Article Figures & Data
Tables
Unweighted Weighted Respondent Characteristic % n Population Estimate (%) Demographic Female 67.7 714 58.5 Age, y 18–29 4.5 47 15.1 30–39 9.2 97 14.3 40–49 19.6 207 24.2 50–59 22.9 241 17.8 >60 43.8 461 28.6 White race 90.5 954 85.3 Culturally or ethnically Hispanic 12.7 134 24.5 Education High school or less 18.1 191 25.1 Some college/technical school 29.6 312 27.6 College graduate 52.2 550 47.3 Household income <$20,000 15.6 164 12.7 $20,000–$34,999 13.9 146 12.6 $35,000–$49,999 12.3 130 10.7 $50,000–$74,999 16.2 171 17.9 $75,000–$100,000 17.3 182 18.1 >$100,000 22.1 233 26.1 Unsure/declined to answer 2.7 28 1.9 Employment status Employed for wages 35.9 378 45.6 Self-employed 11.6 122 11.2 Out of work 5.8 61 5.7 Homemaker 8.6 91 9.7 Student 2.1 22 4.8 Retired 27.9 294 18.8 Unable to work 8.2 86 4.3 Relational status Married 50.0 527 60.7 Not married but partnered 4.8 51 6.9 Separated or divorced 21.4 226 11.8 Widow/widower 11.8 124 6.4 Never married 12.0 126 14.2 Health situation Ever been treated for depression 45.1 475 29.5 Currently under treatment for depression 21.6 228 16.3 Family history of depression 52.7 555 43.0 General health perception Excellent 17.9 189 17.9 Very good 38.5 406 37.1 Good 27.0 285 29.5 Fair 12.0 126 12.2 Poor 4.6 48 3.4 Have regular source of care 88.0 928 81.3 Have health insurance 93.7 988 91.2 Reason for Nondisclosure (Item Label) Response Unweighted Analysis Weighted Estimates % n % 95% CI The doctor might put me on medicines that I’d rather not take (medication aversion) Does not apply 57.3 602 54.6 49.9–59.2 Applies a little 23.4 246 22.5 19.1–26.3 Applies a lot 19.2 202 22.9 18.8–27.5 I do not feel it is my doctor’s job to deal with emotional problems (not doctor’s job) Does not apply 73.3 773 71.0 66.4–75.2 Applies a little 14.1 149 13.4 10.9–16.5 Applies a lot 12.5 132 15.6 12.0–20.0 My medical records might be seen by others such as an employer (medical records) Does not apply 71.5 753 70.3 66.1–74.3 Applies a little 13.2 139 14.3 11.4–17.7 Applies a lot 15.3 161 15.4 12.5–18.9 The doctor might send me to a counselor, psychologist or social worker (counseling) Does not apply 75.8 797 74.0 69.6–78.0 Applies a little 11.8 124 12.3 9.8–15.4 Applies a lot 12.4 130 13.7 10.4–17.7 The doctor might send me to a psychiatrist (psychiatrist) Does not apply 76.0 800 73.9 69.4–78.0 Applies a little 12.1 127 12.7 10.0–15.9 Applies a lot 11.9 125 13.4 10.1–17.5 I would not want to be considered a ‘psychiatric patient’ (psychiatric patient) Does not apply 69.8 734 70.5 66.1–74.6 Applies a little 17.4 183 17.7 14.4–21.6 Applies a lot 12.8 135 11.8 9.2–15.0 I would not want to tell private information to my doctor (private information) Does not apply 84.3 888 80.2 75.7–84.0 Applies a little 9.8 103 10.7 8.0–14.2 Applies a lot 6.0 63 9.1 6.3–12.9 I might cry or become too emotional during the visit (emotional control) Does not apply 77.3 814 78.0 73.8–81.6 Applies a little 15.5 163 14.4 11.3–18.2 Applies a lot 7.2 76 7.6 5.6–10.4 I would not know how to bring up the topic of depression to my doctor (topic introduction) Does not apply 82.7 870 80.5 76.3–84.1 Applies a little 11.5 121 13.1 10.2–16.7 Applies a lot 5.8 61 6.4 4.2–9.6 I would not want to distract the doctor from taking care of my physical health problems (distraction of doctor) Does not apply 86.7 914 86.7 83.2–89.7 Applies a little 7.3 77 8.0 5.6–11.3 Applies a lot 6.0 63 5.3 3.8–7.3 The doctor might think less of me if I brought up my depression symptoms (loss of esteem) Does not apply 86.7 914 87.2 83.7–90.0 Applies a little 9.3 98 9.3 6.8–12.6 Applies a lot 4.0 42 3.6 2.3–5.4 -
CI=confidence interval.
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Note: Reasons have been sorted by percentage of the population estimated to believe the reason applies a lot to them.
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- Table 3
Unweighted Percentage of Respondents With vs Without a History of Depression Treatment Who Reported That a Reason for Not Seeking Depression Care Applies a Lot
Reason for Nondisclosurea History of Treatmentb (n=475) No History of Treatmentb (n=579) P Valuec % n % n Medication aversion 15.6 74 22.2 128 .009 Not doctor’s job 10.1 48 14.5 84 .040 Medical records 17.9 85 13.1 76 .041 Counseling referral 11.4 54 13.1 76 .423 Psychiatrist referral 9.5 45 13.9 80 .036 Psychiatric patient 13.7 65 12.1 70 .511 Private information 4.4 21 7.3 42 .072 Emotional control 9.7 46 5.2 30 .007 Topic introduction 5.7 27 5.9 34 1.00 Distract of doctor 5.9 28 6.0 35 1.00 Loss of esteem 4.8 23 3.3 19 .258 -
Note: Because of nonresponse, the number for analysis for each reason ranges from 1,050 to 1,054.
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↵a Refer to Table 2 for item wording.
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↵b Respondents were classified into the history (n = 475) or no history (n = 579) groups based on their answer to the question, “Have you, personally, ever been treated for depression by a health care provider? A health care provider could be a medical doctor or a mental health professional, such as a psychiatrist, psychologist, social worker, or counselor.”
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↵c Probability values are based on the χ2 test with continuity correction.
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- Table 4
Unweighted Percentage of Respondents Without vs With Moderate or Severe Depressive Symptoms Who Reported That a Reason for Not Seeking Depression Care Applies a Lot
Reason for Nondisclosurea No or Mild Symptomsb (n=899) Moderate or Severe Symptomsb (n=153) P Valueb,c % n % n Medication aversion 17.7 159 27.8 42 .004 Not doctor’s job 11.8 106 17.0 26 .073 Medical records 13.6 122 25.5 39 .001 Counseling referral 11.3 101 18.3 28 .014 Psychiatrist referral 10.8 97 18.3 28 .008 Psychiatric patient 11.6 104 20.3 31 .003 Private information 4.8 43 12.4 19 .001 Emotional control 4.9 44 20.9 32 .001 Topic introduction 4.0 36 16.5 25 .001 Distract of doctor 4.5 40 14.4 22 .001 Loss of esteem 2.6 23 12.4 19 .001 -
PHQ- 9 = 9-item Patient Health Questionnaire.
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Note: Because of nonresponse, the number for analysis for each reason ranges from 1,048 to 1,052.
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↵a Refer to Table 2 for item wording.
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↵b Respondents with a PHQ-9 score of 0–9 were assigned to the no or mild depressive symptoms group; respondents with a PHQ-9 score of 10–27 were assigned to the moderate/severe depressive symptoms group.
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↵c Probability values are based on the χ2 test with continuity correction.
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- Table 5
Weighted Multiple Regression Analyses Predicting Perceived Barriers to Disclosing Depression to One’s Primary Care Physician
Predictors Coefficient 95% CI Demographic variables Age (in years) .001 −.001 to .003 Female .080a .014 to .146 Married or partnered −.003 −.072 to .065 Nonwhite race .025 −.081 to .130 Hispanic .129b .033 to .244 Education High school or less — — Some college/technical −.120a −.223 to −.016 College graduate −.058 −.163 to .047 Income $0–$34,999 — — $35,000–$75,000 −.173c −.276 to −.069 >$75,000 −.120a −.230 to −.010 Health/depression variables General health perception .017 −.021 to .055 Depression symptoms (PHQ-9) .019c .009 to .029 Past diagnosis .035 −.035 to 1.05 Family history −.078a −.140 to −.015 Stigma .136c .092 to .181 Biomedical causes −.005 −.071 to .061 Psychosocial causes −.011 −.057 to .035 Controllable .074b .024 to .123 Timeline (usually >1 y) .040 −.026 to .105 Health insurance −.093 −.266 to .079 Regular source of care −.024 −.134 to .086
Additional Files
The Article in Brief
Suffering in Silence: Reasons for Not Disclosing Depression in Primary Care
Robert A. Bell , and colleagues
Background One-fourth of primary care patients with major depressive disorder do not have their condition diagnosed. This study explores reasons why patients do not disclose depression to their primary care doctors.
What This Study Found Many adults have beliefs that inhibit them from disclosing symptoms of depression to their primary care doctor. In a survey of 1,054 adults, 43 percent of patients report one or more reasons for not talking to a primary care doctor about their depression. The most frequently cited reason is concern that the doctor will recommend antidepressants. Other reported barriers include the belief that it is not the primary care physician�s job to deal with emotional issues, concerns about medical record confidentiality, fear of referral to a counselor or psychiatrist, and fear of being labeled a psychiatric patient.
Implications
- Those who most subscribe to potential reasons for not talking to a primary care physicians about their depression tend to be those who have the greatest potential benefit from such conversations: individuals with moderate to severe depressive symptoms.
- The authors call for the development of office-based interventions that address these patients' concerns and encourage patients with depression symptoms to begin a conversation with their doctors.
ANNALS JOURNAL CLUB:
Sep/Oct 2011
Patients' Reasons for Not Disclosing Depression
The Annals of Family Medicine encourages readers to develop a learning community of those seeking to improve health care and health through enhanced primary care. You can participate by conducting a RADICAL journal club and sharing the results of your discussions in the Annals online discussion for the featured articles. RADICAL is an acronym for Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. The word radical also indicates the need to engage diverse participants in thinking critically about important issues affecting primary care and then acting on those discussions.1HOW IT WORKS
In each issue, the Annals selects an article or articles and provides discussion tips and questions. We encourage you to take a RADICAL approach to these materials and to post a summary of your conversation in our online discussion. (Open the article online and click on "TRACK Comments: Submit a response.") You can find discussion questions and more information online at: http://www.AnnFamMed.org/AJC/.
CURRENT SELECTION
Article for Discussion
- Bell RA, Franks P, Duberstein PR, et al. Suffering in silence: reasons for not disclosing depression in primary care. Ann Fam Med. 2011;9(5):439-446.
Discussion Tips
Depression can be challenging to detect, and it is easy to blame patients for framing their visits in ways that make detection more difficult. More challenging is to try to understand depression from the patients� point of view and to consider the effects of our own behavior in creating an environment in which patients are comfortable sharing their deep concerns, even if those concerns challenge our medical model. This issue�s journal club article gives us data to inform our efforts to create an open environment for patients to share depressive symptoms.
Discussion Questions
- What questions are asked by this study and why does it matter? How was theory used to frame the questions?
- How does this study advance beyond previous research and clinical practice on this topic?
- How strong is the study design for answering the question?
- To what degree can the findings be accounted for by:
- How patients were selected, excluded, or lost to follow-up?
- How the main variables were measured?
- Confounding (false attribution of causality because 2 variables discovered to be associated actually are associated with a 3rd factor)?
- Chance?
- How the findings were interpreted?
- How comparable is the study sample to similar patients in your practice? What is your judgment about the transportability of the findings?
- What are the main study findings?
- What reflections do you have on (1) the factors that patients say affect their disclosure of depressive symptoms, and (2) the characteristics of patients less likely to disclose depression? How might our/your approach to patients in general, and to the diagnosis and treatment of depression in particular, help create an environment in which patients feel safe disclosing depressive symptoms?
- How might this study change your practice? Policy? Education? Research?
- Could patients in your practice be engaged in interpreting or helping your practice to use the findings? How?
- What are the next steps in interpreting or applying the findings to change practice?
- What researchable questions remain?
References
- Stange KC, Miller WL, McLellan LA, et al. Annals Journal Club: It�s time to get RADICAL. Ann Fam Med. 2006;4(3):196-197. http://annfammed.org/cgi/content/full/4/3/196.
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