February 5, 1999

While primary care physicians are committed to detecting and treating depression, they rely more on clinical impression than formal diagnostic criteria, according to a recent study published in Archives of Family Medicine.

Lead investigator John Williams, M.D., told Psychiatric News, "Most primary care physicians are making the effort to diagnose and treat depression consistent with the Agency for Health Care Policy and Research (AHCPR) depression guidelines, including prescribing SSRIs and counseling." Williams is an associate professor of medicine at the University of Texas Health Science Center, San Antonio.

Subspecialty was a major factor, however, in predicting practice patterns among primary care physicians, according to the article in the January-February Archives of Family Medicine. For example, family practitioners and general internists were more likely than obstetrician-gynecologists to use formal diagnostic criteria, assess for psychiatric comorbidity or physical causes of depression, and discuss the diagnosis using the term "depression." This finding is consistent with a previous study showing that none of 50 physicians elicited enough symptoms to make a diagnosis based on DSM-IV, according to the authors.

Williams and his colleagues conducted a national, random survey of primary care physicians including family physicians, general internists, and obstetrician-gynecologists. Of the 3,375 physicians surveyed, 1,350 completed the 53-item questionnaire, which asked them to report on the most recent adult patient they recognized as having a depressive disorder (major, minor, or dysthymia).

The majority of physicians surveyed practiced in single specialty groups and minimally capitated systems. They were evenly divided in terms of gender. Respondents described their patients as predominantly women, white, aged 22 to 65 years, and in good to excellent health.

The investigators found that incomplete knowledge of diagnostic criteria was a barrier to detecting depression for 16 percent of family physicians, 19 percent of general internists, and 45 percent of obstetrician-gynecologists.

Williams attributed these differences to subspecialty residency training. "While family practice training programs have long emphasized the biological, psychological, and social aspects of health, training programs in internal medicine and gynecology have incorporated these aspects relatively recently."

Moreover, family physicians were the most likely to view depression treatment as part of their clinical role (88 percent), general internists were somewhat likely (73 percent), and obstetrician-gynecologists were least likely (41 percent), the article noted.

Treatment approaches also varied considerably by specialty, noted the article: 85 percent of family physicians, 65 percent of internists, and 52 percent of obstetrician-gynecologists preferred antidepressant medication over counseling, exercise or recreation, and referrals to mental health specialists.

Williams and his colleagues also found that mental health referrals were the sole form of treatment for 22 percent of obstetrician-gynecologists, 14 percent of general internists, and 4 percent of family physicians. This pattern corresponds with the respective specialties' commitment to treating depression and knowledge of treatments, according to the article.

To whom they referred patients, however, varied. Family physicians were five times more likely to refer a patient to a psychologist or social worker than to a psychiatrist. In contrast, internists and obstetrician-gynecologists were almost as likely to refer patients to a psychiatrist as to a mental health professional, noted the article.

Williams commented, "Faculty psychologists often participate in family medicine training programs; thus family physicians have experience working with them. Family physicians also tend to prescribe antidepressants, so they are more likely to refer patients to mental health professionals for psychotherapy."

The survey revealed that more than half of all respondents were somewhat or much less satisfied with referrals to psychiatrists compared with referrals to other medical specialists. "This is an area that needs further investigation," commented Williams.

The main organizational barriers to evaluating patients for depression were inadequate time to provide counseling and take a complete history, according to the article. Insurance-limited treatment options and inadequate reimbursement for treatment were also constraints to optimal care.

Because the average primary care visit is 13 minutes, Williams said, further efforts are needed to convince primary care physicians to use formal diagnostic criteria. "There needs to be compelling data showing that DSM-IV or similar criteria are superior to clinical impression and adaptable to the time pressures primary care physicians face."

He also suggested training nurses in basic depression management, so they can educate patients and conduct follow-up conversations.

Obstetrician-gynecologists also need to be better informed about managing depression, a role that is implicit in the AHCPR depression guidelines, said Williams. He suggested that diagnostic and treatment skills for depression be incorporated into their residency training curricula. "However, the decision to treat is a scope-of-practice issue," he added.

The study was limited by a moderate response rate, which may have led to an overrepresentation of respondents with favorable attitudes and better strategies for managing depression, noted the authors. The second limitation was self-reported data, which do not measure actual practice.

"Some questions may have been influenced by social desirability and may reflect the physicians' idealized approach to depression," the authors stated.-C.L.