The Recognition of Depression: The Primary Care Clinician’s Perspective

PURPOSE The purpose of this study was to explore the responses of primary care clinicians to patients who complain of symptoms that might indicate depression, to examine the clinical strategies used by clinicians to recognize depression, and to identify the conditions that influence their ability to do so. METHODS The grounded theory method was used for data collection and analysis. In-depth, in-person interviews were conducted with a purposeful sample of 8 clinicians. All interviews were audiotaped and transcribed. RESULTS This study identified 3 processes clinicians engage in to recognize depression—ruling out, opening the door, and recognizing the person—and 3 conditions—familiarity with the patient, general clinical experience, and time availability—that influence how each of the processes is used. CONCLUSIONS The likelihood of accurately diagnosing depression and the timeliness of the diagnosis are highly influenced by the conditions within which clinicians practice. Productivity expectations in primary care will continue to undermine the identification and treatment of depression if they fail to take into consideration the factors that influence such care.

[1]  B. Sarter.  Paths to knowledge: innovative research methods for nursing. , 1988, NLN publications.

[2]  F. Goodwin,et al.  The de facto US mental and addictive disorders service system. Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. , 1993, Archives of general psychiatry.

[3]  D. Roter,et al.  Counseling by primary care physicians of patients who disclose psychosocial problems. , 1999, The Journal of family practice.

[4]  E. Higgins,et al.  A review of unrecognized mental illness in primary care. Prevalence, natural history, and efforts to change the course. , 1994, Archives of family medicine.

[5]  M. Thase,et al.  The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. , 1997, JAMA.

[6]  A. Dietrich,et al.  Improving the recognition and management of depression: is there a role for physician education? , 1999, The Journal of family practice.

[7]  J. Coyne,et al.  Prevalence, nature, and comorbidity of depressive disorders in primary care. , 1994, General hospital psychiatry.

[8]  T. Oxman,et al.  The prevalence of psychiatric disorders in a primary care practice. , 1988, Archives of general psychiatry.

[9]  H. Pincus,et al.  Aligning incentives in the treatment of depression in primary care with evidence-based practice. , 2003, Psychiatric services.

[10]  J. Barrett,et al.  Recognition of depression by internists in primary care , 2007, Journal of General Internal Medicine.

[11]  W. Manning,et al.  Randomized trial of a depression management program in high utilizers of medical care. , 2000, Archives of family medicine.

[12]  R. Crum,et al.  Characteristics of Patients With Major Depression Who Received Care in General Medical and Specialty Mental Health Settings , 1994, Medical care.

[13]  Howard Waitzkin,et al.  Differences in clinical communication by gender , 1999, Journal of General Internal Medicine.

[14]  J. Froom,et al.  Clinical practice guidelines on depression: awareness, attitudes, and content knowledge among family physicians in New York. , 1998, Archives of family medicine.

[15]  G. Ramirez,et al.  Identifying depression in primary care: a literature synthesis of case-finding instruments. , 2002, General hospital psychiatry.

[16]  Anselm L. Strauss,et al.  Qualitative Analysis For Social Scientists , 1987 .

[17]  W. Katon,et al.  Collaborative Care Model to Improve Outcomes in Major Depression , 2002, The Annals of pharmacotherapy.

[18]  Mark T Hegel,et al.  Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. , 2002, JAMA.

[19]  J. Susman,et al.  Depression in rural family practice. Easy to recognize, difficult to diagnose. , 1995, Archives of family medicine.

[20]  C M Rutter,et al.  Achieving guidelines for the treatment of depression in primary care: is physician education enough? , 1997, Medical care.

[21]  G. Simon,et al.  An international study of the relation between somatic symptoms and depression. , 1999, The New England journal of medicine.

[22]  S Greenfield,et al.  Detection of depressive disorder for patients receiving prepaid or fee-for-service care. Results from the Medical Outcomes Study. , 1989, JAMA.

[23]  G. Wolford,et al.  How physician communication influences recognition of depression in primary care. , 1999, The Journal of family practice.

[24]  M. Howes,et al.  Primary health care providers' recognition and diagnosis of mental disorders in their patients. , 1988, General hospital psychiatry.

[25]  J Ormel,et al.  Training primary-care physicians to recognize, diagnose and manage depression: does it improve patient outcomes? , 1999, Psychological Medicine.

[26]  Michael J. Campbell,et al.  Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial , 2000, The Lancet.

[27]  T. B. Ustün.  The global burden of mental disorders. , 1999, American journal of public health.

[28]  M. Trivedi,et al.  The Texas Medication Algorithm Project: report of the Texas Consensus Conference Panel on Medication Treatment of Major Depressive Disorder. , 1999, The Journal of clinical psychiatry.

[29]  K. Kobak,et al.  Medical costs attributed to depression among patients with a history of high medical expenses in a health maintenance organization. , 1996, Archives of general psychiatry.

[30]  R. C. Hall,et al.  The clinical and financial burden of mood disorders. Cost and outcome. , 1995, Psychosomatics.

[31]  H. Sox.  Common diagnostic tests : use and interpretation , 1987 .

[32]  H. Blumer,et al.  Symbolic Interactionism: Perspective and Method , 1988 .

[33]  Anselm L. Strauss,et al.  Social Organization and Social Process: Essays in Honor of Anselm Strauss , 1991 .

[34]  J. Coyne,et al.  Can case-finding instruments be used to improve physician detection of depression in primary care? , 1997, Archives of family medicine.

[35]  T. Oxman,et al.  The relationship of presenting physical complaints to depressive symptoms in primary care patients , 1992, Journal of General Internal Medicine.

[36]  W. Katon.  The Epidemiology of Depression in Medical Care , 1988, International journal of psychiatry in medicine.

[37]  D. Satcher.  Executive summary: a report of the Surgeon General on mental health. , 2000, Public health reports.

[38]  C. Sherbourne,et al.  Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses. , 1995, Archives of general psychiatry.

[39]  C. Sherbourne,et al.  Are Better Ratings of the Patient-Provider Relationship Associated With Higher Quality Care for Depression? , 2001, Medical care.

[40]  D. Goldberg,et al.  Somatic presentation of DSM III psychiatric disorders in primary care. , 1985, Journal of psychosomatic research.

[41]  G. Simon,et al.  Does physician education on depression management improve treatment in primary care? , 2001, Journal of General Internal Medicine.

[42]  D. Goldberg,et al.  Determinants of the ability of general practitioners to detect psychiatric illness , 1979, Psychological Medicine.

[43]  L. Kirmayer,et al.  Patients who somatize in primary care: a longitudinal study of cognitive and social characteristics , 1996, Psychological Medicine.

[44]  K C Stange,et al.  Illuminating the 'black box'. A description of 4454 patient visits to 138 family physicians. , 1998, The Journal of family practice.

[45]  W. Levinson,et al.  A study of patient clues and physician responses in primary care and surgical settings. , 2000, JAMA.

[46]  Christina Goulding,et al.  Grounded theory , 2015 .

[47]  R R McDaniel,et al.  Practice jazz: understanding variation in family practices using complexity science. , 2001, The Journal of family practice.

[48]  E. Perez-stable,et al.  Depression in medical outpatients. Underrecognition and misdiagnosis. , 1990, Archives of internal medicine.

[49]  M. Lipkin,et al.  Sex Differences in Patients' and Physicians' Communication During Primary Care Medical Visits , 1991, Medical care.

[50]  David Satcher,et al.  Mental health: A report of the Surgeon General--Executive summary. , 2000 .

[51]  C. Sherbourne,et al.  Functioning and utility for current health of patients with depression or chronic medical conditions in managed, primary care practices. , 1999, Archives of general psychiatry.

[52]  J. Susman,et al.  Technician, friend, detective, and healer: family physicians' responses to emotional distress. , 2001, Journal of Family Practice.

[53]  K. Wells,et al.  Improving care for depression in organized health care systems. , 2001, The Journal of family practice.