Persons With Depressive Symptoms And The Treatments They Receive: A Comparison Of Primary Care Physicians And Psychiatrists

ABSTRACT

Objective: To determine if demographic differences exist in patients with depressive symptoms as the principal reason for visits to primary care physicians (PCP) versus psychiatrists. To estimate the likelihood of these patients receiving a range of mental health services from each provider group. Methods: Review and analysis of all outpatient visits made by patients with depressive symptoms using the National Ambulatory Medical Care Surveys (NAMCS) conducted in 1995 and 1996. Results: A significantly greater proportion of visits by persons with depressive symptoms as the principal reason for visit were made to psychiatrists than to primary care physicians (T = -3.56, P = .000). However, men, African-Americans, other Non-White persons, and persons aged 65 to 74 and 75 years and over were proportionately more likely to visit a PCP than a psychiatrist. Women, whites, and persons aged 45 to 64 were proportionately more likely to make a visit to a psychiatrist than to a PCP. The overall intensity of care delivered by PCPs for patients with depressive symptoms was significantly lower than that provided by psychiatrists (t = -2.03, P = .02). Analysis of individual services also revealed significant differences in service provision. Conclusions: Demographic differences among the patient caseloads of these physician groups have implications for mental health service delivery because of known distinctions in prevalence rates, symptom presentation, and functionality among depressed patient subgroups.

INTRODUCTION

Patients with depressive symptoms mood visit general and specialist physicians for mental health treatments in large numbers and constitute a significant proportion of estimated total visits to these providers [1-4]. Depressed mood may precipitate significant impairment characterized by dysphoria, and accompanied by physioogical, motor, cognitive, and interpersonal signs that limit personal functioning [5]. An extensive literature exists on the biology, cognitive patterns and behavioral correlates, and psychodynamics of both normal human emotions and mood disorders [6-9]. The economic, psychological, physical, and social burden of depressive symptoms have also been well-documented [10, II). In response to these burdens, health and mental health professionals use and continue to refine a variety of treatments, which have been the subject of considerable research to assess their clinical effectiveness [12, 13].

Among physicians, psychiatrists and primary care physicians receive the majority of ambulatory visits from patients who exhibit depressive symptoms and whose condition may go undetected [14] or be subsequently diagnosed and treated [15-17]. The epidemiology and clinical characteristics of depressive symptoms in primary care is complicated by patients who have a range of signs and symptoms that are either below threshold or do not meet the standard criteria for mental disorders [18] noted in the Diagnostic and Statistical Manual of Mental Disorders (DSM) [19]. While psychiatrists have been found to generally treat patients with more complex and serious psychopathology (including mood disorders) than primary care providers [20], a sizeable percentage of the latter nonetheless report evaluating patients with complicated depressive symptoms (e.g., history of sexual abuse or suicide potential) [16]. For both provider groups, similar patterns of antidepressant medication usage have been found [21].

These complexities have prompted researchers, clinicians, and payers to explore the question of which depressed patients are most effectively treated by which provider group and in which setting. Among physicians, primary care physicians have been a focus of considerable investigation to determine the effectiveness of these providers alone [22, 23], as referral agents [16], or in collaboration with mental health [24, 25] or allied health specialists [26]. Evidence from several sources suggests that psychotropic medication prescribed by either physician group for persons with mild depressive symptoms is not effective [to, 16, 23]. Treatment studies of psychotherapies provided by mental health professionals for patients with either mild to moderate depression [27] or major depression [13] suggest equal effectiveness as compared to psychotropic medication.

While the clinical features of major depression have 'been reported as more similar than different across age, gender, and ethnic groups [13], important epidemiologic, utilization, and outcome differences have been noted among these patients [27-29]. Women have been found to more likely experience an affective disorder during their lifetime than men [30]. Prevalence rates of major depressive disorders among primary care patients have been found to vary between 4 percent and 9 percent, yet less severe forms of depressive symptoms are even more prevalent in primary care settings [31]. Furthermore, reviews of mental health treatment illustrate, and in some instances validate, that demographic characteristics are important independent variables that affect the choice of treatment and subsequent clinical outcomes among patients with depressive symptoms [27,32, 33].

In primary care settings, patient demographic characteristics represent important indicators for the identification of and response to treatments for depressive symptoms. For example, compared with Whites, African Americans have shown unique, and at times adverse, responses to some classes of antidepressant medications [34], but higher rates of participation in psychotherapy [35]. Compared to child psychiatrists, primary care physicians have been found less effective in diagnosing depressive symptoms in children [36]. It is generally recognized that older adults present to primary care physicians with symptoms of cognitive impairment that complicate the establishment of a differential diagnosis and selection of treatment [37].

To date, no study has used a large and nationally representative sample of patient visits to determine if important demographic differences exist among the patient caseloads of primary care physicians in comparison to psychiatrists. This is noteworthy because recent studies assessing the effectiveness of depression treatment in primary care have either failed to address patient demographic characteristics [26] or have used a relatively homogenous set of study participants [24]. The latter studies have generally used patients who were predominantly female, middle-aged, and white. One extensive review of the depression treatment literature has concluded that a majority of clinical trials and other treatment effectiveness studies are measures of the prevalence of depress ion and efticacy of depression treatment in women alone [27]. Studies that have taken patient demographic characteristics into account have been limited to selected age groups, to patients with DSM-IV diagnoses (this may result in under-representation as primary care physicians may not use formal depression diagnoses) [21], or to small study samples [38].

The present study had two aims: 1) to determine whether demographic differences exist among patients with depressive symptoms who visit primary care physicians and psychiatrists, and 2) to examine whether patients with depressive symptoms receive the same range of mental health services during a visit when physician provider group is taken into account. The existence of demographic differences among patients with depressive symptoms who visit these providers may provide elements of a systematic portrait of depression treatment by physicians that combines patient population characteristics and physician specialty characteristics.

Methods

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