Patient beliefs may determine success of depression care

Michael S. Klinkman, MD, a family physician in Ann Arbor, Mich., knows from experience that patients with depression are often more challenging to treat than those who seek out a psychiatrist or other mental health professional.

"In primary care, we have an adverse selection of patients," said Dr. Klinkman, an associate professor at the University of Michigan Health System. "What we're often left with is this group of patients who haven't already decided [whether] they're going to go to a mental health professional and they haven't already decided [whether] they're going to accept treatment. In many cases they don't even know that what they have is depression."

Dr. Klinkman's theory is common among primary care physicians, but proof supporting it has been lacking -- until now.

According to a paper in the December 2003 Journal of General Internal Medicine, depressed patients treated exclusively in the primary care setting are nearly three times more likely than those treated by mental health professionals to believe that no treatment modality is acceptable. Patients in this group also are more likely to believe that they will get over depression naturally, are less likely to accept antidepressants and are more likely to refuse counseling.

"This is part of the reason that primary care doctors are so frustrated with treating depression," said Daniel E. Ford, MD, MPH, lead investigator and professor of medicine and psychiatry at Johns Hopkins University School of Medicine in Baltimore.

Patient variables, outcome differences

The authors suggest that this inherent patient difference might explain why treatment outcomes tend to be stronger in the mental health care setting. They also suggest that although some patient attitudes are particularly germane to depression, the findings may explain quality gaps found for other conditions.

"When it always looks like quality is poorer in the primary care setting, I'm not sure we've really taken into account all of the patient variables," Dr. Ford said. "Primary care doctors shouldn't be blamed so much when the quality of care doesn't look as good."

Complicating the matter further is that primary care physicians tend to have much less time to deal with the very patients who actually might be more challenging.

But experts maintain that offering these services in the primary care setting is an important option, especially for patients unwilling or unable to seek it elsewhere. One of the advantages it offers is continuity of care and patient contact, a factor that could improve depression care. And the ability to address mental health concerns in this environment would be further maximized if primary care doctors could allow more time for visits related to mental health, they say.

"If the patient has a good relationship with their primary care physician, they're more likely to trust them and to follow their advice, more likely to follow up if the doctor recommends that they see their colleague in psychiatry and more likely to take their medication," said David Mischoulon, MD, PhD, staff psychiatrist at Massachusetts General Hospital in Boston. "There's an important trust issue here, and the worst patients, paradoxically, are the patients who don't go to the psychiatrist."

In a related study in the same journal, researchers found that this concept of patients being resistant to treatment might be particularly widespread among a very specific population -- the elderly.

Researchers at the University of California, Los Angeles, found that nearly half of randomly surveyed patients older than 65 who received primary care at the university attributed depression to aging and did not think it was important to discuss with doctors.

"It's really important that we don't medicalize the aging process," said Catherine Sarkisian, MD, MSPH, lead author and assistant professor in the UCLA division of geriatrics. "We need studies like this one to help us decide when we should try to change people's attitudes and when we should not."