The Need for a System in the Care of Depression

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Original Research

The Need for a System in the Care of Depression

J Fam Pract. 1999 December;48(12):973-979

References

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Methods

We used 3 different techniques to gather the baseline data needed from primary care practices: focus groups, physician surveys, and patient surveys.

Focus Groups

We held 4 focus groups for the purpose of understanding attitudes and perceived behaviors. The participants in these groups were family physicians (n = 6), general internists (n = 5), nurses from the participating physicians’ offices (n = 9), and medical assistants from the same offices (n = 7). The physicians were recruited in the Portland, Maine, area from a group of 16 invited physicians who fit the criteria of representing a diversity of ages, years in practice, sex, and osteopathic or allopathic training. Three physicians declined to participate, and 2 others agreed but did not appear at the focus group meeting. The participating physicians were asked to invite nurses and medical assistants who worked with them to participate in the other groups. All participants signed consent forms and were paid for their time. A senior research fellow and an assistant from the Center for Survey Research at the University of Massachusetts-Boston led the groups, using standard focus group techniques.²² They asked about the participants’ approach to identifying and treating depression, their attitudes toward various systematic ways to facilitate this care, and what barriers they saw to making such changes. The sessions were videotaped and summarized by the leader, using the videotapes to double-check the impressions of what had been said.

Physician Survey

The purpose of the survey was to learn how confident the clinicians felt about managing depression and what they felt were the main barriers to their care of depressed patients, so that appropriate interventions could be provided. We recruited 9 family medicine or internal medicine practices from the areas of Portland, Maine, and Claremont and Manchester, New Hampshire, to participate in this project. One other practice that we approached declined. Other than representing a range of practice sizes, ages, and locations these practices were selected because they had at least 100 patient visits per week and did not include any of the physicians in the earlier focus groups. These 9 practices contained 27 clinicians: 10 family physicians, 11 general internists, 3 physician assistants, and 3 nurse practitioners. Three were solo practices, and the others ranged in size from 2 to 6 clinicians. The questionnaire they were asked to complete had previously been used with a larger sample of Maine physicians²³ and was supplemented by questions from one used in a nationally representative sample of primary care physicians.²⁴

Patient Survey

The purpose of the patient survey was to learn about both clinician and patient behavior from the viewpoint of patients with depressive symptoms visiting these clinics. We collected this information by first asking the clinics to obtain completed 20-item Hopkins Symptom Checklist depression scale (HSCL-d20) questionnaires from all consenting adult regular patients during office visits.^2,25 The only exclusion criterion was the inability to see or read the questionnaire. Practice staff were trained in procedures for consistent collection of these data, and results were not made available to the clinicians seeing the patients. Each practice was asked to obtain written consent and HSCL-d20 completions from 100 consecutive eligible patients.

A research assistant called patients who scored higher than 0.75 on a scale of 0 to 4.0 on the HSCL-d20 within 2 weeks of their visit to complete a structured interview. Although a score higher than 1.75 has reasonable sensitivity (86%) and specificity (93%) for major depression,^26,27 a cut-point score of 0.75 allows overinclusiveness for cases of minor and unrecovered depression.² The interviewer used the Physician Response Questionnaire (PRQ), which questions whether there was any clinician discussion or recommendation about mood or depression during the visit and how the patient responded to those discussions.²⁸

The responses were compared between the group of patients scoring between 0.75 and 1.75 and those scoring higher than 1.75 using a Student’s t test for continuous variables and a chi-square test for categorical variables. Although not the same as a diagnostic interview, splitting the subjects by symptom severity allowed us to look at whether the primary care physicians were more likely to provide attention and treatment to those with more severe symptoms.

Results

Focus Groups

There was unanimous agreement in all 4 focus groups that identifying and treating mental health problems is a big part of primary care and an acceptable part of the physicians’ responsibility.

Perceptions of the Current Care Process

Identification. No physician or practice used any form of routine screening for mental health problems. Although some physicians said they included a few mental health symptoms in their routine checkup histories, most relied on finding these problems as they explored presenting symptoms. When identified, there was little effort reported to define a diagnostic category in specific terms; depression and anxiety were often lumped together as psychological distress.