Psychiatry and Primary CareOutcomes of recognized and unrecognized depression in an international primary care study
Introduction
Depression presenting in primary care is increasingly recognized as a major public health problem. Prevalence of major depression among primary care patients is typically 10% or greater 1, 2. The impact of depression on quality of life is as great as that of major medical conditions 3, 4, 5. Depression is also associated with a large burden of lost productivity 3, 5, 6 and increased use of general health services 7, 8.
Discussion of depression treatment in primary care has often focused on primary care physicians’ failure to recognize the presence of a psychological disorder. Many depressed primary care patients present with nonspecific somatic complaints that may divert attention from identification of depression [9]. Among patients with clinically significant depression, as many as half go unrecognized by the treating physician 10, 11, 12, 13, 14, 15. Recent reviews 16, 17 and expert guidelines [18] have urged efforts to improve recognition of depression by primary care providers.
Some recent reports question the clinical impact of nonrecognition. Three samples of primary care patients treated by Dutch general practitioners [19], U.S. rural family practitioners [13], and physicians at a U.S. health maintenance organization [20] all showed a similar pattern: patients with unrecognized depression were less severely ill and less functionally impaired. Average rates of clinical improvement were similar in recognized and unrecognized groups 19, 20, 21. Two earlier studies of depression among U.S. [22] and Dutch [10] primary care patients also found no clear association between physician recognition and improved outcomes.
Several randomized trials have examined the impact of “forcing” recognition by communicating to primary care physicians the results of depression screening. Both Johnstone and Goldberg [14] and Zung et al. [23] found that feedback of depression screening scores led to improved patient outcomes. Two recent randomized trials, however, failed to demonstrate a significant benefit of “forced” recognition among either British general practice patients studied by Dowrick et al. [24] or elderly U.S. primary care patients studied by Callahan et al. [37]. In reviewing recent research, Tiemens and Ormel [25] have referred to “the capricious relationship between recognition and outcome of mental illness in primary care.”
This report uses data from the World Health Organization Psychological Problems in General Health Care (PPGHC) study to examine the relationship between recognition and clinical outcomes in depressed primary care patients from 15 study sites in 14 countries. This sample includes patients from the U.S. and Dutch sites previously described by Simon and VonKorff [20] and Tiemens et al. [19]. Our analyses differ from previous efforts in two important respects. First, the large size of the complete PPGHC sample (approximately 900 depressed patients completing follow-up assessments) allows detection of modest differences in clinical outcomes. Second, we examined the effect of the primary care physician recognizing a depressive disorder—rather than general recognition of psychological distress. We hypothesize that specific recognition of depression would more often lead to some appropriate management.
Section snippets
Methods
The PPGHC study examined the form, frequency, management, and outcomes of common psychological disorders among primary care patients 2, 26. Participating centers included Ankara, Turkey; Athens, Greece; Bangalore, India; Berlin, Germany; Groningen, Netherlands; Ibadan, Nigeria; Mainz, Germany; Manchester, U.K.; Nagasaki, Japan; Paris, France; Rio de Janeiro, Brazil; Santiago, Chile; Seattle, U.S.A.; Shanghai, China; and Verona, Italy. Each site enrolled patients from clinics selected as typical
Study sample
At the second-stage diagnostic interview, 1174 patients satisfied ICD-10 criteria for current major depressive episode. Of this group, 73% completed the 3-month follow-up assessment, 60% completed the 12-month follow-up assessment, and 80% completed at least one follow-up assessment. Compared with patients missing both follow-up assessments, those completing one or both assessments were slightly older (40.4 years vs 36.2 years, t = 3.07, p = 0.002). Likelihood of completing at least one
Discussion
In this large, international primary care survey, approximately 42% of patients with a current ICD-10 depressive episode were recognized by the primary care physician and given an appropriate diagnosis. Recognized patients had significantly higher levels of psychological distress and functional impairment at the baseline assessment. Recognition at baseline was associated with significantly greater symptomatic improvement at the 3-month follow-up assessment, but no significant effects were
Acknowledgements
Participating investigators in the Psychological Problems in General Health Care project include Orhan Ozturk M.D. and Murat Rezaki M.D., Ankara, Turkey; Costas Stefanis M.D. and Venetsanos Mavreas M.D. Ph.D., Athens, Greece; S. M. Channabasavanna M.B.B.S., M.D., and T. G. Sriram M.B.B.S. M.D., Bangalore, India; Hanfried Helmchen M.D. and Michael Linden M.D. P.D., Berlin, Germany; Wim van den Brink M.D. and Bea Tiemens Ph.D., Groningen, The Netherlands; Michael Olawatura M.D. and Oye Gureje
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