Management. The main management approach was to rely on medication. Only a few physicians reported doing some counseling themselves, citing time, training, and interest as barriers to doing more. Although most reported that they encouraged counseling, they cited the shortage of mental health professionals in the area, patient reluctance, and the difficulty of coordinating care as reasons for the small number of patients who actually see counselors. Only 2 clinicians had developed working relationships with counselors in their areas. Follow-up appeared to consist primarily of checks on medications; once satisfied with this issue there was no effort at active monitoring or routine follow-up. No office had nurses or other staff routinely involved in follow-up, although staff reported occasionally facilitating follow-up for individual patients who came to their attention.
Attitudes and Barriers to Systematizing Care
Identification. All 4 focus groups were against the routine use of any type of screening questionnaire, partly because “that is not the way to practice medicine” and partly because of concern about negative reactions from patients. However, there was also a physician belief that most significant problems would surface eventually, and they were not sure they wanted to unearth additional potential problems in this area.
Management. Although there was much more receptivity to the idea of organized monitoring and follow-up of identified patients by telephone (primarily for those on medications), most physicians were not sure that most patients would need it. Staff reported that it was not uncommon for patients to talk to them informally about their problems. All of the groups, except the family physicians, were enthusiastic about having a mental health counselor on site part-time. Possible roles suggested for such a person included medication monitoring by phone, phone discussions with callers who had mental health concerns, and office sessions with people needing counseling. Office staff felt there was a strong unmet need for obtaining easily accessible counseling for these patients. The family physicians had less interest in such a position for counseling, preferring the position be used for outreach and monitoring. Staff also wanted someone who was knowledgeable about mental health resources in the area and someone who could deal with managed care plans about mental health. The physicians’ main concerns were how to cover the cost of such a person and the complexity of sharing care.
Physician Survey Responses
Seventeen of the 27 clinicians completed the survey, and there was at least one respondent from each of the 9 practices. These 13 physicians and 4 midlevel practitioners nearly unanimously agreed that recognizing and treating depression was their responsibility (one physician was neutral). They reported seeing approximately 7 patients with depression per week and treating approximately one half of these entirely by themselves. Twelve felt “very” or “mostly” confident in their ability to manage them; 5 were “somewhat” confident.
Table 1 displays physicians’ report of the barriers they perceive to be affecting their ability to treat patients with depression. Lack of time was the biggest barrier, although 75% reported that patient reluctance for treatment and the unavailability of mental health consultation were at least a minor problem. Reimbursement issues and the discomfort of dealing with mental health problems did not seem very troublesome to most clinicians.
Patient Survey Responses
Of the 900 HSCL-d20 surveys requested from the 9 clinics, 668 (74%) were completed and returned. The range of responses per clinic was 35 to 100 with an average of 74. A total of 284 (42%) of these patients had a score of at least 0.75 (possible depression), and 75 (11%) scored higher than 1.75 (possible major depression). After at least 5 attempts to contact these patients, we reached 220 (77%) who agreed to complete the PRQ interview.
Table 2 shows the main responses relevant to this report. Compared with the less symptomatic patients, the more severely symptomatic patients were more likely to feel depressed (53% vs 21%), to be taking psychotropic medications (49% vs 29%), or to be seeing a psychotherapist (23% vs 6%). They were also more likely to mention mood to the clinician (49% vs 34%), and the clinician was more likely to have suggested that the patient was depressed (28% vs 8%), even if the clinician did not ask about mood. These differences suggest that more severely symptomatic patients do get attention from the clinician and are more likely to receive treatment than less symptomatic patients.
Although 49% of the patients with possible major depression and 29% of those with possible minor depression reported taking psychotropic medications, only 19% and 12% of these patients, respectively, reported being given a follow-up appointment. The low proportions receiving follow-up are similar if any type of treatment is considered (psychotropics, psycho therapy, or support groups). Moreover, even if they were receiving psychotropics, these patients were still relatively highly symptomatic.