Abstract
OBJECTIVE: To determine patient and provider characteristics associated with increased risk of nondetection of mental health problems by primary care physicians.
DESIGN: Cross-sectional patient and physician surveys conducted as part of the Medical Outcomes Study.
PARTICIPANTS: We studied 19,309 patients and 349 internists and family physicians.
MEASUREMENTS AND MAIN RESULTS: We counted “detection” of a mental health problem whenever physicians reported, in a postvisit survey, that they thought the patient had a mental health problem or that they had counseled or referred the patient for mental health. Key independent variables included patient self-reported demographic characteristics, health-related quality of life (HRQOL), depression diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders, and physician demographics and proclivity to provide counseling for depression. Logistic regression analysis, adjusted for HRQOL, revealed physicians were less likely to detect mental health problems in African Americans (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.46 to 0.86), men (OR, 0.64; 95% CI, 0.54 to 0.75), and patients younger than 35 years (OR, 0.61; 95% CI, 0.44 to 0.84), and more likely to detect them in patients with diabetes (OR, 1.4; 95% CI, 1.0 to 1.8) or hypertension (OR, 1.3; 95% CI, 1.1 to 1.6). In a model that included DSM-III diagnoses, odds of detection remained reduced for African Americans as well as for Hispanics (OR, 0.29; 95% CI, 0.11 to 0.71), and patients with more-severe DSM-III diagnoses were more likely to be detected. Physician proclivity toward providing counseling for depression influenced the likelihood of detection.
CONCLUSIONS: Patients’ race, gender, and coexisting medical conditions affected physician awareness of mental health problems. Strategies to improve detection of mental health problems among African Americans, Hispanics, and men should be explored and evaluated.
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Wells KB, Hays RD, Burnam MA, Rogers W, Greenfield S, Ware JE Jr. Detection of depressive disorder for patients receiving prepaid or fee-for-service care: results from the Medical Outcomes Study. JAMA. 1989;262:3298–302.
Wells KB, Sturm R, Sherbourne CD, Meredith LS. Caring for Depression. Cambridge, Mass: Harvard University Press; 1996.
Ormel J, Koeter MWJ, van den Brink W, van de Willege G. Recognition, management, and course of anxiety and depression in general practice. Arch Gen Psychiatry. 1991;48:700–6.
Borus JF, Howes MF, Devins NP, Rosenberg R, Livingston WW. Primary health care providers’ recognition and diagnosis of mental disorders in their patients. Gen Hosp Psychiatry. 1988;10:317–21.
Perez-Stable EJ, Miranda J, Munoz RF, Ying YW. Depression in medical outpatients: underrecognition and misdiagnosis. Arch Intern Med. 1990;150:1083–8.
Katon W, Von Korff M, Lin E, Bush T, Ormel J. Adequacy and duration of antidepressant treatment in primary care. Med Care. 1992;30:67–76.
Wells KB, Katon W, Rogers B, Camp P. Use of minor tranquilizers and antidepressant medication by depressed outpatients: results from the Medical Outcomes Study. Am J Psychiatry. 1994;151:674–700.
Barrett JE, Barrett JA, Oxman TE, Gerber PD. The prevalance of psychiatric disorders in a primary care practice. Arch Gen Psychiatry. 1988;45:1100–6.
Kamerow DB, Pincus HA, MacDonald DI. Alcohol abuse, other drug abuse, and mental disorders in medical practice: prevalence, costs, recognition, and treatment. JAMA. 1986;255:2054–7.
Wells KB, Stewart A, Hays RD, et al. The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA. 1989;262:914–9.
Johnson J, Weissman MM, Klerman GL. Service utilization and social morbidity associated with depressive symptoms in the community. JAMA. 1992;267:1478–83.
Broadhead WE, Blazer DG, George LK, Tse CK. Depression, disability days and days lost from work in a prospective epidemiologic survey. JAMA. 1990;264:2524–8.
Shapiro S, Skinner EA, Kessler LG, et al. Utilization of health and mental health services: three epidemiologic catchment area sites. Arch Gen Psychiatry. 1984;41:971–8.
Unitzer J, Patrick DL, Simon G, et al. Depressive symptoms and cost of health services in HMO patients aged 65 years and older. JAMA. 1997;277:1618–23.
Mullan E, Katona P, Dath P, Katona C. Screening, detection and management of depression in elderly primary care attenders. II. Detection and fitness for treatment: a case record study. Fam Pract. 1994; 11(3):267–70.
Garrard J, Rolnick SJ, Nitz NM, et al. Clinical detection of depression among community-based elderly people with self-reported symptoms of depression. J Gerontol. 1988;53(2):M92-M101.
Banazak DA. Late-life depression in primary care: how well are we doing? J Gen Intern Med. 1996;11(3):163–7.
Potts MK, Burnam MA, Wells KB. Gender differences in depression detection: a comparison of clinician diagnosis and standardized assessment. Psychol Assess. 1991;3:609–15.
Meredith LS, Wells KB, Kaplan S, Mazel RM. Counseling typically provided for depression: role of clinician specialty and payment system. Arch Gen Psychiatry. 1996;53:905–12.
Hu T, Snowden LR, Jewell JM, Nguyen TD. Ethnic populations in public mental health service and level of use. Am J Public Health. 1991;81:1429–34.
Padgett DK, Patrick C, Burns BJ, Schlesinger H. Ethnicity and the use of mental health services in a national insured population. Am J Public Health. 1994;84:222–6.
Sussman LK, Robins LN, Earl F. Treatment-seeking for depression by black and white Americans. Soc Sci Med. 1987;24:187–96.
Wells KB, Golding JM, Hough RL, Burnam MA, Karno M. Factors affecting the probability of use of general and medical health and social/community services for Mexican Americans and non-Hispanic whites. Med Care. 1988;26:441–52.
Fortney JF, Rost K, Zhang M, Warren J. The impact of geographic accessibility on the intensity and quality of depression treatment. Med Care. 1999;37:884–93.
Klinkman MS. Competing demands in psychosocial care: a model for the identification and treatment of depressive disorders in primary care. Gen Hosp Psychiatry. 1997;19:98–111.
Williams JW. Competing demands: does care for depression fit in primary care? J Gen Inter Med. 1998;13:137–9.
Wells KB, Schoenbaum M, Unutzer J, Lagomasino IT, Rubenstein LV. Quality of care for primary care patients with depression in managed care. Arch Fam Med. 1998;M92–101.
Tarlov AR, Ware JE, Greenfield S, et al. MOS: an application of methods for monitoring the results of medical care. JAMA. 1989;262:925–30.
Stewart AL, Ware JE Jr. Measuring Functioning and Well-being: The Medical Outcomes Study Approach. Durham, NC: Duke University Press; 1992.
Burnam MA, Wells KB, Leake B, et al. Development of a brief screening instrument for detecting depressive disorders. Med Care. 1988;26:775–89.
Robins LN, Helzer JE, Croughan J, et al. National Institute for Mental Health Diagnostic Interview Schedule: its history, characteristics, and validity. Arch Gen Psychiatry. 1981;38:381–9.
Wells KB, Manning WG Jr, Valdez RB. The effects of insurance generosity on the psychological distress and psychological well-being of a general population. Arch Gen Psychiatry. 1989;46:315–21.
Blendon RL, Aiken L, Freeman H, et al. Access to medical care for black and white Americans. JAMA. 1989;261:278–81.
Wenneker MB, Epstein AM. Racial inequalities in the use of procedures for patients with ischemic heart disease in Massachusetts. JAMA. 1989;261:253–7.
Ayanian JZ, Udvarhelyi IS, Gatsonis CA, et al. Racial differences in the use of revascularization procedures after coronary angiography. JAMA. 1993;269:2642–6.
Whittle J, Conigliaro J, Good CB, et al. Racial differences in the use of cardiovascular procedures in the Department of Veterans Affairs medical system. N Engl J Med. 1993;329:621–7.
Cooper-Patrick L, Powe NR, Jenckes MW, et al. Identification of patient attitudes and preferences regarding treatment of depression. J Gen Intern Med. 1997;12:431–8.
Ford DE, Kamerow BD, Thompson JW. Who talks to physicians about mental health and substance abuse problems? J Gen Intern Med. 1988;3:363–9.
Brody DS, Khaliq AA, Thompson TL. Patients perspectives on the management of emotional distress in primary care settings. J Gen Intern Med. 1997;12:403–6.
Cooper-Patrick L, Gallo JJ, Powe NR, Steinwachs DM, Eaton WW, Ford DE. Mental health service utilization by African Americans and whites: the Baltimore Epidemiologic Catchment Area Follow-up. Med Care. 1999;37:1034–104.
Callahan CM, Wolinsky FD. The effect of gender and race on the measurement properties of the CES-D in older adults. Med Care. 1994;32:341–56.
Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282:583–9.
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The views expressed in this article are those of the author and do not necessarily represent the views of the Department of Veterans Affairs.
Dr. Borowsky is a VA HSR&D Career Development Awardee.
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Borowsky, S.J., Rubenstein, L.V., Meredith, L.S. et al. Who is at risk of nondetection of mental health problems in primary care?. J GEN INTERN MED 15, 381–388 (2000). https://doi.org/10.1046/j.1525-1497.2000.12088.x
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DOI: https://doi.org/10.1046/j.1525-1497.2000.12088.x