Counseling typically provided for depression. Role of clinician specialty and payment system

Clinician burden and depression treatment: disentangling patient- and clinician-level effects of medical comorbidity

BACKGROUND

Efforts to improve primary care depression treatment have assessed strategies across heterogeneous groups of patients, but few have examined clinician-level influences on depression treatment.

OBJECTIVE

To examine clinician characteristics that affect depression treatment in primary care settings, using multilevel ordinal regression modeling to disentangle patient- from clinician-level effects.

DESIGN

Secondary analysis from the Quality Improvement in Depression Study dataset.

PARTICIPANTS

The participants were 1,023 primary care patients with depression who reported on treatment in the 6-month follow-up and whose clinicians (n = 158) had at least 4 patients in the study.

MEASUREMENTS

Primary outcome variable was depression treatment intensity, derived from assessment of concordance with AHCPR depression treatment guidelines based on patient-reported data on their treatment. Primary independent variable was clinical practice burden for treating depression, derived from patient- and clinician-reported composite measures tested for significant association with clinician-reported practice burden.

RESULTS

Clinicians who treat patients with more chronic medical comorbidities perceive less burden from treating depressed patients in their practice (Spearman's rho = -.30, p < .05). Clinicians who treat patients with more chronic medical comorbidities also provide greater intensity of depression treatment (adjusted OR = 1.44, p = .02), even after adjusting for the effects of patient-level chronic medical comorbidities (adjusted OR = 0.95, p = .45).

CONCLUSIONS

Clinicians who provide more chronic care also provide greater depression treatment intensity, suggesting that clinicians who care for complex patients can integrate depression care into their practice. Targeting interventions to these clinicians to enhance their ability to provide guideline-concordant depression care is a worthwhile endeavor and deserves further investigation.

Non-pharmacological treatment of psychiatrists in addition to the prescribing of an antidepressant drug

BACKGROUND

Guidelines for the treatment of depression regularly emphasize that pharmacotherapy of depression should be accompanied by supportive counseling and other psychotherapeutic interventions. It is unknown which role psychiatrists in routine care give to such verbal therapies.

METHODS

In a drug utilization study of venlafaxine, psychiatrists in private practice and in hospitals were asked to tell what non-pharmacological therapies they saw as an important part of the treatment of the present depressive episode. Additionally patient characteristics, treatment variables, setting characteristics and physician characteristics were assessed.

RESULTS

Psychiatrists reported some kind of verbal therapies in 19.0% of outpatients and 36.8% of inpatients. Verbal therapies were reported more often for younger patients, who got more double diagnoses and were more severely ill. Patients with verbal therapies got more psychotropic medication. In the inpatient setting verbal therapies were related to generally more treatment overall and a higher rate of treatment response. In both treatment settings verbal therapies were related to lower rates of discontinuation of the antidepressant.

CONCLUSION

Verbal interactions are part of any patient-physician encounter and should be theory guided as part of the therapeutic process in the treatment of depressive disorders. Under this assumption the rate of patients for which psychiatrists reported some kind of verbal therapy as explicit part of their treatment could be higher. More research is needed on patient guidance, counseling and supportive psychotherapy in psychiatry.

Provider type and depression treatment adequacy

We investigate the effect of initial provider (psychiatrist versus primary care physician or non-physician mental health specialist) on the adequacy of subsequent treatment for persons with depression. Our data are from MarketScan, a medical and pharmacy insurance claims database, which we use to estimate models of the likelihood of treatment for depression and the likelihood that any anti-depression treatments received are adequate. Patients initially seeing psychiatrists are most likely to receive adequate treatment. Provider type has a statistically and medically significant effect on whether any treatment occurs but a smaller effect on treatment adequacy among treated patients. Our results show the importance of provider type in treatment patterns, but the effects on patient outcomes are yet to be determined definitively.

Physician conceptions of responsibility to individual patients and distributive justice in health care

PURPOSE

Physicians' values may be shifting under managed care, but there have been no empirical data to support this claim. We describe physician conceptions of responsibility to individual patients and distributive justice in health care, and explore whether these values are associated with type of managed care practice and professional satisfaction.

METHODS

We mailed a questionnaire to 500 primary care physicians from 80 out-patient clinics in 11 managed care organizations (MCOs) who were participating in 4 studies designed to improve the quality of depression care in primary care.

RESULTS

We received 414 responses (response rate 83%). Twenty-eight percent of physicians strongly agreed that their main responsibility was to the individual patient rather than to society (strong sense of responsibility to individual patients). Physicians with a strong sense of responsibility to individual patients were older (43% of physicians older than 50 years reported a strong sense of responsibility to individual patients, compared with 26% of physicians aged 36 to 50 years, and 21% of physicians younger than 35 years, P = .009) and tended to practice in network- rather than staff-model MCOs (33% of physicians in network-model MCOs reported a strong sense of responsibility to individual patients compared with 24% in staff-model MCOs, P = .077). Scores on a scale measuring egalitarian conceptions of distributive justice within the health care system were similar for physicians regardless of whether they reported a strong sense of responsibility to individual patients. When we controlled for physician and practice characteristics, physicians with a strong sense of responsibility to individual patients and physicians with higher scores on an egalitarian scale were more likely to be very satisfied overall with their practices (adjusted odds ratio [AOR] = 2.23, 95% confidence interval [CI], 1.11-4.49, and AOR = 1.18, 95% CI, 1.09-1.29, respectively).

CONCLUSIONS

Physicians with a strong sense of responsibility to individual patients are older and less likely to practice in staff-model MCOs. Stronger commitment to an egalitarian health care system and a strong sense of responsibility to individual patients are independently associated with greater practice satisfaction among physicians. The impact of these values on patient care should be a priority for future research and the subject of professional education and debate.

Clinician screening and treatment of alcohol, drug, and mental problems in primary care: results from healthcare for communities

OBJECTIVE

We sought to estimate national rates of screening and treatment of alcohol, drug, and mental (ADM) problems in primary care.

DESIGN

This was a cross-sectional survey administered from 1997 to 1998.

PARTICIPANTS

Our study included a nationally representative household probability sample of 7301 primary care patients.

MEASUREMENT

We used patient self-reports from a telephone survey to estimate rates of screening and treatment of common ADM problems, to examine the types of screening and treatment received, and to investigate adherence with treatment recommendations. Covariates included measures of ADM conditions, physical health, and sociodemographic indicators.

RESULTS

Among adult primary care patients, 38.6% (95% confidence intervals [CI] 37.2-40.0) reported clinician screening for an ADM problem. Alcohol or drug screening occurred more frequently (28.3%; 95% CI 27.0-29.6) than screening for depression and anxiety (21.2%; 95% CI 20.1-22.2). Among those screened, 30.1% (95% CI; 27.8-32.4) reported ADM treatment in primary care. Medications (16.4%; 95% CI 14.3-18.5) and counseling (18.2%; 95% CI 16.1-20.3) were the most common treatments. Rates of screening were higher among individuals with ADM disorders, the young and middle aged, and the college educated. Treatment rates were higher among individuals with ADM disorders.

CONCLUSIONS

Substantial effort is expended screening and treating common ADM problems in primary care, and these efforts are targeted towards those with ADM disorders. However, only about half of individuals with an ADM disorder report being screened, and among this group, about 60% report receiving any treatment.

A health service perspective on anorexia nervosa

This article reviews anorexia nervosa from a health services perspective. From such a perspective, costs of care, changes in insurance types, lack of empirically supported treatments, and involvement of legislative and judicial processes are discussed. Based on this review, processes for designing optimal insurance strategies are outlined, needs for treatment, service, and prevention development suggested, and the need for systematic evaluation of effective treatments identified.

Race, quality of depression care, and recovery from major depression in a primary care setting

Racial variations in the use of effective medical care and subsequent clinical outcomes have been identified for many medical conditions. Still, it is unclear whether racial variations in care and clinical outcomes exist for depressed primary care patients. Primary care patients presenting for routine treatment were screened for major depression as part of a study to disseminate a depression treatment guideline. Primary care physicians (PCPs) were informed of their patients' depression via an electronic medical record system and asked whether they agreed with the diagnosis. Treatment patterns and depressive symptoms over the following six-months were assessed by chart review and the Hamilton Rating Scale for Depression, respectively. Over a 20-month period, 8,944 African-American and Caucasian patients aged 18-64 were approached for screening. African-Americans were less likely to agree to undergo screening than Caucasians (83% vs. 88%; P<.0001), but those doing so were more likely to report mood symptoms (26% vs. 15%; P<.001). 204 patients, including 52 African-Americans (25%), met protocol-eligibility criteria and completed a baseline interview. Baseline sociodemographic and clinical characteristics, and PCPs' agreement rate with the depression diagnosis were similar. Although PCPs were less likely to counsel their African-American than Caucasian patients for depression (P=.03), this difference resolved after adjusting for education level, employment, and insurance status and we found no other variations in the depression care provided or in clinical outcomes by race. We found little racial variation in either process measures or clinical outcomes for depression in our sample of African-American and Caucasian primary care patients.

Are psychiatrists' characteristics related to how they care for depression in the medically ill? Results from a national case-vignette survey

The authors' goal was to examine the relationship between psychiatrists' characteristics and their decisions regarding depression care. A national sampling of 278 psychiatrists answered diagnosis and treatment questions for one of four case vignettes with depression and various degrees of medical comorbidity. They also responded to a questionnaire assessing practice and demographic characteristics. Tendency to diagnose major depression was significantly associated with being board certified, being in practice for less time, having a greater percentage of patients with managed care, and having a greater percentage of patients on psychotropic medications. Tendency to recommend an antidepressant was significantly associated with the psychiatrist being male, being less satisfied with practice, and having a greater percentage of patients on psychotropic medications. These findings remained significant even after controlling for case characteristics. Diagnostic and prescribing tendencies of psychiatrists appear to be associated with specific physician characteristics and not simply case characteristics. These findings have implications for further studies of predictors of quality of care.

Meeting the needs of primary care physicians: a guide to content for programs on depression

OBJECTIVE

The purpose of this article is to identify literature-based content for the design of educational programs on depression for practicing primary care physicians.

METHODS

A MEDLINE search was conducted of English-language medical literature published from 1982 through July 1997 for studies describing primary care physicians' knowledge, skills, practice patterns, and perceived barriers related to care of depressed patients. Studies focusing exclusively on residency training and those describing physician practices outside North America were excluded. Of 377 articles identified, forty met inclusion and exclusion criteria.

RESULTS

Recommendations for educational content were identified from the literature review. For recognition, educators should prioritize communication skills and strategies for the use of depression questionnaires. For diagnosis, practice interpreting symptoms in the medically ill, strategies for efficient diagnosis, and systematic approaches to assessing suicide risk should be emphasized. For treatment, greater attention to the therapeutic alliance, staged therapy, and strategies for improving medication adherence are indicated.

CONCLUSIONS

There is a moderately well developed literature describing self-perceived and observed gaps in the current care for depression in primary care. Addressing the entire list of needs would take more time than practicing physicians are likely to have. An important challenge for educators is to design flexible programs based on individualized needs assessment or, when not possible, to prioritize the most generalizable needs.

Who is at risk of nondetection of mental health problems in primary care?

OBJECTIVE

To determine patient and provider characteristics associated with increased risk of nondetection of mental health problems by primary care physicians.

DESIGN

Cross-sectional patient and physician surveys conducted as part of the Medical Outcomes Study.

PARTICIPANTS

We studied 19,309 patients and 349 internists and family physicians.

MEASUREMENTS AND MAIN RESULTS

We counted "detection" of a mental health problem whenever physicians reported, in a postvisit survey, that they thought the patient had a mental health problem or that they had counseled or referred the patient for mental health. Key independent variables included patient self-reported demographic characteristics, health-related quality of life (HRQOL), depression diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders, and physician demographics and proclivity to provide counseling for depression. Logistic regression analysis, adjusted for HRQOL, revealed physicians were less likely to detect mental health problems in African Americans (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.46 to 0.86), men (OR, 0.64; 95% CI, 0.54 to 0.75), and patients younger than 35 years (OR, 0.61; 95% CI, 0.44 to 0.84), and more likely to detect them in patients with diabetes (OR, 1.4; 95% CI, 1.0 to 1.8) or hypertension (OR, 1.3; 95% CI, 1.1 to 1.6). In a model that included DSM-III diagnoses, odds of detection remained reduced for African Americans as well as for Hispanics (OR, 0.29; 95% CI, 0.11 to 0.71), and patients with more-severe DSM-III diagnoses were more likely to be detected. Physician proclivity toward providing counseling for depression influenced the likelihood of detection.

CONCLUSIONS

Patients' race, gender, and coexisting medical conditions affected physician awareness of mental health problems. Strategies to improve detection of mental health problems among African Americans, Hispanics, and men should be explored and evaluated.

Awareness, diagnosis, and treatment of depression

OBJECTIVES

To review recent findings on the epidemiology, burden, diagnosis, comorbidity, and treatment of depression, particularly in general medical settings; to delineate barriers to the recognition, diagnosis, and optimal management of depression in general medical settings; and to summarize efforts under way to reduce some of these barriers.

DESIGN

MEDLINE searches were conducted to identify scientific articles published during the previous 10 years addressing depression in general medical settings and epidemiology, co-occurring conditions, diagnosis, costs, outcomes, and treatment. Articles relevant to the objective were selected and summarized.

CONCLUSIONS

Depression occurs commonly, causing suffering, functional impairment, increased risk of suicide, added health care costs, and productivity losses. Effective treatments are available both when depression occurs alone and when it co-occurs with general medical illnesses. Many cases of depression seen in general medical settings are suitable for treatment within those settings. About half of all cases of depression in primary care settings are recognized, although subsequent treatments often fall short of existing practice guidelines. When treatments of documented efficacy are used, short-term patient outcomes are generally good. Barriers to diagnosing and treating depression include stigma; patient somatization and denial; physician knowledge and skill deficits; limited time; lack of availability of providers and treatments; limitations of third-party coverage; and restrictions on specialist, drug, and psychotherapeutic care. Public and professional education efforts, destigmatization, and improvement in access to mental health care are all needed to reduce these barriers.

Treating depression in staff-model versus network-model managed care organizations

OBJECTIVE

To compare primary care providers' depression-related knowledge, attitudes, and practices and to understand how these reports vary for providers in staff or group-model managed care organizations (MCOs) compared with network-model MCOs including independent practice associations and preferred provider organizations.

DESIGN

Survey of primary care providers' depression-related practices in 1996.

SETTING AND PARTICIPANTS

We surveyed 410 providers, from 80 outpatient clinics, in 11 MCOs participating in four studies designed to improve the quality of depression care in primary care.

MEASUREMENTS AND MAIN RESULTS

We measured knowledge based on depression guidelines, attitudes (beliefs about burden, skill, and barriers) related to depression, and reported behavior. Providers in both types of MCO are equally knowledgeable about treating depression (better knowledge of pharmacologic than psychotherapeutic treatments) and perceive equivalent skills in treating depression. However, compared with network-model providers, staff/group-model providers have stronger beliefs that treating depression is burdensome to their practice. While more staff/group-model providers reported time limitations as a barrier to optimal depression treatment, more network-model providers reported limited access to mental health specialty referral as a barrier. Accordingly, these staff/group-model providers are more likely to treat patients with major depression through referral (51% vs 38%) or to assess but not treat (17% vs 7%), and network-model providers are more likely to prescribe antidepressants (57% vs 6%) as first-line treatment.

CONCLUSIONS

Whereas the providers from staff/group-model MCOs had greater access to and relied more on referral, the providers from network-model organizations were more likely to treat depression themselves. Given varying attitudes and behaviors, improving primary care for the treatment of depression will require unique strategies beyond enhancing technical knowledge for the two types of MCOs.

Treatment of depression in older primary care patients in health maintenance organizations

OBJECTIVE

To examine whether older HMO patients with depression are treated differently than younger patients in terms of diagnosis, treatment by specialty provider, and pharmacotherapy.

DESIGN

Chart-review, Cross sectional study.

SETTING AND PARTICIPANTS

Patients were selected from six HMOs in the United States who had one or more of five medical diagnoses: arthritis, asthma, otitis media, epigastric pain/ulcer, and hypertension, (n = 9143). From this group, chart diagnoses and pharmacy records were used to identify patients who also had a diagnosis of depression (n = 416) or who had a diagnosis of depression and/or treatment with antidepressant medication (n = 1286).

MEASUREMENT

Medical records and computerized service and pharmacy records were reviewed to obtain diagnoses, office visits by provider type, and psychiatric medication prescription counts.

RESULTS

Significant differences were found in treatment of depression for older versus younger patients. Although depression was identified at a similar rate for both groups, older patients received fewer mental health specialty visits and fewer prescriptions for SSRI antidepressants. Older patients with a diagnosis of depression were more likely to be treated with benzodiazepines (49.2% of older vs. 33.2% of younger) though they were less likely to receive long half-life benzodiazepines.

CONCLUSIONS

Psychotropic medication management is an important target for improving quality of care for older patients with depression in HMOs. Decreasing inefficient minor tranquilizer use and increasing use of newer antidepressant medications may lead to improved outcomes for older depressed adults.