Depression Treatment in Primary Care

W. David Robinson, PhD; Jenenne A. Geske, PhD; Layne A. Prest, PhD; Rachel Barnacle, MS

Disclosures

J Am Board Fam Med. 2005;18(2):79-86. 

In This Article

Discussion

The results of this study were consistent with our hypotheses. Physicians prescribed pharmacotherapy more frequently than any other intervention. Female physicians were also more likely than male physicians to recommend psychotherapy to their depressed patients. In addition, FM and female physicians were more likely than IM and male physicians, respectively, to use combination therapy, with female physicians being the most likely to recommend such measures. Because of insufficient statistical power, it was difficult to isolate the interaction effects of specialty and gender on treatment decisions. Although no statistically significant interaction between physician gender and medical specialty was found, 46% of the FM physicians in this sample were women, whereas only 30% of the IM physicians were women.

A possible explanation behind these results is that family physicians are encouraged to use a biopsychosocial model when working with patients.[22,23,24] On-site behavioral medicine faculty train FM physicians at this location in this model, which emphasizes assessing and treating the patient as a whole person, including recognizing the important role of cognition, affect, and the relationship context in the origin of and recovery from depression. The FM physicians in this setting also had mental health practitioners on site, so referrals to psychotherapy could be easily made, and the physician could discuss the patient's case with the therapist. This leads to the consideration of why other specialties are less likely than FM to hire psychotherapists to work within medical clinics. Further research on these trends is warranted.

With regard to our investigation of gender differences, Hall,[20] in a meta-analysis of provider characteristics, found that female providers spend more time with their patients, talk more about psychosocial topics, engage in more partnership building, and express more positive verbal and nonverbal behaviors than male doctors. Female physicians have shown significantly greater psychosocial orientation and patient-centeredness than male physicians. These differences could explain why more women choose to become FM than IM physicians.[21] This is important because current research and treatment recommendations indicate that psychotherapy is often a patient preference.[25,26] A female doctor with partnership building skills may be more likely to ask for the patient's treatment preference (which is often psychotherapy), leading female physicians to refer their depressed patients to psychotherapy more frequently. The prevalence of female FM practitioners also suggests the likelihood of more combined prescriptions, given that women are both more likely to be FM physicians and to prescribe such treatments.

There are many reasons that psychotherapy, alone or in combination with pharmacotherapy, should be the recommended treatment. Not only is psychotherapy often the patient's preference, but therapy approaches, specifically cognitive, behavioral, or interpersonal models, have also been shown to be at least as effective as medication in treatment of mild to moderate depression.[1,27] Ward et al (2000) found that psychological therapy reduced depression more quickly than traditional general practitioner care.[28] Psychotherapy combined with medical therapy is an option for patients who do not respond to either alone.[14,19,29] Researchers have found that patients with a severe depressive disorder who are treated with a combination of psychotherapy and pharmacotherapy had an 85% remission rate as opposed to 55% for medication, and 52% in response to psychotherapy.[25] This finding indicates that combination therapy is the most effective treatment strategy available and is indicated for severely depressed patients. Despite the research findings, the current study confirms that pharmacotherapy continues to be the primary treatment modality among primary care physicians.[19,30]

The guidelines cited in the introduction recommend psychotherapy for all levels of depression, with the addition of pharmacotherapy for patients with moderate or severe depression. In addition, combination therapy (ie, psychotherapy and pharmacotherapy) has also been recommended for use when patients present with a more complex major depressive disorder.[14] For example, a fairly common yet underdiagnosed mood disorder frequently manifesting with symptoms of depression is bipolar disorder.[31] Although combination treatment is recommended for both depression and bipolar disorder, the suggested pharmacotherapy regimens for these 2 mood disorders are different. Therefore, a correct diagnosis is critical. Barriers to a correct diagnosis will be discussed in more detail below.

Another advantage to the prescription of psychotherapy or combination therapy is that persons who receive individual, couple, or family therapy have been found to require health care services less often after their therapy was completed. For example, Law et al[32] found that individuals receiving marital and family therapy significantly decreased their use of medical services by 53% 6 months after termination of therapy. Similar results were found in those persons receiving individual therapy; their health care utilization significantly decreased by 48%. Thus, prescribing psychotherapy or combination therapy to depressed persons can significantly lower the health service costs associated with these patients.

The results from this study led the researchers to question why there is such a discrepancy between research on effective depression treatment and patient preferences on the one hand and actual treatment decisions on the other. Many barriers to effective depression treatment have been previously identified, including underdiagnosis of depression. The US Preventive Services Task Force[33] reported that depression is undetected in up to 50% of all cases in primary care.

Adherence. Once patients are screened, diagnosed, and prescribed treatment, their adherence to the treatment plan becomes a potential barrier to effectively addressing the depression. Twenty-five to 30% of primary care patients treated with antidepressant medication discontinue treatment within 1 month, and 40% to 50% stop treatment within 3 months.[34,35]

Finances and Insurance. Finances can contribute to lack of patient adherence to treatment. Although there seems to be no difference in cost among general practitioner care, cognitive-behavioral therapy, and nondirective counseling,[36,37] whether or not the patient possesses insurance and the type of insurance coverage seems to influence which treatment is prescribed for a depressed patient. For example, patients who had private insurance were more likely than those who did not to receive pharmacotherapy for the treatment of their depression.[38] For this reason, patients were then less likely to receive combination therapy—the most effective treatment modality for depression.

Furthermore, patients who have little or no mental health third party coverage will often not be able to follow through on the referral for mental health services. Thus, to spare their patients financial hardship (which could intensify rather than treat the depression), physicians will purposely not diagnose patients as depressed, even when they meet the criteria for a major depressive episode. They will treat the physical symptoms (eg, lack of sleep, decreased appetite, fatigue, etc), but not the psychological ones (eg, sadness, hopelessness, guilt, etc).[39]

Physician-Patient Communication. In addition to financial concerns, another barrier may be ineffective physician-patient communication. Past evidence suggests that effective physician-patient communication leads to improved depression identification, treatment, and patient satisfaction.[40,41,42,43,44,45,46] Patients state that physicians do not encourage them to ask questions, ask their opinions about the ailment or treatment, or give advice on lifestyle changes that could possibly affect patients' health. In general, patients are satisfied with the competency of medical care, but feel that communication with their physician is lacking.[47] In addition, Nutting et al[48] suggested that poor physician-patient interaction may reduce the likelihood that primary care physicians will use treatment strategies other than medication.

Improving physician-patient communication may not only lead to improved identification and treatment of depression but also aid in the accurate diagnosis and subsequent treatment of more complex mood disorders that may initially appear as depression, such as bipolar disorder.[49] Studies suggest that 30% to 40% of patients in psychiatric and primary care settings who have been diagnosed with major depression are inaccurately diagnosed and meet the criteria for bipolar II disorder.[31,50]

Concerns With Antidepressants and Bipolar Patients. According to the National Institute of Mental Health (NIMH), the recommended treatment for bipolar disorder is a combination treatment (ie, psychotherapy and pharmacotherapy).[51] In fact, there is evidence that prescribing standard antidepressants to patients with bipolar disorder may induce mania or worsen the disorder over the long term.[52] If antidepressant medications without psychotherapy are used for the treatment of bi-polar disorder, guidelines recommend that a "mood stabilizer" be included as part of the treatment.[51,52] Ineffective physician-patient communication may contribute to the inaccurate diagnoses and subsequently the potentially damaging treatment recommendation of antidepressant medications alone. It is clear that a better understanding of the physician-patient communication process is needed. Improving the physician/patient communication process is vital in improving the care provided to depressed patients.

One limitation of this study is the small sample size. This study used a convenience sample. Consequently the researchers did not control for gender, age, ethnic group, and other demographic and social characteristics. In addition, the sample is representative of only the Midwest urban population, so the results cannot be widely generalized.

The results of this pilot study point to the need for further research. To verify the current treatment strategies indicated by these results, a larger, nationally representative sample of physicians would be an important next step. More complex mood disorders, such as bipolar and anxiety disorders, should also be included in future studies. In addition, a study including IM physicians who also have psychotherapists available on-site for referral would ensure clearer results regarding differences between IM and FM physicians' treatment recommendations.

Although the current literature describes physician treatment decisions, patient preferences, and treatment outcomes, further research efforts need to focus on what occurs during the patient-physician negotiation of treatment that so often results in drug prescriptions rather than other treatments. A detailed examination of the initial encounter between the physician and a depressed patient can provide researchers the knowledge necessary to design interventions that will enhance the physician-patient interaction and result in decisions that will improve the treatment of this major health problem.

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