventions should include guidelines on w h e n to refer, to w h o m to refer, and h o w to refer patients w h o n e e d specialized mental health care. For patients w h o are referred, interventions should be d e v e l o p e d that are integrated w i t h the care provided b y the mental health specialist. Additional research is also n e e d e d to d e v e l o p methods to train p r i m a r y care physicians to provide effective mental health care to depressed patients. It is particularly important that, as m u c h as possible, the clinical e x p e r i e n c e s of students, residents, and practicing physicians should take place in p r i m a r y care settings. Individuals w h o learn to diagnose disorders and provide mental health care in a mental health setting with well-defined and highly motivated patients and f e w e r time constraints may have difficulty transferring their mental health k n o w l e d g e and skills to the real w o r l d of p r i m a r y care. Finally, research is n e e d e d to d e v e l o p m e t h o d s to
JOURNALOFGENERALINTERNALMEDICINE,Volume 7 (March/April), 1992
promote, maintain, and reward performance of effective mental health care by primary care physicians. Primary care physicians may fail to recognize and manage depression because they lack knowledge and skills. It is also possible that this failure is due to their perceptions that mental health problems are either irrelevant to their objectives for the medical visit or beyond their capacities to effectively change. When a patient with a potential mental health problem is encountered in the medical setting, the physician commonly considers some or all of the following questions: 1) How important is it for me to address this mental health problem?; 2) Is there something that I can do for the patient with this problem?; 3) How effective is the care I can provide likely to be?; and 4) Howwill I be compensated for my efforts to manage this problem? It is, therefore, critical to develop clinical approaches to: 1) increase primary care physicians' awareness of the clinical relevance of identifying and managing depression; 2) enhance perceived effectiveness in treating this problem; and 3) ensure that primary care physicians are adequately compensated for their efforts to manage depression. There are several approaches to achieving these objectives. First, educational programs should focus on the relationship between depression and somatic symptoms, physical disease and functional status. In addition, the impact of effective management of depression on patient satisfaction with the physician and the excessive utilization of health services should be emphasized. Second, primary care physicians should be taught when and how to provide effective and practical mental health interventions that are clearly defined. Third, insurance companies must be encouraged to provide compensation for the management of depression in the primary care setting. Fourth, primary care physicians should receive more feedback on both patients' initial interest in mental health care and the perceived impact of the mental health care on illness outcomes and patient satisfaction following the medical visit. A recent study demonstrated that more effective counseling was provided when a medical resident received feedback on the following: 1) the presence of a mental health problem; 2) the impact of this problem on patient functioning; 3) the situational sources of this problem; 4) the patient's desire for help with this problem; and 5) the specific types of mental health interventions the patient desired. 27 When compared with control patients who completed the same set of questionnaires, patients seen by physicians who had received this feedback reported that the counseling they received was more valuable and they were also more satisfied with their physicians. Patients in the feedback group also reported greater decreases in the amount of overall stress experienced and greater increases in their perceived control over this stress following the medical visit when compared with control
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group patients. Further research seems warranted, therefore, on the use of patient feedback to motivate and guide physicians' management of depression.
CONCLUSIONS In summary, depression is a common and important problem in the primary care setting. There is no doubt that the quality of mental health care provided by primary care physicians can and should be improved. Before this goal can be achieved, however, a revised diagnostic nomenclature must be developed and then field-tested in primary care settings. This diagnostic system must adequately identify and describe the most prevalent types of patients with depressive symptoms seen in the primary care settings; it must be easily understood by primary care physicians; and it must clinically relate to morbidity and treatment specificity. Clearly, some depressed patients will be best served by referrals to mental health specialists. The consultation-liaison model seems to be a promising approach to providing mental health care to primary care patients. Further research is needed, however, to identify those patients who should be referred as well as the role of the primary care physician in making the initial referral and facilitating the patient's continued participation in this type of mental health care. Other patients may be appropriately managed by primary care physicians. In this regard, research is needed to accomplish the following: 1) identify mental health interventions that can be adapted effectively for use in the primary care setting; 2) evaluate methods of training primary care physicians to use these techniques; and 3) develop ways of increasing the motivation of primary care physicians to provide mental health care. We recognize that primary care physicians will never have the same knowledge, skills, and time as their mental health colleagues. Thus, it would not be appropriate for them to independently manage patients with chronic or life-threatening depression. They should, however, be able to identify patients experiencing less serious depressive symptoms and to reduce their emotional distress through mental health treatments that can be adapted for use in the general medical setting. Primary care-based management of depression might include the following: 1) supportive listening; 2) reassurance; 3) problem solving; 4) recommending selfhelp materials; 5) prescribing medications; and 6) scheduling follow-up appointments. Indeed, primary care physicians have some unique advantages over mental health specialists in providing this type of mental health care to primary care patients. Primary care physicians are particularly well situated to reassure patients who manifest their emotional distress by complaining of somatic symptoms, as well as pa-
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tients w h o s e mental health s y m p t o m s are caused or exacerbated by concerns about their physical wellbeing. The continuity o f care that exists in the primary
care setting affords primary care physicians opportunities t o e s t a b l i s h t h e r a p e u t i c r e l a t i o n s h i p s w i t h t h e i r patients over time. The trust and confidence that develop in this setting make it possible for primary care physicians to effectively influence patient behavior. For example, most studies have shown a not-immodest 5 - 10% quitting rate when a physician simply commun i c a t e s a s m o k i n g c e s s a t i o n m e s s a g e t o a p a t i e n t , s2s4 Primary care physicians generally have several opportunities to modify their patients' perceptions and beh a v i o r s as t h e y f o l l o w t h e m o v e r t i m e . Prompt attention by primary care physicians to the emotional problems of patients with depressive symptoms associated with stressful life events would help reduce the dysfunction associated with their distress and decrease the likelihood of a more deteriorated functional status or a major depressive disorder. We believe, therefore, that primary care physicians can and should play a role in the management of depression. Future research aimed at improving manage depression seems indicated.
their ability to
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40. Andersen SM, Harthorn BH. Changing the psychiatric knowledge of primary care physicians: the effects of a brief intervention on clinical diagnosis and treatment. Gen Hosp Psychiatry. 1990;12:177-90. 41. Gask L, McGrath G, Goldberg D, et al. Improving the psychiatric skills of the experienced family doctor: an evaluation of a group training course. In: Seattle, WA: Mental Disorders in General Health Care Settings: A Research Conference. 1987;209-11. 42. Roter D, Cole K, Kern D, et al. The effects of training on physicians' diagnosis and management of psychosocial problems. In: Seattle, WA: Mental Disorders in General Health Care Settings: A Research Conference. 1987;215-7. 43. Cohen-Cole SA, BirdJ, BokerJ. Medical residents' knowledge and skill after psychiatric training. In: Seattle, WA: Mental Disorders in General Health Care Settings: A Research Conference, 1987;221-2. 44. Magruder-Habib K, Zung WWK, Feussner JR, et al. Management of general medical patients with symptoms of depression. Gen Hosp Psychiatry. 1989; 11:201-6. 45. Rand EH, Badger LW, Coggins DR. Recognition of mental disorders by family practice residents: the effect of GHQ feedback. In: Seattle, WA: Mental Disorders in General Health Care Settings: A Research Conference. 1987;164-6.
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46. Linn LS, YagerJ. The effect of screening, sensitization and feedback on notation of depression. J Med Educ. 1980;55:942-9. 47. Hoeper EW, Kessler LG, Nycz GR, et al. The usefulness of screening for mental illness. Lancet. 1984;i:33-5. 48. German PS, Shapiro S, Skinner EA, et al. Direction and management of mental health problems of older patients by primary care providers. JAMA. 1987;257:489-93. 49. Shapiro S, German PS, Skinner EA, et al. An experiment to change detection and management of mental morbidity in primary care. Med Care. 1987;25:327-39. 50. Linn LS, Yager J. Screening of depression in relationship to subsequent patient and physician behavior. Med Care. 1982; 20:1233-40. 51. Johnstone A, Goldberg D. Psychiatric screening in general practice: a controlled trial. Lancet. 1976;i:605-8. 52. Rnssel MAH, Wilson C, Taylor C, et al. Effect of general practitioners' advice against smoking. Br MedJ. 1979;2:231-4. 53. Wilson D, Wood G,Johnston N, et al. Randomized clinical trial of supportive follow-up for cigarette smokers in a family practice. Can MedAssoc J. 1982;126:127-9. 54. Stewart PJ, Rosser WW. The impact of routine advice on smoking cessation from family physicians. Can Med Assoc J. 1982;126:1051-4.
AMERICAN BOARD OF INTERNAL MEDICINE 1992 Certification and Recertification Examinations in Internal Medicine Registration period: N o v e m b e r 1, 1991 - F e b r u a r y 1, 1992 ( $ 3 0 0 penalty fee for applications postmarked February 1 - A p r i l 1, 1992. No application a c c e p t e d after April 1, 1992.) Examination dates: S e p t e m b e r 15 - 16, 1992
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