Primary care clinicians' recognition and management of depression: a model of depression care in real-world primary care practice

BACKGROUND

Depression is prevalent in primary care (PC) practices and poses a considerable public health burden in the United States. Despite nearly four decades of efforts to improve depression care quality in PC practices, a gap remains between desired treatment outcomes and the reality of how depression care is delivered.

OBJECTIVE

This article presents a real-world PC practice model of depression care, elucidating the processes and their influencing conditions.

DESIGN

Grounded theory methodology was used for the data collection and analysis to develop a depression care model. Data were collected from 70 individual interviews (60 to 70 min each), three focus group interviews (n = 24, 2 h each), two surveys per clinician, and investigators' field notes on practice environments. Interviews were audiotaped and transcribed for analysis. Surveys and field notes complemented interview data.

PARTICIPANTS

Seventy primary care clinicians from 52 PC offices in the Midwest: 28 general internists, 28 family physicians, and 14 nurse practitioners.

KEY RESULTS

A depression care model was developed that illustrates how real-world conditions infuse complexity into each step of the depression care process. Depression care in PC settings is mediated through clinicians' interactions with patients, practice, and the local community. A clinician's interactional familiarity ("familiarity capital") was a powerful facilitator for depression care. For the recognition of depression, three previously reported processes and three conditions were confirmed. For the management of depression, 13 processes and 11 conditions were identified. Empowering the patient was a parallel process to the management of depression.

CONCLUSIONS

The clinician's ability to develop and utilize interactional relationships and resources needed to recognize and treat a person with depression is key to depression care in primary care settings. The interactional context of depression care makes empowering the patient central to depression care delivery.

[Innovative care models for treating depression]

Depressive disorders rank among the widespread diseases, and their relevance for the health care system is steadily increasing. Even though depressive disorders can generally be treated well, there is a further need to improve the care for depressive patients with regard to diagnostics, therapy, and cooperation of care sectors. Innovative and integrative models of care such as case management, disease management programs, and integrated care models are currently being discussed. They are expected to be useful in overcoming boundaries in the current care system and amending the course of disease and of patients' quality of life. Furthermore, changes in utilization of the health system are anticipated, leading to a diminishment of deficient care, undersupply and oversupply, and chronification. However, evidence is lacking to demonstrate the usefulness of these models of care in Germany now.