Psychiatric Annals

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DEPRESSION IN PRIMARY CARE 

Depression: A Common Illness Uncommonly Diagnosed

Joseph A Lieberman, III, MD, MPH

Abstract

It is well recognized that there is a high prevalence of psychiatric disorders in our population. A study by Kessler et al.1 found the prevalence of any affective disorder in our population to be 11.3% in any 12 months and 19.3% in a lifetime. They further deterrrtined that the prevalence of a major depressive disorder was 10.3% in 12 months and 17.1% in a lifetime. The incidence and prevalence of mental health problems figures for patients seen in a primary care office are even higher. Perhaps two thirds to three fourths of patients who visit their primary care physician have a significant psychodynamic or behavioral problem, such as depression or anxiety. Included in this population, as a subset of the group, are those patients suffering from a major depressive disorder. According to Goldman et al.,2 "As many as 5% to 10% of primary care patients suffer from major depression at any one time, and another 10% to 15% will be experiencing some lesser degrees of depression." These data suggest mat primary care practitioners see a large number of patients with mental health disorders, and in many ways these physicians are the backbone of the American mental health system.3"5

Despite the presence of a large number of patients in primary care offices afflicted with mental health problems, a review of the literature indicates that physicians who are practicing primary care are not doing a particularly good job of identifying or treating these patients. One study revealed that as many as 79% of patients with a psychiatric disorder went unidentified when presented to a family medicine residency center in Alabama.6 In a study looking at only major depressive disorders, 36% of patients with depression went unrecognized in a primary care setting.7 In another study it was found that primary care physicians counseled only 60% of the patients who disclosed psychosocial problems,8 Trie issue of appropriate treatment after identification compounds the problem of identifying patients with depression in a primary care setting.

In the Medical Outcomes Study, Wells et al.9 discovered considerable evidence of the under-treatment of depressive disorders. Of the 634 patients identified with depressive disorders, 59% received no antidepressant or tranquilizing medication, 19% received minor tranquilizer only, 12% received antidepressants only, and 11% received antidepressants and minor tranquilizers (but in these two cohorts, 39% of the patients using antidepressants were receiving subtherapeutic doses). Compounding all of these problems is the fact that not only are these unrecognized patients suffering unnecessarily, but they also impose an undue and unnecessary burden on the offices of those physicians who are not recognizing these disorders.

In a study of patients with depression, Lind et al.10 observed that patients with depression were high users of medical services and put a strain on health care resources. They required multiple office visits, made numerous phone calls, had multiple physical complaints, often with negative workups, and were generally viewed to be a source of frustration for physicians. (Thirty-seven percent of high users [n=228] were rated as "frustrating" by their physicians). Katon et al.11 studied these high utilizing also and, among other findings, determined that major depression was present in 24% of high utilizing patients, whereas 68% of these patients had a lifetime history of a major depressive disorder.

MEDICAL EDUCATION: A FUNDAMENTAL PROBLEM

There are many possible reasons to explain why primary care physicians are apparently doing a suboptimal job with mental health issues, including time pressures, unfavorable reimbursement, and the stigma associated with the diagnosis of a mental health disorder. Although these are all items that are part of this issue, there is a more fundamental explanation why…

It is well recognized that there is a high prevalence of psychiatric disorders in our population. A study by Kessler et al.1 found the prevalence of any affective disorder in our population to be 11.3% in any 12 months and 19.3% in a lifetime. They further deterrrtined that the prevalence of a major depressive disorder was 10.3% in 12 months and 17.1% in a lifetime. The incidence and prevalence of mental health problems figures for patients seen in a primary care office are even higher. Perhaps two thirds to three fourths of patients who visit their primary care physician have a significant psychodynamic or behavioral problem, such as depression or anxiety. Included in this population, as a subset of the group, are those patients suffering from a major depressive disorder. According to Goldman et al.,2 "As many as 5% to 10% of primary care patients suffer from major depression at any one time, and another 10% to 15% will be experiencing some lesser degrees of depression." These data suggest mat primary care practitioners see a large number of patients with mental health disorders, and in many ways these physicians are the backbone of the American mental health system.3"5

Despite the presence of a large number of patients in primary care offices afflicted with mental health problems, a review of the literature indicates that physicians who are practicing primary care are not doing a particularly good job of identifying or treating these patients. One study revealed that as many as 79% of patients with a psychiatric disorder went unidentified when presented to a family medicine residency center in Alabama.6 In a study looking at only major depressive disorders, 36% of patients with depression went unrecognized in a primary care setting.7 In another study it was found that primary care physicians counseled only 60% of the patients who disclosed psychosocial problems,8 Trie issue of appropriate treatment after identification compounds the problem of identifying patients with depression in a primary care setting.

In the Medical Outcomes Study, Wells et al.9 discovered considerable evidence of the under-treatment of depressive disorders. Of the 634 patients identified with depressive disorders, 59% received no antidepressant or tranquilizing medication, 19% received minor tranquilizer only, 12% received antidepressants only, and 11% received antidepressants and minor tranquilizers (but in these two cohorts, 39% of the patients using antidepressants were receiving subtherapeutic doses). Compounding all of these problems is the fact that not only are these unrecognized patients suffering unnecessarily, but they also impose an undue and unnecessary burden on the offices of those physicians who are not recognizing these disorders.

In a study of patients with depression, Lind et al.10 observed that patients with depression were high users of medical services and put a strain on health care resources. They required multiple office visits, made numerous phone calls, had multiple physical complaints, often with negative workups, and were generally viewed to be a source of frustration for physicians. (Thirty-seven percent of high users [n=228] were rated as "frustrating" by their physicians). Katon et al.11 studied these high utilizing also and, among other findings, determined that major depression was present in 24% of high utilizing patients, whereas 68% of these patients had a lifetime history of a major depressive disorder.

MEDICAL EDUCATION: A FUNDAMENTAL PROBLEM

There are many possible reasons to explain why primary care physicians are apparently doing a suboptimal job with mental health issues, including time pressures, unfavorable reimbursement, and the stigma associated with the diagnosis of a mental health disorder. Although these are all items that are part of this issue, there is a more fundamental explanation why physicians have difficulty in dealing with psychological and behavioral issues. To understand this rationale, we need to revisit the history of medical education in the United States.

Prior to the Flexner report of 1910, the American medical education system was a mixed bag of experiences.12 While early efforts were being mounted, primarily at Johns Hopkins University, to link the medical education process to the scientific method of scholarly inquiry housed in a traditional university setting, a popular medical educational model was the pedagogical opposite of this academic approach. The prevailing model used medical preceptorships where students spent varying periods of time with a community-based physician, learning their craft and acquiring the tools of their trade. When the preceptor deemed the student to be adequately prepared, he (and occasionally she) was presented to the state medical society where after a series of nonstandardized evaluations the successful candidate was awarded the doctor of medicine degree by the state society. There were formal medical schools operating at the time, but there was wide variation in the curricula, testing and measurement, quality of faculty, adequacy of the physical plant, and other determinants of an adequate medical education facility. Flexner's report on this state of affairs accelerated what was already underway - the process of changing the medical education system.

Those efforts resulted in the system that is in place today, where medicine is treated as an academic discipline and the scientific method, reductionism, and evidence-based decision making drive both the study of medicine and the process of care. The end product of this process of reductionism is the traditional medical subspecialist whose interests reside in either a specific organ system or even a specific disease. These clinical entities are all too frequently viewed in isolation from the afflicted patient, an approach that is, in many ways, reflective of the thinking of René Descartes (1596-1650), the French philosopher and mathematician who was also an unabashed advocate of the separation of mind and body. Somehow his dualism has persevered through the centuries and has been enhanced by the clinicians' reductionist approach that has emerged as the dominant method of scholarly inquiry and exploration in medical science.

However, this approach has not been without its detractors. In Descartes' Error: Emotion, Reason, and the Human Brain, Antonio R. Damasio takes issues with Decartes' separation of most refined operations of mind from the structure and operation of a biological organism.13 Likewise in a more specific reference to this model, George Ingel makes the following observation:14

The crippling flaw of the model is that it does not include the patient and his attributes as a person, as a human being. The biomedical model can make provision neither for the person as a whole nor for data of a psychological or social nature, for the reductionism and mind-body dualism on which the model is predicated requires that these must first be reduced to physicochemical terms before they can have meaning. Hence, the very essence of medical practice perforce remains art and beyond the reach of science.

The former United States Surgeon General C. Everett Koop expressed his sentiments in an article published in the Medical Tribune when he stated, "While the science of medicine has flourished, the art of medicine, which is largely the art of communication or relationship building, has languished."15 Still more commentary on this issue was provided by Epstein et al.16 when they observed, "Until recently the content, structure and function of communication between doctors and patients has received little attention and has been excluded from the realm of scientific inquiry; as a result, most clinicians have little formal training in communication skills."

Finally, another observer, Jackson,17 carried this analysis a step further and emphasized the importance of listening in communication when he observed, "The place of listening in depth and with empathy is a crucial element in healing. While the emphasis on looking remains significant in the gathering and appraisal of data, at times it threatens to overwhelm the need for an attentive and concerned listener."

THE MIND-BODY CONNECTION

With this as background, one is better able to consider the impact of the prevailing model of academic preparation on the thinking and problem solving abilities oí the contemporary practitioner. There are data indicating that when patients with a psychiatric disorder present with a psychological symptom, practitioners establish the correct diagnosis in 94% of cases. However they only establish the correct diagnosis in 50% of cases when these same patients present with a somatic problem.18 This study also looked at the way patients' with psychiatric disorders presented to primary care physicians and found that in 83% of the cases, the presenting complaint was somatic. On the other hand, psychological presenting complaints were found in only 17% of cases. From these data one can surmise that the potential for error is high. Keep in mind that the vast majority of times patients with a psychiatric disorder will present with somatic symptoms, the very presentation with which clinicians fare the poorest in terms of accurate recognition of the patient's underlying problem.

In concert with this thinking, Kroenke et al.19 looked at a large number of undifferentiated patients over a 3-year period. These patients presented to his clinic with a variety of somatic complaints. They were then thoroughly studied for the 3-year period and at the conclusion a determination was made as to whether or not an organic cause had been found to explain their symptomatology. Again, in the vast majority of cases no organic cause was established to explain the patient's symptomatology.

All of these data, taken collectively, give credence to the notion that the body and the mind are connected and that patients with psychological illness frequently have accompanying organic symptoms. However to focus purely on the organic symptomatology to the exclusion of communicating with the patient and exploring other possible explanations for the patient's plight, one would poorly serve both the patient and the clinician. I am not advocating abandoning the scientific method nor totally dismantling the American medical education system. There are many good things to be said for our system. Rather I would submit that our challenge is to devise a system that builds upon and incorporates the contemporary training of the clinician but adds an additional dimension to that physician's skill set that would enable him or her to deal more effectively with the psychodynamic dimension of any patient's presentation. It is our challenge to engage both the science and art of medicine to optimize the doctorpatient relationship and the outcomes that emanate from it.

TECHNIQUES AND MNEMONICS

To accomplish the goal of bringing the mind and body together in a substantive whole and handle the patient's psychodynamic and physical issues, physicians should employ the BATHE technique developed by myself and Dr. Marian Stuart in our textbook, The Fifteen Minute Hour: Applied Psychotherapy for the Primary Care Physician. BATHE (Sidebar) was developed to build upon the commonly accepted problem-oriented medical record and the SOAP (Sidebar) format of records keeping developed by Dr. Larry Weed in the early 1970s. This format is now in common use in creating a medical record in the primary care office as it has general applicability and it is fairly standardized across practice sites.20 The SOAP acronym puts the problem-oriented medical record into operation and is an excellent approach for defining and dealing with a patient's problem. However, SOAP does not deal specifically with the psychosocial component, so we developed the BATHE technique, which denotes the protocol to determine the total context of the patient's visit.

The BATHE technique enables the physician to establish rapport with a patient quickly and efficiently, bridging the communications gap (the art and science disequilibrium referred to by Dr. Koop). In addition to obtaining information, the clinician is also performing a psychotherapeutic procedure in the context of the relationship he or she has with patients in order to affect the patients' views of their reality. In the process, patients are empowered to trust in themselves and others, affirm their positive feelings about themselves, and enhance their ability to control the circumstances of their lives. Patients express themselves in a directed and focused fashion and, in the process, provide the physician with much information in a relatively brief period of time.

When to Use BATHE

* To determine why the patient is seeking treatment as part of obtaining a medical history;

* To quickly establish personal rapport with patients;

* To screen for anxiety depression, or situational stress disorders;

* To probe for psychosocial precipitants related to somatic complaints;

* To put the biopsychosocial model into operation by ascertaining the context of the patient's illness;

* To help patients connect their physical symptoms and emotional responses to the circumstances of their lives;

* To explore patients' reactions to being given a diagnosis;

* To handle unexpected psychosocial revelations during an interview;

* To explore compliance issues, inappropriate requests for referrals, or other difficult situations in the doctor /patient relationship.;

* To provide a structure for a brief counseling session or a family interview.

When Not to Use BATHE

* The patient is in severe pain or life-threatening circumstances;

* Resistance on the part of the patient, expressed as suspiciousness or hostility;

* A patient is suicidal or a battered spouse, sexual abuse victim, or substance abuser. Although BATHE may be helpful in uncovering these conditions, an empathie response must be followed by further exploration and possible action;

* The patient may be psychotic (BATHE may also be ineffective with personality disorder patients, especially borderline patients);

* Modification may need to be made for patients with developmental disorders or physical handicaps, of different cultural backgrounds, or when language is a barrier.22

If the answers to the BATHE questions lead the physician to suspect that the patient is suffering from depression, the mnemonic SIG E CAPS (Sidebar) can be used to confirm the diagnosis.

The physician who employs SOAPing, BATHEing, and SIG E CAPS where appropriate will efficiently and effectively diagnose the overwhelming majority of patients with a mood disorder and may uncover other problems that are affecting the patient's quality of life, health, and well-being. Making these determinations, assisting patients as they work through these problems, and the sense of accomplishment that accompanies these clinical triumphs is the practice of the art of medicine in its finest form. Physicians would be well served and serve their patients well when they master these techniques and employ them effectively.

REFERENCES

1. Kessler RC, McGonagle KA, Zaho S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the national comorbidity survey. Arch Gen Pyschiatry. 1994;51:8-19.

2. Goldman LS, Wise TN, Brody DS. Psychiatry for Primary Care Physicians. Chicago, IL: American Medical Association; 1998:77.

3. Regier DA, Goldberg ID, Taube CA. The de facto US mental health services system: a public health perspective. Arch Gen Psychiatry. 1978;35:685-693.

4. Barrett JE, Barrett JA, Oxman TE, Gerber PD. The prevalence of psychiatric disorders in a primary care practice. Arch Gen Psychiatry. 1988;45:1100-1106.

5. Norquist GS, Regier DA. The epidemiology of psychiatric disorders and the de facto mental health care system. Ann Rev Med. 1996;47:473-479.

6. Higgens ES. A review of unrecognized mental illness in primary care: prevalence, natural history, and efforts to change the course. Arch Fam Med. 1994;3:908-917.

7. Simon GE, VonKorff M. Recognition, management and outcomes of depression in primary care. Arch Fam Med. 1995;4:99-105.

8. Robinson JW, Roter DL. Counseling by primary care physicians of patients who disclose psychosocial problems. J Fam Pract. 1999;48:698-705.

9. Wells KB, Katon W, Rogers B, Camp P. Use of minor tranquilizers and antidepressant medications by depressed outpatients; results from the medical outcomes study. Am !Psychiatry. 1994;151:694-700.

10. Lin EH, Katon W, Von Korff M, et al. Frustrating patients: physician and patient perspectives among distressed high users of medical services. J Gen Intern Med. 1991;6:241-246.

11. Katon W, Von Korff M, Lin E, et al. Distressed high utilizers of medical care. DSM III-R diagnoses and treatment needs. Gen Hosv Psychiatry. 1990;12:355-369.

12. Flexner A. Medical Education in the United States and Canada. New York, NY: Carnegie Foundation tor the Advancement of Teaching; 1910.

13. Damasio, AR. Descartes Error: Emotion, Reason and the Human Brain. New York, NY: Grosset/ Putnam; 1994:249-250.

14. Engel GL. The clinical application of the biopsychosocial mode. Am J Psychiatry. 1980;137:535-544.

15. Mann D. Doctors, patients need to talk more. Medical Tribune. 1998:39.

16. Epstein RM, Campbell TL, Cohen-Cole SA, McWhinney IR, Smilkstein G. Perspectives on patient-doctor communication. J Fam Pract. 1993;37:377-388.

17. Jackson SW. The listening healer in the history of psychological healing. Am J Psychiatry. 1992;149:1623-1632.

18. Bridges KW, Goldberg DP. Somatic presentation of DSMHJ psychiatric disorders in primary care. J Psychosom Res. 1985;29:563-569.

19. Kroenke K, Magelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy and outcome. Am J Med. 1989;86:262-266.

20. Weed LD. The problem oriented record as a basic tool in medical education, patient care and clinical research. Ann Clin Res. 1971;3:131-134.

21. Stuart MR, Lieberman JA. The Fifteen Minute Hour. Applied Psychotherapy for the Primary Care Physician. Westport, CT: Praeger; 1993:96-97.

22. Lieberman JA, Stuart MR. The BATHE method: incorporating counseling and psychotherapy into the everyday management of patients. Primary care companion. J Clin Psychiatry. 1999;1:35-38.

23. Wise MG, Rundell JR. Concise Guide to Consultation Psychiatry. 2nd ed. Washington, DC: American Psychiatric Press; 1994:55-56.

10.3928/0048-5713-20020901-07

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