The Role of Competing Demands in the Treatment Provided Primary Care Patients With Major Depression
Kathryn Rost, PhD;
Paul Nutting, MD;
Jeffrey Smith, BS;
James C. Coyne, PhD;
Lisa Cooper-Patrick, MD;
Lisa Rubenstein, MD
Arch Fam Med. 2000;9:150-154.
Objective To examine whether competing demands explain the appearance of inadequate primary care depression treatment observed at a single visit.
Design A cross-sectional patient survey.
Participants and Setting Two hundred forty patients with 5 or more symptoms of depression seeing 12 physicians in 6 primary care practices, representing 77.4% of the depressed patients identified through 2-stage screening of more than 11,000 primary care attenders.
Main Outcome Measures In patients with elevated depressive symptoms, discussing depression as a possible diagnosis in untreated patients, and changing depression management in treated patients.
Results Physicians and patients discussed depression in 46 (47.9%) of 96 untreated patients; physicians changed depression treatment recommendations in 87 (60.4%) of 144 treated patients with current symptoms. Chronic physical comorbidity decreased the odds that physicians and untreated patients discussed depression as a possible diagnosis (odds ratio = 0.66, P = .01). New problems decreased the odds that treatment recommendations would be changed in treated patients who remained depressed (odds ratio = 0.39, P = .05). Physicians and untreated patients were more likely to discuss depression as a possible diagnosis if patients reported antidepressant medication was acceptable (odds ratio = 4.57, P = .01) and less likely to discuss depression if patients reported specialty care counseling was acceptable (odds ratio = 0.33, P = .05).
Conclusions The attention depression gets during a given medical visit is less associated with the severity of the patient's depressive symptoms than with the number or recency of other problems the patient has. If competing demands provide ongoing barriers to depression treatment, interventions will be needed to assure that patients with chronic physical problems receive high-quality mental health care in the primary care setting.
From the Centers for Mental Healthcare Research, Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Dr Rost and Mr Smith); Ambulatory Sentinel Practice Network, Denver, Colo (Dr Nutting); Department of Family Medicine, University of Michigan, Ann Arbor (Dr Coyne); Department of Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md (Dr Cooper-Patrick); and Sepulveda Veterans Administration, Sepulveda, Calif, RAND, Santa Monica, Calif, and University of California at Los Angeles (Dr Rubenstein).
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