How physician communication influences recognition of depression in primary care.

BACKGROUND: The relationship between physician communication patterns and the successful recognition of depression is poorly understood. METHODS: We used unannounced visits by actors playing standardized patients to evaluate verbal communication between primary care physicians and a patient presenting with a minor depression scenario. Participants (n = 77) were assigned to receive 2 visits from a man or woman portraying a 26-year-old patient with chronic headaches who meets the criteria for minor depression. The standardized patients carried hidden audiotape recorders and high-fidelity microphones to document the encounters. The audiotapes were coded at 2-second intervals. These data were linked to information gathered from standardized patient checklists, medical records, and debriefing telephone calls with participants. RESULTS: We obtained complete data on 59 (77%) of the physician-patient encounters; of those, 43 (73%) of the physicians recognized depression. Physicians who recognized depression asked twice as many questions about feelings and affect compared with those who did not (for feelings: 1.9% of total physician activity vs. 0.9%, P = .017; for affect: composite score of 2.7% of total physician activity vs 1.3%, P = .003). We found no differences in the proportion or timing of broad to narrow questioning between those who did and did not recognize depression. Physicians who successfully recognized depression later in the interview showed an increase in questions about feelings in the quartile just before recognition occurred. CONCLUSIONS: Physicians who recognized depression differed significantly in the percentage of questions about feeling and affect, and an increase in questions about feelings may precede a diagnosis of depression, though more research is needed to establish this as an important finding.

Recognizing and managing depression in primary care: a standardized patient study.

BACKGROUND: Guidelines for recognition and management of depression in primary care provide a framework for detailed exploration of physician practice patterns. METHODS: Our objective was to explore physician diagnosis and management approaches to depressive disorders according to type (major vs. minor) and presenting complaint (difficulty sleeping and concentrating vs. headache). The participants were community primary care internists and family physicians in northern New England, Washington, and Alabama (N = 149) who were randomly assigned to receive a visit from an unannounced actor portraying a standardized patient in 1 of 2 depression scenarios: (A) insomnia and poor concentration meeting Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) criteria for major depressive disorder; or (B) tension headaches meeting the criteria for minor depression. RESULTS: All physicians who were assigned to the standardized patients presenting with scenario A recognized depression, and 49% (38 of 78) of those assigned to scenario B patients diagnosed depression. Of those recognizing depression, 72% and 42% queried patients about anhedonia and mood, respectively. For both scenarios, if fewer than 2 DSM-III-R criteria were explored, depression was not diagnosed. Management for scenario A was compatible with Agency for Health Care Policy and Research guidelines, including the prescription of an antidepressant (94%), scheduling of a follow-up visit within 2 weeks (61%), and exploration of suicidal ideation (69.4%). For scenario B, management included over-the-counter analgesics for the headache (84%), exercise (63%), prescription for an antidepressant (53%), recommendation for ongoing counseling (100%), and follow-up within 2 weeks (42%). CONCLUSIONS: Major depression is recognized in primary care at a very high rate. Guidelines for recognizing and managing depression are often followed in primary care. Patients' presentations of depression influence its recognition and management.

Variations in approaching the diagnosis of depression: a guided focus group study.

BACKGROUND: Primary care physicians are often held to the same standard of performance as mental health specialists, yet they face special challenges in recognizing and treating depression. The purpose of this study was to explore the range of approaches to diagnose depression. METHODS: A purposeful sample of 21 primary care physicians in three US cities participated. A semistructured series of questions and clinical cases stimulated discussions about recognizing and managing major and minor depression. The focus groups were videotaped, and data were analyzed by two independent reviewers using the classic method of content analysis. RESULTS: Primary care providers have three major ways of approaching the diagnosis of depression: a biomedical exclusionary approach, where investigation of all physical complaints occurs first; a mental health approach, where psychosocial aspects of a presentation are pursued first; and a synergistic approach, where physical and mental health complaints are addressed simultaneously. Physicians move freely across all approaches depending on patient cues. CONCLUSIONS: Physicians' approaches to depression vary depending on patient characteristics and cues. Through a better understanding of current practices, future researchers can identify the optimal clinical approaches to match the characteristics and cues of specific patients. This study informed the development of a larger objective study of primary care physician performance.

The case for integration of social work psychosocial services into rural primary care practice.

This article argues for health and mental health collaboration between social workers and rural primary care physicians and describes a study of physicians' attitudes toward integrated services. The physicians who expressed interest in a collaborative arrangement differed in practice characteristics, attitudes toward social workers, and endorsement of social work roles. Also, interested physicians treated significantly more patients, had the lowest proportion of patients over age 65, and endorsed as useful a significantly larger number of social work activities. If social workers aspire to collaborative arrangements in rural primary care, they must provide excellent services now, continue to work toward a better understanding of their broad mental health competencies, and be willing to provide services that conform to the expectations and limitations of primary care.

Stability of standardized patients' performance in a study of clinical decision making.

BACKGROUND: Standardized patients (SPs) have been used extensively in teaching, but their reliability for use in research has been infrequently addressed. This study analyzes the reliability of performance of 13 SPs during 228 doctor-patient encounters in a year-long study related to the diagnosis of depression. METHODS: Patient scenarios were based on real patient cases. Four of the five cases had major depressive disorder. Two to three SPs were coached to enact each of the five case scenarios. Medical encounters were videotaped. Interview content was extracted onto a standardized checklist. Interaction between physician and patient was measured by the Interactional System for Interview Evaluation. Tests of SP performance reliability included the: 1) consistency of symptoms volunteered, 2) stability of affect and behavior, and 3) association of SP performance to detection of depression. RESULTS: The mean number of SP performances was 20.8 (SD = 5.8), with a range of 6 to 28. Problems with reliability emerged in one of the five patient cases. Results otherwise revealed high intra-performance and inter-performance reliabilities. Detection of depression was consistent across SPs and with the rates reported in the literature. CONCLUSIONS: This study provides evidence that performances, within and among SPs, remained consistent, even when intervals between performances were as long as 3 months.

Psychosocial interest, medical interviews, and the recognition of depression.

OBJECTIVES: To measure primary care physicians' attitudes toward psychosocial issues, determine their relationship to the style of the medical interview, and assess whether attitudes and interview behaviors lead to correct diagnosis in patients with depression. DESIGN: Physicians were videotaped while interviewing four patients standardized with criteria symptoms of major depression. Physicians were unaware of the mental health focus of the study. SETTING: Patient examining rooms. PARTICIPANTS: Physicians were eligible for recruitment if they were board certified or eligible in family practice or internal medicine, practiced primary care medicine, and were listed in regional directories. Standardized patients were recruited from the community. MAIN OUTCOME MEASURES: Attitudes toward psychosocial issues (measured by the Physician Belief Scale), interview content (measured by review of the videotaped encounters), interview behaviors (measured by the Interaction Analysis System for Interview Evaluation), and a listing of depression in the differential diagnosis (determined by physician debriefing interviews). RESULTS: Forty-seven community-based practitioners participated. Forty-eight percent of interviews resulted in a diagnosis of depression. Physician Belief Scale scores were not significantly correlated with patient-centered interviewing, psychosocial questions, inquiry about depression symptoms, or a depression diagnosis. Longer interviews were more likely to result in a depression diagnosis. CONCLUSIONS: High interest in psychosocial issues was not associated with patient-centered interviewing behaviors, questions about psychosocial or depression symptoms, or depression diagnoses. However, certain patient-centered interviewing behaviors, particularly those defined as "affective," did lead to the recognition of depression.

Patient presentation, interview content, and the detection of depression by primary care physicians.

This study was undertaken in order to better understand the detection of depression by primary care physicians. Specifically, we investigated the relationship between information gathered during the course of the medical interview and the subsequent diagnosis of depression. Forty-seven community-based primary care physicians, unaware of the mental health focus of this research, were videotaped in the office setting, as they interviewed two "typical" standardized patients who met DSM-III-R criteria for major depression. One patient presented with headaches and the other presented with palpitations and chest pain. After each interview, physicians were provided with physical findings and results of any diagnostic procedures they ordered, then asked to construct and explicate their differential diagnoses. The two patients were correctly diagnosed as depressed by 53 and 45% of the physicians. Although detection was related to greater amounts of information gathered, inquiry about the DSM-III-R criteria symptoms was generally low, and in no case was sufficient information acquired to make a formal DSM-III-R diagnosis of depression. However, a subset of the DSM-III-R symptoms (those related to disturbances of appetite, sleep, and other neurovegetative functions) were among the reasons cited for inclusion of depression in the differential, as were psychosocial stressors and the patient's appearance. These findings suggest that detection of depression is low by primary care physicians.

Reporting of child abuse: influence of characteristics of physician, practice, and community.

This survey of 120 Alabama pediatricians, family physicians, and general practitioners investigated the relationship between physician, practice, and community characteristics and the factors that impede reporting of detected child abuse. Solo practitioners and rural physicians were most concerned about the effect of reporting on their relationship with their patients. Small town physicians, recent medical school graduates, and physicians who had attended child abuse workshops were most likely, and urban physicians least likely, to endorse an ethical or legal responsibility to report. Attendees of workshops were more confident in their ability to recognize abuse and less likely to think they could best handle the case themselves. Male physicians were reluctant to report because of the likelihood of having to appear in court. All physicians were reluctant to report cases about which they were uncertain and were concerned about the lack of prompt action after their reports; general practitioners expressed reluctance to report due to a wide variety of factors.

Utility of the psychiatric screen among the Navajo of Chinle: a fourth-year clerkship experience.

This study presents a trial in which the General Health Questionnaire (GHQ) was introduced among general medicine clinic patients on a Navajo Indian reservation in Chinle, Arizona, to test its utility in enhancing recognition of significant psychiatric problems. It was found useful in alerting physicians to suicidal patients, and in identifying risk factors such as household size and number of children for symptoms of anxiety and depression. The few problems encountered in administration of the screening tool could easily be overcome.

Toward a resolution of contradictions. Utility of feedback from the GHQ.

Methodologic problems in prior research have contributed to contradictory findings about the effect of feedback from self-report questionnaires on the recognition of mental disorders in primary care settings. This study addresses those problems by assigning family practice resident physicians (N = 32), not their patients, to experimental and control groups, and by collecting baseline as well as postintervention data, for a total of 1040 patient encounters. The 28-item GHQ served as the screening instrument and was given to all participating patients seen by the experimental group. Following training in their interpretation, feedback of GHQ results constituted the intervention. Measures of recognition included a psychiatric diagnosis, psychologic and psychosocial chart notations, and various treatment options (e.g., therapy, consultation, referral, drugs, singly and in combination). Evidence for a diagnosis of mental disorder was limited to the Assessment portion of the SOAP note. Results indicate that GHQ feedback resulted in a significant twofold increase in the total number of psychiatric diagnoses. Recognition was heightened in all diagnostic categories, with a statistically significant increase in the number of depression diagnoses. Similarly, employment of all treatment modalities increased following feedback, although the only statistically significant increase was the prescription of antidepressant drugs. Psychologic notations increased as well, but psychosocial notations did not. Physicians who tended to recognize psychiatric morbidity at pretest benefited most from GHQ feedback. Implications for future research are discussed.

Mental health training of primary care physicians: an outcome study.

It is well documented that primary care physicians encounter many patients in their practices who suffer psychiatric morbidity, especially affective, anxiety and substance abuse disorders. These physicians have been unable to effectively address the needs of these patients, over half of whom receive care exclusively in the primary care sector. Five years after implementing a curriculum to train family practice physicians to assume a comprehensive psychiatric role with patients in their practices, the authors undertook an outcome evaluation. The focus was on psychiatric disorder recognition, diagnosis, documentation, and management, including referral. It was hoped that biopsychosocial and community mental health orientations emphasized during training would be incorporated into the subsequent primary care practices of physicians in the study. In the research design, physician-generated diagnoses were compared with DIS/DSM-III diagnoses; physician interviews and chart audits enabled processes of care delivery to be evaluated. Unexpectedly, physicians were not found to assume an appropriately active or comprehensive mental health role in their practices following the training intervention. Of ninety-four DIS-generated diagnoses in the study population of fifty-one patients, 79 percent were unrecognized. Patients were assumed to function well emotionally, and psychiatric dimensions of patient complaints were not examined in the majority of cases. The physicians did diagnose and treat a number of patients with mental symptoms who were not identified by the DIS. These patients had high, but sub-diagnostic, DIS symptom counts. Most received a diagnosis of adjustment disorder in response to medical illness. Though this finding underscores shortcomings of present psychiatric nosology when applied in the general medical setting, the foremost consideration was the large number of DIS-identified patients with serious psychopathology, needing active assessment and intervention, who were unrecognized, undiagnosed or untreated. Implications of these findings for the psychiatric training of primary care physicians are examined.

Unlearning psychiatry: a cohort effect in the training environment.

The purposes of this study were to investigate the relationship between 1) residents' psychiatric performance and their primary care training environment; 2) residents' psychiatric performance and their year of training; and 3) the utility of feedback from the General Health Questionnaire (GHQ) and the year of training. Resident physicians (N = 32) were assigned to experimental and control groups; feedback of GHQ results constituted the intervention in the experimental site. Baseline data, as well as post intervention data, were collected on a total of 1040 patient encounters. Residents' psychiatric performance was measured by notation of a mental disorder in the Assessment portion of the SOAP note. Results showed that control group residents achieved superior performance at pretest and, in spite of a two-fold increase in the number of psychiatric diagnoses following GHQ feedback, experimental site posttest diagnoses did not significantly exceed control site frequency. In addition, experimental site first-year residents outperformed second-year residents, who likewise outperformed third-year residents, in recognizing their patient's mental distress. Differences in patient morbidity, over-diagnosis by first-year residents, and failure to have acquired psychiatric skills when a first-year resident were all tested and rejected as explanations for the unexpected inverse relationship between performance and years in training. It was therefore concluded that integration of psychiatric knowledge and skills into a primary care practice may be profoundly (and negatively) influenced by factors in the residents' training environment.

Inside the hidden mental health network. Examining mental health care delivery of primary care physicians.

Mental disorder diagnoses among 51 patients, made by a group of 20 family physicians, were compared with diagnoses generated by the Diagnostic Interview Schedule (DIS). Processes of diagnosis, decision making, and treatment planning were then examined through structured physician interviews and chart audits. In this study, 75 of 94 DIS diagnoses (79%) were undetected. During interview and chart audit, the physicians were found to have consistently underestimated, misinterpreted, or neglected psychiatric aspects of care among a majority of patients in the study. These physicians had all satisfactorily completed a psychiatry curriculum designed for family physicians. Analysis of these results suggests that a mental health role is often not integrated into primary care practice, regardless of physician performance during psychiatric training experiences. Assumption of this role appears to be state dependent on involvement with a psychiatric treatment setting. Primary care practice patterns do not seem to result in application of appropriate skills and therapeutic attitudes to detect, diagnose, and correctly manage the majority of mental disorders that occur. The need is reaffirmed for active collaboration between mental health professional and primary care providers in training and in incorporation of psychiatric skills into primary care practice.

First year residency stress: sources and mediators.

This study expands on previous research on stress in the internship year by identifying potential sources of stress in the training requirements and faculty contacts of first year family practice residents. All first year residents completed the Profile of Mood States (POMS) and the Zung Self-Rating Depression Scale (SDS) once a month throughout the year. It was shown that specific training demands, such as the number of beeper calls, the number of nights on call, the amount of sleep, etc., correlated with the POMS and the SDS only in the early rotations. The residents' ratings of commitment to teaching, availability, and sensitivity of the faculty on each service, however, were consistently related to the residents' moods regardless of time of year. When residents rated faculty as low on these characteristics, they scored higher on the stress indicators, whereas when residents rated faculty as high on these characteristics, their stress scores were significantly reduced.

Family practice residents' evaluation of a competency-based psychiatry curriculum.

The authors report the formal evaluation of a competency-based curriculum in psychiatry in a family practice residency program at a community hospital five years after the program was implemented. In interviews, the 35 residents in the program in 1985 responded to a questionnaire on their understanding of and attitude toward the requirements of the competencies and the difficulties they encountered in documenting the competencies. All but two of the residents were aware of the nature of the curriculum, but only 43 percent had completed one or more of the 15 required competencies. The residents' attitude toward the requirements of demonstrating specific competencies in psychiatry during the residency were generally negative, although they were favorable toward required competencies in other disciplines. The results of the present study identify specific problems in implementing such a curriculum. Successful implementation may have been impeded by the novelty of the new educational format and a lack of reinforcement by faculty members.

Epidemiology of depressive symptoms in black communities. A comparative analysis.

Data from a community survey of depressive symptoms in a black community in Alabama are analyzed using a binary regression procedure to assess the effects of sociodemographic risk factors. These results are compared to two other studies of depressive symptoms in black communities using the same methods to assess the interaction of risk factors with community/region. Community/region is found to modify the relationship of sex, marital status, and income to rates of depressive symptoms within black populations. It is argued that this interaction is evidence of differential sociocultural processes operating in these communities. Suggestions for more detailed research on depressive symptoms in the black community are offered.

Mental disorders among physical disability determination patients.

Persons claiming physical disability who were evaluated at a primary care health center in a small southern city were administered the Diagnostic Interview Schedule. Fifty-six per cent of the 43 patients were found to have one or more psychiatric disorders. The relationship between physical disability and psychiatric disorders needs to be recognized in the disability evaluation system.

Forensic training in family practice residencies.

Knowledge and skill in forensic medicine are important in primary care not only for defensive purposes but also because of potential therapeutic value in patient care. The major role in future mental health services envisioned for primary care physicians makes such training especially important. A national survey of family practice residency programs reveals that 47 percent of programs do not address forensic aspects of medical practice. A model forensic medicine curriculum is described that would require minimal adjustment of existing programs. The need for inclusion of forensically qualified clinicians in training programs for primary care physicians is evident.