Patient Perception, Preference and Participation
Relational barriers to depression help-seeking in primary care

https://doi.org/10.1016/j.pec.2010.05.007Get rights and content

Abstract

Objective

To identify attitudinal and interpersonal barriers to depression care-seeking and disclosure in primary care and in so doing, evaluate the primary care paradigm for depression care in the United States.

Methods

Fifteen qualitative focus group interviews in three cities. Study participants were English-speaking men and women aged 25–64 with first-hand knowledge of depression. Transcripts were analyzed iteratively for recurring themes.

Results

Participants expressed reservations about the ability of primary care physicians (PCPs) to meet their mental health needs. Specific barriers included problems with PCP competence and openness as well as patient–physician trust. While many reflected positively on their primary care experiences, some doubted PCPs’ knowledge of mental health disorders and believed mental health concerns fell outside the bounds of primary care. Low-income participants in particular shared stories about the essentiality, and ultimate fragility, of patient-PCP trust.

Conclusion

Patients with depression may be deterred from care-seeking or disclosure by relational barriers including perceptions of PCPs’ mental health-related capabilities and interests.

Practice implications

PCPs should continue to develop their depression management skills while supporting vigorous efforts to inform the public that primary care is a safe and appropriate venue for treatment of common mental health conditions.

Introduction

Depression is the most prevalent and costly mental health disorder [1] and is commonly treated in primary care [2]. Although identification and treatment rates are improving, at least 25% of primary care patients with clinically significant depression remain undiagnosed [1], [3]. Experimental evidence suggests that patient requests for treatment can sharply reduce under-diagnosis and promote the initial treatment of depression [4]. Therefore, encouraging patients to seek care and ask about treatment may be an effective strategy for improving depression care in general medical settings.

Most patients with symptoms of depression desire help from their physician [5], [6] but face significant obstacles [7], [8]. Among those who want help, disclosure of distress may be impeded by organizational barriers, including impaired access to care, short visit times, and scant resources. However, interpersonal barriers such as social distance [9], [10], [11], patient–physician collusion [12], and low patient–physician trust may also be important. Such barriers may be especially salient for individuals with lower incomes, who bear higher levels of disease burden and hold more stigmatized attitudes toward care for mental health issues [13], [14].

In the current study, we explored potential challenges and barriers to depression care-seeking and disclosure in a diverse sample of working-aged adults. The project was part of a larger investigation of strategies for enhancing depression care-seeking in primary care practice. Strategies of interest are demographically targeted public service announcements (PSAs) and an interactive multimedia computer program tailored to patients’ attitudes and beliefs about depression. As part of the foundational work required to produce these tools, we convened focus groups of people who had experience with depression. We asked participants in broad terms about individual, interpersonal, and organizational barriers to care-seeking. As primary care clinicians and researchers, we began this work assuming that patients would share our perception of primary care physicians in the modern era as ready, willing, and able to diagnose and treat depression.

Section snippets

Study design and rationale

Focus groups are advantageous when “there is a power differential between participants and decision makers…when there is a gap between professionals and their target audience…and when investigating complex behavior and motivations” [15]. These conditions apply well to depression in primary care. We anticipated that interaction among focus group members would allow us to capture the diversity of patient care-seeking experiences in a supportive environment and to seek out areas of consensus.

Study sites and participants

The

Characteristics of study participants

Of 183 potentially eligible participants responding to our recruitment strategies, 37 were unavailable or deemed ineligible. Among the 146 remaining, 116 (79%) attended one of 15 focus groups of whom 88% had a personal history of depression (Table 2). The majority were white and female, but minorities and men were well represented; 47% participated regularly in a religious community. Nearly half had college degrees, but 75% had annual household incomes below $50,000. While 78% were insured, 36%

Discussion

The principal finding of this study is that despite increasing recognition of primary care as the de facto source of mental health services for the majority of Americans [30], increased emphasis on the evaluation and treatment of mental health conditions in primary care residency training [31], [32], and the emergence of effective models for the delivery of high quality depression care [33], [34], [35], many participants reported gaps in care and regarded the primary care paradigm for diagnosis

Acknowledgements

The authors thank Tracy Carver, Joe Grasso, and Jennifer Becker for research assistance. Dr. Kravitz has received unrestricted research grants from Pfizer during the past 3 years.

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    Support: This work was funded with support from grants # R01MH79387 and K24MH72756 from the National Institute of Mental Health (R. Kravitz, PI).

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