Primary care physicians' approach to depressive disorders - Effects of physician specialty and practice structure

Background: Because primary care physicians (PCPs) are the initial health c are contact for most patients with depression, they are in a unique positio n to provide early detection and integrated care for persons with depressio n and coexisting medical illness. Despite this opportunity, care for depres sion is often suboptimal. Objectives: To better understand how to design interventions to improve car e, we examine PCPs' approach to recognition and management and the effects of physician specialty and degree of capitation on barriers to care for 3 c ommon depressive disorders. Methods: A 53-item questionnaire was mailed to 3375 randomly selected subje cts, divided equally among family physicians, general internists, and obste trician-gynecologists. The questionnaire assessed reported diagnosis and tr eatment practices for each subject's most recent patient recognized to have major or minor depression or dysthymia and barriers to the recognition and treatment of depression. Eligible physicians were PCPs who worked at least half-time seeing outpatients for longitudinal care. Results: Of 2316 physicians with known eligibility, 1350 (58.3%) returned t he questionnaire. Respondents were family physicians (n = 621), general int ernists (n = 474), and obstetrician-gynecologists (n = 255). The PCPs repor t recognition and evaluation practices related to their most recent case as follows: recognition by routine questioning or screening for depression (9 %), diagnosis based on formal criteria (33.7%), direct questioning about su icide (58%), and assessment for substance abuse (68.1%) or medical causes o f depression (84.1%). Reported treatment practices were watchful waiting on ly (6.1%), PCP counseling for more than 5 minutes (39.7%), antidepressant m edication prescription (72.5%), and mental health referral (38.4%). Diagnos tic evaluation and treatment approaches varied significantly by specialty b ut not by the type of depression or degree of capitation. Physician barrier s differed by specialty more than by degree of capitation. in contrast, org anizational barriers, such as time for an adequate history and the affordab ility of mental health professionals, differed by degree of capitation more than by physician specialty. Patient barriers were com mon but did not var y by physician specialty or degree of capitation. Conclusions: A substantial proportion of PCPs report diagnostic and treatme nt approaches that are consistent with high-quality care. Differences in ap proach were associated more with specialty than with type of depressive dis order or degree of capitation. Quality improvement efforts need to (1) be t ailored for different physician specialties, (2) emphasize the importance o f differentiating major depression from other depressive disorders and tail oring the treatment approach accordingly, and (3) address organizational ba rriers to best practice and knowledge gaps about depression treatment.