Recognizing and managing depression in primary care - A standardized patient study

BACKGROUND. Guidelines for recognition and management of depression in prim ary care provide a framework for detailed exploration of physician practice patterns. METHODS. Our objective was to explore physician diagnosis and management ap proaches to depressive disorders according to type (major vs minor) and pre senting complaint (difficulty sleeping and concentrating vs headache). The participants were community primary care internists and family physicians i n northern New England, Washington, and Alabama (N = 149) who were randomly assigned to receive a visit from an unannounced actor portraying a standar dized patient in 1 of 2 depression scenarios: (A) insomnia and poor concent ration meeting Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) criteria for major depressive disorder; or (B ) tension headaches meeting the criteria for minor depression. RESULTS. All physicians who were assigned to the standardized patients pres enting with scenario A recognized depression, and 49% (38 of 78) of those a ssigned to scenario B patients diagnosed depression. Of those recognizing d epression, 72% and 42% queried patients about anhedonia and mood, respectiv ely. For both scenarios, if fewer than 2 DSM-III-R criteria were explored, depression was not diagnosed. Management for scenario A was compatible with Agency for Health Care Policy and Research guidelines, including the presc ription of an antidepressant (94%), scheduling of a follow-up visit within 2 weeks (61%), and exploration of suicidal ideation (69.4%). For scenario B , management included over-the-counter analgesics for the headache (84%), e xercise (63%), prescription for an antidepressant (53%), recommendation for ongoing counseling (100%), and follow-up within 2 weeks (42%). CONCLUSIONS. Major depression is recognized in primary care at a very high rate. Guidelines for recognizing and managing depression are often followed in primary care. Patients' presentations of depression influence its recog nition and management.