Pshychiatry and Primary CareDiagnosis of depression by primary care physicians versus a structured diagnostic interview: Understanding discordance
Introduction
Guidelines have been recently promulgated in the USA, the Netherlands, and in other countries to improve quality of care for depressive illness 1, 2, 3. There is growing evidence that management according to these guidelines improves clinical outcomes among primary care patients 4, 5, 6, 7, 8, 9, 10. Accurate diagnostic evaluation of depressive illness is a prerequisite for implementation of these evidence-based treatment guidelines.
Many studies of the accuracy of diagnostic assessment in primary care have focused on recognition of undifferentiated psychological illness rather than the accuracy of the diagnosis of the depressive syndrome 11, 12, 13, 14, 15, 16. Recognition of undifferentiated psychological illness is a first step toward accurate diagnosis, but it lacks sufficient specificity to guide treatment. The accuracy of primary care physicians’ diagnosis of current depressive illness is examined in this paper.
Typically, the accuracy of primary care physicians’ diagnosis, in relation to the gold standard of a research diagnosis, is assessed in terms of false or true negatives and positives. Two complicating factors need to be considered. First, patients with recent onset of depressive symptoms or patients who are recovering may not meet criteria for a depressive disorder when examined with a research diagnostic interview. Their physician may identify them as relapsing or recovering from a depressive episode. Second, there is a high rate of comorbidity of depressive disorder with other psychiatric disorders 17, 18. When primary care physicians do not diagnosis a depressive disorder, they may identify a co-morbid psychiatric illness such as panic disorder, generalized anxiety disorder, or alcohol abuse. This situation needs to be differentiated from those in which no psychological illness is diagnosed at all. Differentiating levels of disagreement may help us understand better why physicians’ diagnoses and research diagnoses disagree.
The data we report were collected in Seattle, USA, and Groningen, The Netherlands, as part of the multicenter collaborative study on Psychological Problems in General Health Care of the World Health Organization [19]. This paper is the result of collaborative efforts of these two centers to develop a differentiated approach for comparing diagnoses by primary care physicians and a standardized research interview. Three levels of disagreement are identified: 1) complete disagreement about the presence of psychiatric symptoms (called true false-negatives and true false-positives); 2) disagreement about the severity of the psychiatric problems (cases with underestimated severity and overestimated severity); and 3) disagreement about what psychiatric diagnosis to assign (cases who were misdiagnosed and cases given another CIDI diagnosis).
We then compared these groups in terms of factors that prior research has found to be associated with recognition 11, 20, 21, 22, 23, 24 (symptom severity, psychiatric history, disability, patient’s health perception, reason for encounter, duration since the last visit, and demographic characteristics). The aim of these analyses is to better understand the reasons for diagnostic disagreement and its significance for clinical practice.
Section snippets
Setting
In Seattle, the study subjects were enrolled from three primary care centers (50 physicians) of Group Health Cooperative of Puget Sound (GHC), a staff model health maintenance organization. Study clinics were selected to represent the range of income and education in GHC’s Seattle area population.
In Groningen, the study was carried out in six primary care practices (11 physicians). The selected practices were typical of the Dutch primary care system and included one solo (1 physician) and five
Study samples
In Seattle, 1962 (93%) of 2110 patients who were asked to fill out the GHQ-12 completed this questionnaire. Among the 608 patients sampled for second-stage baseline assessment, 373 (61%) completed the interview. In Groningen, 1271 (96%) of the 1320 patients approached completed the GHQ-12 and 340 (69%) of the 493 sampled patients completed the second-stage baseline assessment. In Seattle as well as in Groningen, second-stage respondents did not differ from nonrespondents with respect to sex and
Discussion
In this paper we differentiated reasons for disagreement between the primary care physician’s diagnosis of depressive illness and a research psychiatric interview diagnosis of depression. We found that complete disagreement about the presence of psychiatric symptoms contributed somewhat more than one-third of the discordance. Disagreement about severity or specific diagnosis contributed a little less than one-third each.
Different diagnostic practices of the primary care physicians in the two
Acknowledgements
This study was financially supported by grant MH47765 from the National Institute of Mental Health, Bethesda, Md (Seattle), Delagrange Laboratories and Synthélabo Pharmacie, Paris, France, Grants 900-571-036 and 940-20-802 from the Dutch Organization for Scientific Research, Medical Sciences, KWAZO-program, and by SGO, the Promotion Program Health Research (Groningen).
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