Primary Care Clinicians’ Recognition and Management of Depression: A Model of Depression Care in Real-World Primary Care Practice

Abstract

BACKGROUND: Depression is prevalent in primary care (PC) practices and poses a considerable public health burden in the United States. Despite nearly four decades of efforts to improve depression care quality in PC practices, a gap remains between desired treatment outcomes and the reality of how depression care is delivered. OBJECTIVE: This article presents a real-world PC practice model of depression care, elucidating the processes and their influencing conditions. DESIGN: Grounded theory methodology was used for the data collection and analysis to develop a depression care model. Data were collected from 70 individual interviews (60 to 70 min each), three focus group interviews (n=24, 2 h each), two surveys per clinician, and investigators' field notes on practice environments. Interviews were audiotaped and transcribed for analysis. Surveys and field notes complemented interview data. PARTICIPANTS: Seventy primary care clinicians from 52 PC offices in the Midwest: 28 general internists, 28 family physicians, and 14 nurse practitioners. KEY RESULTS: A depression care model was developed that illustrates how real-world conditions infuse complexity into each step of the depression care process. Depression care in PC settings is mediated through clinicians' interactions with patients, practice, and the local community. A clinician's interactional familiarity ("familiarity capital") was a powerful facilitator for depression care. For the recognition of depression, three previously reported processes and three conditions were confirmed. For the management of depression, 13 processes and 11 conditions were identified. Empowering the patient was a parallel process to the management of depression. CONCLUSIONS: The clinician's ability to develop and utilize interactional relationships and resources needed to recognize and treat a person with depression is key to depression care in primary care settings. The interactional context of depression care makes empowering the patient central to depression care delivery.

Depression Screening and Measurement-Based Care in Primary Care

“…d 4 (3,5) 4 (4,5) .328 I am very familiar with how to use antidepressant medications. d 4 (2,5) 4 (1,5) .471 I feel confident in knowing when to change antidepressant medications. c 4 (2, 5) 4 (1,4) .270 I know what medications can be used to augment an antidepressant medication.…”

“…c 4 (2, 5) 4 (1,4) .270 I know what medications can be used to augment an antidepressant medication. d 4 (2,5) 4 (1,4) .562 I feel comfortable talking with my patients about their mental health. d 5 (3,5) 4.5 (4,5) .474 How easy is the VitalSign6 software program to use with your daily workflow?…”

“…The prevalence of at least 1 major depressive episode among US adults aged 18 years or older, was 17.3 million, representing 7.1% of all US adults. 1 Depression is disabling and costly, 2-9 with an estimated $210 billion annual medical care and lost productivity cost. 3,10 Untreated depression causes emotional suffering, reduced productivity, lost wages, impaired relationships, and increased comorbidity risk.…”

How general practitioners decide on maxims of action in response to demands from conflicting sets of norms: a grounded theory study

“…In the study by Baik et al, GPs who recognised that a patient was depressed spent considerable time “selling” this diagnosis in a way that the patient might agree with [20]. Their need for self-protection was evident in their hesitation to “open the door” because of the lengthy negotiations that would surely ensue.…”

Selective Serotonin Reuptake Inhibitor (SSRI) Efficiency, and Comparison to Alternative Antidepressant Treatments

“…[8.,9] This study was carried out because depression is a serious public health concern world-wide. [10] The number of individuals receiving antidepressant pharmacologic treatments has in-creased. Yet, recently there has been found a statistically significant decrease in the rate of effec-tive treatments.…”