The role of competing demands in the treatment provided primary care patients with major depression

Objective: To examine whether competing demands explain the appearance of i nadequate primary care depression treatment observed at a single visit. Design: A cross-sectional patient survey. Participants and getting: Two hundred forty patients with 5 or more symptom s of depression seeing 12 physicians in 6 primary care practices, represent ing 77.4% of the depressed patients identified through 2-stage screening of more than 11 000 primary care attenders. Main Outcome Measures: In patients with elevated depressive symptoms, discu ssing depression as a possible diagnosis in untreated patients, and changin g depression management in treated patients. Results: Physicians and patients discussed depression in 46 (47.9%) of 96 u ntreated patients; physicians changed depression treatment recommendations in 87 (60.4%) of 144 treated patients with current symptoms. Chronic physic al comorbidity decreased the odds that physicians and untreated patients di scussed depression as a possible diagnosis (odds ratio = 0.66, P = .01). Ne w problems decreased the odds that treatment recommendations would be chang ed in treated patients who remained depressed (odds ratio = 0.39, P = .05). Physicians and untreated patients were more likely to discuss depression a s a possible diagnosis if patients reported antidepressant medication was a cceptable (odds ratio = 4.57, P = .01) and less likely to discuss depressio n if patients reported specialty care counseling was acceptable (odds ratio = 0.33, P = .05). Conclusions: The attention depression gets during a given medical visit is less associated with the severity of the patient's depressive symptoms than with the number or recency of other problems the patient has. If competing demands provide ongoing barriers to depression treatment, interventions wi ll be needed to assure that patients with chronic physical problems receive high-quality mental health care in the primary care setting.