Original article
Recognition and treatment of depression in primary care: Effect of patients' presentation and frequency of consultation

https://doi.org/10.1016/j.jpsychores.2008.10.008Get rights and content

Abstract

Objective

Primary care physicians (PCPs) are expected to recognize depression and appropriately prescribe antidepressants. This article investigated the single and combined effects of different patient presentations and frequency of visits on detection and antidepressant use.

Methods

Data came from an Italian nationwide survey on depressive disorders in primary care, involving 191 PCPs and 1910 attenders. Two hundred fifty patients suffering from major or subthreshold depression were compared in relation to their presentation (psychological, physical, and pain) and frequency of visits (low and high).

Results

Recognition of depression significantly varied according to both presentation and frequency of visits. When compared to patients with psychological complaints, the odds ratios for nonrecognition of depression were higher for patients presenting with physical symptoms [2.3; 95% confidence interval (CI)=1.1–5.3] and with pain (4.1; 95% CI=1.6–9.9). Subjects who rarely attended the practice were 2.3 times less likely to receive a diagnosis of depression, compared with those having a high frequency of visits (95% CI=1.2–4.6). Similarly, patients presenting with physical symptoms or with pain and those with a low frequency of visits were rarely treated with antidepressants. The combination of physical or pain presentation with low frequency of visits further increased the risk for nonrecognition, which was sixfold that of the reference category.

Conclusions

Some subgroups of depressed patients still run a high risk of having their depression unrecognized by the PCP. Screening for depression among patients presenting with pain might be useful in order to improve recognition and management.

Introduction

It is widely known that the majority of patients suffering from depression are managed in primary care settings [1]. However, studies have shown that the management of depression in primary care may be suboptimal. Low recognition rates of depression and underprescription of antidepressant drugs have been reported [2], [3], suggesting that many patients suffering from depression do not receive an appropriate diagnosis or pharmacological treatment. The WHO Study on Psychological Disorders in General Health Care found that primary care physicians (PCPs) detected only 39.1% of cases of ICD-10 current depression (CD) and prescribed antidepressants to 22.2% of them [4].

Recently, some researches have identified an improvement in recognition rates by PCPs [5], [6], [7] and a notable increase in the use of antidepressants in primary care [8]. On the other hand, some authors still report low recognition and treatment rates [9].

The literature shows that recognition and treatment of depression can be influenced by factors related to health service organization, PCPs, and patient characteristics. With regard to patients, a large number of studies have demonstrated that recognition of depression might vary depending on ethnicity [10], gender [11], or age [12], as well as patient presentation. If the patient reports only somatic symptoms, the detection of depression may be missed or delayed. This may be relevant, since the percentage of depressed patients not explicitly complaining about social or psychological problems has been demonstrated to be as high as 50% [7], [13], [14].

It has been found that the frequency of visits may also influence detection [15], [16]. According to an “exposure theory,” an increased number of consultations may lead the physician to have a greater exposure to the patient's symptomatology with greater opportunities to make the diagnosis of depression [11], [17]. Less data are available on the influence of this factor on depression management.

The aim of this article is to investigate the single and combined effects of patient presentation and frequency of visits on recognition and treatment of depression in the primary care setting using data from a nationwide epidemiological survey on depressive disorders conducted in Italy [18].

Our expectations were that depressed patients presenting with physical symptoms and with pain and those rarely attending PCP office would be underrecognized and less frequently treated with antidepressants.

Section snippets

Study design

A national survey on depressive disorders in primary care was conducted in 18 out of 20 Italian regions, with the collaboration of 191 PCPs [18]. Because PCP participation was voluntary, no formal selection criteria were adopted; however, an effort was made to balance the number of PCPs from urban versus rural areas.

The study population consisted of patients, aged 14 and above, seen for any reason by their PCP during an index week. In each clinic, 10 patients were selected using a randomization

Study population

Two thousand twenty-four subjects were evaluated: 79 refused to participate, 35 met exclusion criteria, and 14 provided incomplete data, yielding the final sample of 1896 subjects. Two thirds (65.5%) were female and mean (±S.D.) age was 49.1 (±17.4) years (range, 14–92 years). Our sample was comparable to the general Italian population with regard to age groups, while female gender was overrepresented [24]. Further details on the study population are available elsewhere [18].

Research and PCP diagnosis of depression

Out of the 1896 PCP

Discussion

Using data gathered from an Italian survey on depressive disorders in primary care, we investigated the influence of presentation and frequency of consultation on PCPs' recognition and pharmacological treatment of depression. Two main results emerged from our analyses.

First, PCPs underrecognized depression in patients presenting with primarily physical complaints and having a low frequency of visits. This was also observed in patients presenting with pain symptoms. Second, the use of

Conclusions

In recent years, some researchers have suggested an improvement in PCP ability to recognize depression; pharmacoepidemiology studies have also showed a notable increase in antidepressant prescription in primary care. This may reflect an increase in PCPs' knowledge of depression and antidepressant drugs. On the other hand, our data show that some groups of patients affected by depression still have a high risk of not being correctly diagnosed and, subsequently, of not being adequately treated.

Acknowledgments

The study was funded by Eli Lilly with an unrestricted grant.

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