Patient beliefs may determine success of depression care

A new study says outcomes are poorer in primary care because these patients are less likely to accept treatment.

By Victoria Stagg Elliott — Posted Feb. 2, 2004

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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."

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How study was done

Objective: To explore whether depressed patients treated in the primary care setting are less accepting of treatment than those seen by mental health professionals.

Participants: 881 patients with major depression who participated in the Quality Improvement for Depression Collaboration study.

Method: Based on responses to the study's initiation questionnaire, patients were categorized as either having received mental health care exclusively from their primary care doctor or in conjunction with specialty care. Minors and patients with a life-threatening condition or history of alcohol dependence were excluded.

Results: Patients receiving treatment only in the primary care setting were nearly three times more likely to believe that no treatment was acceptable. This group was also more likely to believe they would recover naturally, less likely to accept antidepressants and more likely to refuse counseling.

Conclusion: These findings may explain why some studies have found that mental health outcomes are poorer in the primary care setting.

Source: Journal of General Internal Medicine

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The primary facts

  • The World Health Organization estimates that 19 million Americans experience depression each year.
  • Despite high prevalence of depressive symptoms and major depressive episodes, the condition remains underdiagnosed and undertreated in primary care.
  • Primary care physicians are likely to hear somatic complaints from patients with depression, including headaches, backaches, fatigue, sleep problems and gastrointestinal difficulties.
  • The U.S. Preventive Health Services Task Force recommends routine primary care screening of adults for depression in primary care settings where systems are in place to assure accurate diagnosis, treatment and follow-up.

Source: "Depression in primary care: Recognizing the physical and emotional symptoms and treating to remission," AMA

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External links

"Primary Care Patients with Depression Are Less Accepting of Treatment Than Those Seen by Mental Health Specialists," abstract, Journal of General Internal Medicine, December 2003 (link)

"Do Depressed Older Adults Who Attribute Depression to 'Old Age' Believe It Is Important to Seek Care?" abstract, Journal of General Internal Medicine, December 2003 (link)

Information on the AMA's complementary CME program on recognizing and treating depression in primary care (link)

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