The Recognition of Depression: The Primary Care Clinician’s Perspective

Seong-Yi Baik and colleagues have produced a thoughtful qualitative study of the processes that family doctors go through in arriving at a diagnosis of depression. Their descriptions resonate well with the realities of clinical decision-making in primary care.

However I have fundamental concerns about the validity of the premise underlying their paper.

I do not agree that 'underrecognition of depression in primary care is a critical public health problem'. The authors fail to cite several papers - e.g.Dowrick et al BMJ 1995,311,1274-6, or Goldberg et al BrJGenPract 1998,48,1840-4 - which show that patients whose depression goes undignosed tend to have a better outcome than those who are diagnosed: primarily because their conditions are milder. This ties in with the finding from the Hampshire Depression Ptudy that GPs are in fact very good at detecting severe cases of depression and in general only miss one case in every 28.6 consultations (Thompson et al BrJPsych 2001,179,317 -23.

Indeed, I think that family doctors these days (of whom I am one) are more likely to over-diagnose depression. Since the concept of depression now brings with it some very simple treatment procedures (prescribe one pill a day and/or refer to practice counsellor), it is very tempting for us to shoehorn all sorts of problems into this diagnostic label, package the patient nicely, and send them on their way with a minimum of disruption to our busy working lives. But in so doing, we risk ignoring the complexity of their lives and belittling the reality of their distress. And by medicalizing their distress, we also risk reducing their sense of agency and self-determination, which are crucial ingredients in human flourishing. (see Dowrick C. Beyond Depression OUP, 2004)

Competing interests:   None declared

We commend Dr. Baik and her colleagues for their cogent analysis of the complex factors influencing the primary care physician’s diagnosis of depression. Of particular interest is their depiction of three distinct processes whereby the physician can gather information needed to formulate this psychiatric diagnosis. While the “ruling out” process is often employed in clinical practice, Baik, et al note that this strategy does not necessarily pertain when experienced physicians recognize “something different” in their patient’s presentation. Baik, et al conclude that a physician’s level of experience, familiarity with the troubled patient, and amount of time allotted for the visit generate multiple diagnostic strategies for the assessment of depression.

Despite acknowledged limitations in the authors’ methodology for deriving needed data, their conclusion already has a face validity not to be ignored. Thus, several alternatives emerge with regard to the “ruling out” manner in which primary care physicians often are taught to diagnose depression.1 First, it is striking that the two symptoms most often used by physicians to screen for depression according to Baik, et al are sleep problems and low energy level despite the greater sensitivity of sad mood and anhedonia in identifying this mood disorder.2 Can physicians, therefore, be taught to screen with the latter rather than the former symptoms so that depression is a diagnosis of inclusion rather than exclusion? Second, can the rank of depression in the physician’s diagnostic hierarchy be elevated when he/she is provided clinical information such as the patient’s score on the PRIME-MD or PHQ-9 communicated via an electronic medical record? 3 Furthermore, does the physician’s willingness to use such clinical information relate to his/her experience level and degree of familiarity with the patient? Third, is the physician’s reluctance to pursue the diagnosis of depression in the face of time constraints diminished when a care manager is available in the practice to assist in the assessment process ? 4

The forgoing questions are of more than academic interest since most educational programs for improving physician recognition of depression are standardized rather than creative in nature. To their credit, Baik, et al remind us that one educational package does not fit all clinicians and that customized approaches warrant significant attention if the recognition of depression is to be improved at all levels of primary care practice.

1 Depression Guideline Panel. Depression In Primary Care. Volume 1. Detection and Diagnosis. Agency For Healthcare Policy and Research, 1993. Rockville, MD

2 Whooley M, Avins A, Miranda J, Browner W. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med 12: 439-445, 1997.

3 Rollman B, Hanusa B, Gilbert T, Lowe H, Kapoor W, Schulberg H. The electronic medical record: A randomized trial of its impact on primary care physicians’ initial management of major depression. Arch Inter Med 161: 189-197, 2001.

4 Bruce M, Ten Have T, Reynolds C, Katz I. Schulberg H, Mulsant B, Brown G, Pearson J, Alexopolous G. Reducing suicidal ideation and depressive symptoms in depressed older primary care patients. A randomized controlled trial. J Amer Med Assn 291:1081-1091, 2004.

Herbert C. Schulberg, Ph.D., Dept.of Psychiatry, Weill Medical College of Cornell University, White Plains, NY Bruce L. Rollman, M.D., Dept. of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA

Competing interests:   None declared