A conceptual model for educating primary care providers in the diagnosis and treatment of depression

Schulberg, Herbert C.; McClelland, Maureen

doi:10.1016/0163-8343(87)90094-6

Cited by 51 publications

(22 citation statements)

References 64 publications

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“…Primary care physicians are often anxious not to miss a life-threatening organic condition, and those who are less confident in depression diagnoses will investigate somatic symptoms first-sometimes at length-before considering depression as the underlying cause. 9 In primary care, the depressed patient's tendency to attribute unexplained somatic symptoms to a normalizing nonpathologic cause, rather than a psychological cause, is a principal driver in misdiagnosis. [54][55][56][57] Physicians at 1 primary care practice in the United Kingdom failed to recognize depression (or anxiety) in 85% of patients with a normalizing attributional style, compared with 38% of patients with a psychologizing style.…”

Section: Somatic Symptoms Decrease the Recognition Of Depressionmentioning

confidence: 99%

“…As a result, many physicians become preoccupied with lengthy investigations into possible underlying organic disease rather than considering depression as a diagnosis. 9 Indeed, depression is mostly difficult to recognize in patients who present with chiefly somatic complaints. 8,10 We conducted a review of the recent literature to ascertain the importance of somatic symptoms in depression in primary care, focusing particularly on their effects on the recognition of depressive symptomatology.…”

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confidence: 99%

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The Importance of Somatic Symptoms in Depression in Primary Care

Gandhi¹

2005

Prim. Care Companion CNS Disord.

241

186

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Objective:Patients with depression present with psychological and somatic symptoms, including general aches and pains. In primary care, somatic symptoms often dominate. A review of the literature was conducted to ascertain the importance of somatic symptoms in depression in primary care.Data sources and extraction: MEDLINE, EMBASE, and PsychLIT/PsychINFO databases ( -January 2004 were searched for the terms depression, depressive, depressed AND physical, somatic, unexplained symptoms, complaints, problems; somatised, somatized symptoms; somatisation, somatization, somatoform, psychosomatic; pain; recognition, underrecognition; diagnosis, underdiagnosis; acknowledgment, underacknowledgment; treatment, undertreatment AND primary care, ambulatory care; primary physician; office; general practice; attribution, reattribution; and normalising, normalizing. Only English-language publications and abstracts were considered.Study selection: More than 80 papers related to somatic symptoms in depression were identified using the content of their titles and abstracts.Data synthesis: Approximately two thirds of patients with depression in primary care present with somatic symptoms. These patients are difficult to diagnose, feel an increased burden of disease, rely heavily on health care services, and are harder to treat. Patient and physician factors that prevent discussion of psychological symptoms during consultations must be overcome.Conclusions: Educational initiatives that raise awareness of somatic symptoms in depression and help patients to reattribute these symptoms should help to improve the recognition of depression in primary care.( 3 Despite improved awareness of the condition in primary care, depression remains difficult to diagnose initially, and the majority of cases are only recognized at subsequent consultations, sometimes several years after the patient's initial visit. 4 In primary care, physicians require sophisticated consulting skills to enable them to differentiate a wide range of symptoms from a complex narrative in a short period of time. Symptoms of depression include classic psychological symptoms, such as low mood, loss of interest, poor concentration, and associated anxiety, and somatic symptoms, such as changes in appetite, lack of energy, sleep disturbance, and general aches and pains. 5,6 The suspicion of depression is usually raised by the presence of psychological symptoms. However, in approximately two thirds of patients with depression, the clinical picture is dominated by somatic symptoms, such as lack of energy and general aches and pains, 7,8 which patients frequently attribute to normalizing causes. As a result, many physicians become preoccupied with lengthy investigations into possible underlying organic disease rather than considering depression as a diagnosis.9 Indeed, depression is mostly difficult to recognize in patients who present with chiefly somatic complaints. 8,10 We conducted a review of the recent literature to ascertain the importance of somatic symptoms in depress...

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Section: Somatic Symptoms Decrease the Recognition Of Depressionmentioning

confidence: 99%

mentioning

confidence: 99%

The Importance of Somatic Symptoms in Depression in Primary Care

Gandhi¹

2005

Prim. Care Companion CNS Disord.

241

186

View full text Add to dashboard Cite

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“…Somatic complaints may impede depression identification by competing for the attention and time of the physicians, 61 especially if a lengthy investigation of somatic symptoms is carried out. 28 Patients and physicians may erroneously believe there is no reason to initiate depression treatment, although data indicate that treatment with antidepressants can improve outcomes. 62,63 The patient-related and physician-related barriers to the detection of depression among men and women with somatic symptoms may be similar.…”

Section: 48-53mentioning

confidence: 99%

“…27 Primary care physicians may pursue a lengthy investigation of somatic symptoms rather than considering depression as a possible diagnosis. 28 Our goal was to examine the association between somatization and depression as rated by primary care physicians. In addition, we investigated the characteristics of patients who were identified by the physician as somatizing, depressed, or both depressed and somatizing.…”

mentioning

confidence: 99%

A Cross-Sectional Study of Somatic Symptoms and the Identification of Depression Among Elderly Primary Care Patients

Bogner

Shah²,

Vries³

2009

Prim. Care Companion J. Clin. Psychiatry

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omatization, the presentation of medically unexplained symptoms, is very common in primary care.Objective: To examine the relationship between somatization and depression as rated by primary care physicians.Method: This study was a cross-sectional survey of 355 older adults with and without significant depressive symptoms. Physicians' ratings of somatization and depression were obtained for 341 of the 355 patients. Patients were sorted into 4 groups on the basis of physician ratings (no depression/no somatization, somatization only, depression only, and both somatization and depression). Data were collected from [2001][2002][2003].Results: Patients who were rated as somatizing were 4.03 (95% CI, 2.52-6.45) times as likely to be rated as depressed as well as somatizing. A comparison of the 4 groups defined by physicians' ratings found that functional status, ethnicity, number of medical conditions, depressive symptoms, and anxiety were statistically significantly different (P < .05). Primary care physicians were 3.95 (95% CI, 1.53-10.16) times more likely to identify older black patients as somatizing only versus depressed and somatizing compared to older white patients among patients above a threshold on a standard depression instrument.Conclusions: Our study fills a gap in the literature by focusing on the primary care physician ratings of depression and somatization, and also specifically on older primary care patients. Blacks are less likely to be rated as depressed, but this may reflect the tendency of doctors to rate them as somatizing.

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“…In general, this method appears reliable and valid (14). However, it allowed us to study only one element of recognition: the GPs' knowledge of depression (e.g., interview skills were not considered) (15). Thus no conclusions can be drawn with regard to actual performance in practice.…”

Section: A Recognition: the Case-vignettesmentioning

confidence: 99%

Management of depression in elderly general practice patients

Marwijk

Bock

Jong

et al. 1994

Scandinavian Journal of Primary Health Care

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Objective -To describe general practitioners' (GP) management (i.e., recognition and treatment) of depression in elderly patients.Design -Two separate studies were performed: (a) to study recognition of depression, a postal survey was sent to GPs; (b) to evaluate the consistency of treatment, patients considered depressed by GPs were described.Setting -general practices in the West of The Netherlands. Subjects -65 GPs, and 44 patients of 7 GPs. Main outcome meusures -(a) degree of recognition of depression as described in major depression case-vignettes (b) consistency of treatment.Results -(a) On average 65% of the GPs recognized every depressive symptom in case-vignette one, while 52% of GPs recognized each symptom in case two. Most (39) doctors used a time criterion of less than 5 weeks for depressive disorder. (b) Depressed patients with at least three depressive symptoms all received treatment. Chronically depressed patients appeared to be treated somewhat inadequately. Conclusion -The results suggest some inadequate knowledge of criteria for major depression and some inconsistency in treatment. The management of depression in elderly GP patients appears to need improvement.

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A conceptual model for educating primary care providers in the diagnosis and treatment of depression

Cited by 51 publications

References 64 publications

The Importance of Somatic Symptoms in Depression in Primary Care

The Importance of Somatic Symptoms in Depression in Primary Care

A Cross-Sectional Study of Somatic Symptoms and the Identification of Depression Among Elderly Primary Care Patients

Management of depression in elderly general practice patients

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