Commentary and perspective
Competing demands in psychosocial care: A model for the identification and treatment of depressive disorders in primary care

https://doi.org/10.1016/S0163-8343(96)00145-4Get rights and content

Abstract

A considerable body of knowledge now exists in the area of depressive disorders in primary care. Primary care clinicians appear to identify less than half of patients with major depressive disorder and adequately treat only a portion of those they identify. However, recent research suggests that identification and treatment of depressive disorders in primary care is a far more complex process than previously assumed. The presence of significant differences in patient expectations, the process of care, and the clinical epidemiology of depression between psychiatric and primary care settings makes it difficult to interpret existing studies of primary care clinician performance. This paper describes an alternative conceptual model for the identification and management of depression in primary care which incorporates the concept of “competing demands” derived from the preventive services literature. The central premise of this model is that primary care encounters present competing demands for the attention of the clinician and that there is not enough time to address each demand. The identification and treatment of depression represents an active choice from multiple clinician and patient priorities such as treatment of acute illness, provision of preventive services, and response to patient requests. Choice is influenced by three sets of interrelated “domains,” representing the clinician, the patient, and the practice ecosystem. Each domain is indirectly influenced by the general policy environment. Detection and treatment of depression in this model occurs over time as clinicians work through these competing demands. Although the competing demands model contains many unproven elements, it is likely to have a great deal of “face validity” for practicing primary care clinicians, and its validity can be empirically tested. Using the model as a framework to guide inquiry into the identification and management of depression and other mood disorders in primary care may lead to the discovery of more creative and effective solutions to the problem of underdiagnosis and undertreatment.

References (116)

  • M Von Korff et al.

    Anxiety and depression in a primary care clinic

    Arch Gen Psychiatry

    (1987)
  • H.C. Schulberg et al.

    Assessing depression in primary medical and psychiatric practices

    Arch Gen Psychiatry

    (1985)
  • J.L. Coulehan et al.

    Medical comorbidity of major depressive disorder in a primary medical practice

    Arch Intern Med

    (1990)
  • J.M. Zich et al.

    Screening for depression in primary care clinics: the CES-D and the BDI

    Int J Psychiatry Med

    (1990)
  • L.G. Kessler et al.

    Psychiatric disorders in primary care

    Arch Gen Psychiatry

    (1985)
  • A. Burnam et al.

    Prevalence of depression in general medical and mental health outpatient practices in three health care systems

  • L.N. Robins et al.

    Lifetime prevalence of specific psychiatric disorders in three sites

    Arch Gen Psychiatry

    (1984)
  • J Johnson et al.

    Service utilization and social morbidity associated with depressive symtoms in the community

    JAMA

    (1992)
  • S.F. Jancks

    Recognition of mental distress and diagnosis of mental disorder in primary care

    JAMA

    (1985)
  • K.B. Wells et al.

    Detection of depressive disorder for patients receiving prepaid or fee-for-service care: results from the Medical Outcomes Study

    JAMA

    (1989)
  • P.D. Gerber et al.

    Recognition of depression by internists in primary care: a comparison of internists and “gold standard” psychiatric assessments

    J Gen Intern Med

    (1989)
  • E.S. Higgins

    A review of unrecognized mental illness in primary care: prevalence, natural history, and efforts to change the course

    Arch Fam Med

    (1994)
  • K Magruder-Habib et al.

    Improving physician's recognition and treatment of depression in general medical care

    Med Care

    (1990)
  • L.S. Linn et al.

    The effect of screening, sensitization, and feedback on notation of depression

    J Med Educ

    (1980)
  • Depression Guideline Panel
  • Depression Guideline Panel
  • Rost Z, Zhang M, Fortney J, Smith J, Coyne J, Smith GR: The course of disorder in primary care patients with untreated...
  • I Elkin et al.

    National Institute of Mental Health Treatment of Depression Collaborative Research Program

    Arch Gen Psychiatry

    (1989)
  • C.M. Callahan et al.

    Improving treatment of late life depression in primary care: a randomized clinical trial

    J Am Geriatr Soc

    (1994)
  • W Katon et al.

    Adequacy and duration of antidepressant treatment in primary care

    Med Care

    (1992)
  • W Katon et al.

    Collaborative management to achieve treatment guidelines: impact on depression in primary care

    JAMA

    (1995)
  • G.E. Simon et al.

    Outcomes of “inadequate” antidepressant treatment

    J Gen Intern Med

    (1995)
  • E.J. Perez-Stable et al.

    Depression in medical outpatients: underrecognition and misdiagnosis

    Arch Intern Med

    (1990)
  • K Rost et al.

    The deliberate misdiagnosis of major depression in primary care

    Arch Fam Med

    (1994)
  • J.L. Susman et al.

    Depression in rural family practice: easy to recognize, difficult to diagnose

    Arch Fam Med

    (1995)
  • J.E. Barrett

    Practice-based mental health research in primary care: directions for the 1990s

  • M.S. Klinkman

    Nailing Jell-O to the wall: psychosocial episodes in primary care

  • P Freeling et al.

    Unrecognized depression in general practice

    Br Med J

    (1985)
  • A.E. Farmer et al.

    Labeling and illness in primary care: comparing factors influencing general practitioners' and psychiatrists' decisions regarding patient referral to mental illness services

    Psychol Med

    (1992)
  • J Angst et al.

    Recurrent brief depression: a new subtype of depressive disorder

    J Affect Disord

    (1990)
  • L.L. Judd et al.

    Subsyndromal symptomatic depression: a new mood disorder

    J Clin Psychiatry

    (1994)
  • F deGruy et al.

    NOS: Subthreshold conditions in primary care

  • K Kroenke et al.

    Multisomatoform disorder: defining the optimal symptom threshold and eliminating hierarchical bias for diagnosing somatization in primary care

  • J.G. Johnson et al.

    Psychiatric comorbidity, health status, and functional impairment associated with alcohol abuse and dependence in primary care patients: findings of the PRIME-MD 1000 study

    J Consult Clin Psychol

    (1995)
  • S.M. Stahl

    Mixed anxiety and depression: clinical implications

    J Clin Psychiatry

    (1993)
  • W.W.K. Zung et al.

    The comorbidity of anxiety and depression in general medical patients: a longitudinal study

    J Clin Psychiatry

    (1990)
  • J.A. Barrett et al.

    The prevalence of psychiatric disorders in a primary care practice

    Arch Gen Psychiatry

    (1988)
  • T.B. Ustun

    The International Classification of Disease 10—Primary Health Care Version

  • D Goldberg

    The concept of a ‘case’ in general practice

    Soc Psychiatry

    (1982)
  • L Eisenberg

    Treating depression and anxiety in primary care. Closing the gap between knowledge and practice

    N Engl J Med

    (1992)
  • Cited by (239)

    • Frequent attendance and the concordance between PHQ screening and GP assessment in the detection of common mental disorders

      2018, Journal of Psychosomatic Research
      Citation Excerpt :

      In addition, FAs tend to be better known to the GP as shown in our study, thus making detection potentially easier [37]. However, personal knowledge of the patient may not always improve detection [36], as doctors are sometimes reluctant to attach psychiatric diagnoses to patients they know well [38], perceiving their role as helping patients become aware of their symptoms rather than establishing strict diagnoses [39]. Nonetheless, increased detection among FAs suggests that FA may be a “necessary behaviour” so that greater needs can be met.

    View all citing articles on Scopus
    View full text