Recognition of depressive disorders by primary care providers in a military medical settings

Military Medicine, Apr 2002 by Hunter, Christopher L

This study examined the accuracy of military primary care providers in detecting depressive disorders in their patients. For a 5-day period, each patient who entered the primary care clinic completed the depression section of the Patient Health Questionnaire (PHQ). Appointment notes were examined for depressive disorder diagnoses and then compared with PHQ responses. Of 337 respondents, 19 (5.6%) were identified by the PHQ as meeting the criteria for major depression; 4 (21%) of these 19 were identified by their provider as having a major depressive disorder. Eighteen (5.3%) were identified as having minor depression by the PHQ; none of these individuals were identified by their provider as having minor depression. These results suggest that military primary care providers, like their civilian counterparts, are not diagnosing depressive disorders as frequently as they present. Given the financial, medical, and personal consequences of not recognizing and treating depressive disorders, suggestions for increasing appropriate depression diagnoses are discussed.

Introduction

It has been estimated that primary care providers give the majority of all mental health services in the United States. 1-4 Studies suggest that 60 to 80% of all primary care visits involve significant mental health issues.5,6 This translates into at least 12 hours per week that primary care providers spend in direct treatment of psychiatric conditions.7 Treatment of mood disorders, such as major depression, account for a large portion of this time. It has been estimated that 6 to 8% of all patients seen in general medical clinics suffer from a current major depressive episode8 and that 24% of frequent users of primary health care meet the criteria for a depressive mood disorder.9 Patients with depressive disorders have been shown to have substantial disability and suffering10-13 and higher medical costs than the average patient.14,15 In fact, it has been demonstrated that patients in primary care with depressive disorders have physical and mental functioning impairments similar to those with chronic diseases such as diabetes, arthritis, and lung disorders.16,11 Furthermore, depression increases morbidity and mortality when it occurs with other medical conditions.13,16,18,19

Despite the considerable cost of untreated depressive syndromes, they frequently go undetected in the primary care setting. It has been estimated that only one-third to one-half of patients who meet the criteria for a depressive mood disorder are recognized by a primary care provider.10 A review of studies examining depressive mood recognition in primary care during the 1980s20 suggests that recognition of depressive disorders is widely varied (25-75%), with more recent studies21-23 placing diagnostic accuracy from 33 to 64%. Based on past research, it would be reasonable to assume that, on average, at least half of the diagnosable depressive disorders in civilian primary care settings go undetected and thus untreated.

Although there is ample research examining the detection of depressive disorders in a civilian primary care setting, no published study to date has examined the rate of recognition of depressive disorders in a military primary care setting. Given the multiple consequences of not recognizing and treating depressive disorders, it is imperative that military providers recognize depressive syndromes to maximize the health and readiness of the fighting force. Recent research has shown that military and civilian patient populations do not differ statistically in the prevalence of mood disorders present in primary care.24 However, a military setting may provide unique challenges for detection based on the stigma of mental health problems and the perceived job consequences of having mental health difficulties. This study examined the concordance rate between self-reported depressive symptoms of patients and primary care manager diagnoses.

Methods

Setting

Patients were seen at one of three primary care clinics within a regional military medical center. The hospital serves approximately 68,000 active duty, retired active duty, and family member patients. The primary care clinic was staffed by 4 internal medicine physicians, 10 internal medicine residents, 2 family practice physicians, and 3 physician assistants.

Subjects

The sample was composed of 371 patients who made a primary care visit during a 5-day period in October 1999. No patient refused to participate in the study. However, as a result of missing medical charts and missing outpatient record chart notes, 34 participants were excluded from the final analysis, leaving a final sample of 337. Of these, 67 were active duty personnel, 40 were family members of active duty personnel, 123 were retired active duty personnel, 105 were family members of retired active duty personnel, and 2 were reservists. Fifty-seven percent of the sample was female, 75% Caucasian, 10% African American, 11% Hispanic, 2% Asian or Pacific Islander, 1% Native American, and 1% marked "other." The average age of participants was 54.15 years (SD = 18.72), with ages ranging from 18 to 91 years. Subject demographic features appear to be similar to the demographic characteristics of other military primary care patients.24