Reinvention of Depression Instruments by Primary Care Clinicians

Seong-Yi Baik; Junius J. Gonzales; Barbara J. Bowers; Jean S. Anthony; Bas Tidjani; Jeffrey L. Susman

doi:10.1370/afm.1113

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Overcoming Obstacles to the Primary Care Physician�s Use of Depression Screening Instruments
Herbert C. Schulberg

Published on: 27 May 2010
System Broken; one on one geniuses perservere
Jeff Susman

Published on: 17 May 2010
One-on-one geniuses, systems laggards
Richard L. Brown

Published on: 14 May 2010

Published on: (27 May 2010)
Page navigation anchor for Overcoming Obstacles to the Primary Care Physician�s Use of Depression Screening Instruments
Overcoming Obstacles to the Primary Care Physician�s Use of Depression Screening Instruments
Herbert C. Schulberg, White Plains
Other Contributors:
“Build it and they will come” is considered a successful strategy for creating demand for a ball field. The construction of psychometrically sound and patient-friendly depression screening instruments for use by primary care physicians produces no such consequence, however. Observers of such physicians have long recognized and lamented that they fail in routine practice to administer and assess depression with such well-...
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“Build it and they will come” is considered a successful strategy for creating demand for a ball field. The construction of psychometrically sound and patient-friendly depression screening instruments for use by primary care physicians produces no such consequence, however. Observers of such physicians have long recognized and lamented that they fail in routine practice to administer and assess depression with such well- established instruments as the PHQ-9. Baik, et al are to be commended, therefore, for analyzing why this is so. The three factors that they identify as influencing the physician’s decision to assess depression with a structured instrument, i.e. extent of competing demands, lack of objective evidence, and degree of familiarity with the patient, ring true but also highlight disturbing incongruities. For example, it is precisely when faced with competing demands on finite time that the physician can increase efficiency by administering a depression screening instrument and quickly obtain an overview of the patient’s mood state. In pondering whether primary physicians will continue to limit their use of depression assessment tools to the circumstances described in this study, we would note that the data reported by Baik, et al were gathered during 2005-2008. Since then, techniques for computerized administration of the PHQ-9 and similar instruments are readily available and require no effort by the primary care physician. Will he/she now expand the manner in which the resulting information is used? Finally, Baik, et al note the overarching influence of stigma on the patient’s willingness to consider depression an illness warranting diagnosis and treatment in the primary care setting. The finding that only 3.6% of Swedish primary care patients identified their depression as having biological reasons (Hansson, et al, 2010) underscores the persisting challenges in characterizing depression as just another medical illness. Our Cornell group, therefore, has developed psychosocial interventions for primary care physicians and allied staff that target such stigma and beliefs about depression (Sirey, et al, in press). We also encourage shared decision-making about treatment (Raue et al, in press) so as to engage both patients and health care providers in the depression caregiving process.
Hansson M, Chotai J, Bodlund O. Patients’ beliefs about the cause of their depression. J Affect Dis 2010;124: 54-59.
Raue PJ, Schulberg HC, Lewis-Fernandez R, Boutin-Foster C, Hoffman AS, Bruce ML. Shared decision-making in the primary care treatment of late -life major depression: a needed new intervention? Int J Geriatr Psychiatry, in press.
Sirey JA, Bruce ML, Kales HC. Improving antidepressant adherence and depression outcomes in primary care: the treatment initiation and participation (TIP) program. Am J Geriatr Psychiatry, in press.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (17 May 2010)
Page navigation anchor for System Broken; one on one geniuses perservere
System Broken; one on one geniuses perservere
Jeff Susman, Cincinnati, OH, USA
Thank you Dr Brown for your observations. We heartily agree that many of the approaches to enhancing primary care and behavioral health must be system driven and poppulation-based. That said, in the eyes of many practicing physicians, we are asking them to invest even more time, energy and expense in changing the processes and culture of primary care without improving their resource base.
While there are wo...
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Thank you Dr Brown for your observations. We heartily agree that many of the approaches to enhancing primary care and behavioral health must be system driven and poppulation-based. That said, in the eyes of many practicing physicians, we are asking them to invest even more time, energy and expense in changing the processes and culture of primary care without improving their resource base.
While there are wonderful examples of innovative practices, the ability to scale and spread these improvments remains challenging given the current environment of primary care. Our situation reminds one of the classic Lucille Ball comedies: of being on the assembly line and clearly seeing the disaster that is occuring, but feeling helpless in changing the system. We need to re-empower primary care clinicians and provide them the resources to feel self-efficacious and supported in their care of patients and communities.
On behalf of the authors
Competing interests: None declared
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Competing Interests: None declared.
Published on: (14 May 2010)
Page navigation anchor for One-on-one geniuses, systems laggards
One-on-one geniuses, systems laggards
Richard L. Brown, Madison, Wisconsin, USA
Thanks, Dr. Baik and colleagues, for interesting and well-done research.
We primary care clinicians are scrappy and brilliant when it comes to managing individual patients. It's sad that most of us don't do nearly as well at crafting practice systems that would systematically help many more patients. Despite much research and many evidence-based recommendations (eg, US Preventive Services Task Force), most of...
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Thanks, Dr. Baik and colleagues, for interesting and well-done research.
We primary care clinicians are scrappy and brilliant when it comes to managing individual patients. It's sad that most of us don't do nearly as well at crafting practice systems that would systematically help many more patients. Despite much research and many evidence-based recommendations (eg, US Preventive Services Task Force), most of us continue not to implement systematic screening and intervention - for depression, as well as tobacco use and excessive drinking.
We tend to blame lack of provider time and inadequate reimbursement, but many health plans reimburse now for such tobacco and alcohol services, and billable clinicians can charge for services provided by ancillary staff, who can be trained to administer protocol-guided, evidence-based services. Primary healthcare settings can realize a gross profit of >$20,000 per year for each ancillary staffperson who provides 14 billable services a day, and there's ample time left over for them to assist providers with as yet unreimbursed screening, behavioral activation intervention, referral, and case management services for depression.
Let's channel more of that one-on-one genius into systems engineering that would help many more patients!
Competing interests: Owner, Wellsys, LLC, which helps clinical sites implement comprehensive behavioral screening and intervention services
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Competing Interests: None declared.