Previously published surveys of general public and primary care patient attitudes about depression treatment show that while a majority agree that depression requires professional treatment, with counseling preferred over medication, there is significant misunderstanding about the efficacy and appropriateness of both standard and alternative treatments for depression.^9,14,15 However, these studies were limited by the fact that a minority of the study samples were depressed; the results may not represent the preferences of patients actually undergoing treatment. The present study extends this previous work by examining preferences and their correlates in more detail among a larger, more diverse group of depressed primary care patients.

We sought to answer the following questions in a group of 1,187 depressed primary care patients: (1) Do a majority of depressed patients prefer active treatment over no treatment for depression? (2) Do a majority of depressed primary care patients prefer medication or psychotherapy as their first choice treatment, and if psychotherapy is the first choice, which modality (individual or group) is preferred? and (3) What patient characteristics are associated with specific treatment preferences?

Eligible patients (i.e., those who intended to use the clinic as their source of primary care for the following year and who had insurance that covered care from the PIC behavioral health care providers) signed written informed consents approved by the human subjects committees of RAND and the managed care organizations. Patients were eligible to take part even if they were already receiving treatment for depression.

Patient predisposing factors are individual characteristics that may influence preference. They included demographic characteristics(gender, age, race, and education) and a measure of household wealth ranked within age categories; past treatment experience with medication and counseling; knowledge about antidepressant medication(5 items, α = 0.589) and counseling(2 items, α = 0.648) adapted from the Medical Outcomes Study¹; perceived stigma regarding treatment for depression reflecting how much difficulty or embarrassment they felt they would suffer in applying for a job, applying for insurance, or with family or friends if others knew that they had been treated for depression (α = 0.808); and patient perception of need for treatment. Patient perception of need for treatment included severity of depressive symptoms measured using a 23-item version of the Center for Epidemiological Studies Depression Scale (CES-D) adapted by Dr. Daniel Ford (personal communication) to be more compatible with DSM-IV symptoms; (2) depressive disorder status, defined as major depression, single episode or recurrent; dysthymia; or “depressive symptoms only” (history of depressive symptoms for 30 days or more but not meeting diagnostic criteria for major depression or dysthymia), as determined by the CIDI; (3) diagnosis of anxiety disorder(panic disorder with or without agoraphobia, generalized anxiety disorder, obsessive compulsive disorder), as determined by the CIDI; (4) any chronic medical condition;(5) mental or physical well-being and functioning, as measured by the Medical Outcomes Study 36-item Short Form.¹⁹

Table 2 presents the adjusted, predicted percentage of patients in each category with a given treatment preference, based on the final regression models which included the independent variables listed in this table and “block.” Among the whole sample, those who preferred active treatment over no treatment were wealthier (OR, 3.74; 95% CI, 1.77 to 7.91; z = 3.46; P = .001), had greater knowledge about antidepressant medication (OR, 2.60; 95% CI, 1.55 to 4.36; z = 3.64; P < .001), and were more likely to have a concurrent 12-month anxiety disorder (OR, 1.74; 95% CI, 1.14 to 2.65; z = 2.58; P = .01). There was a significant interaction of disorder status and recent treatment for depression (z = −2.34; P = .019); patients who had recent treatment and had symptoms only (no disorder) were more likely to say they wanted treatment compared to other patients (see Table 2).

Among all patients preferring active treatment, factors associated with selecting counseling over medication were (1) female gender (OR, 1.45; 95% CI, 1.01 to 2.09; z = 2.00; P = .046); (2) ethnicity (African Americans compared to whites) (OR, 2.22; 95% CI, 1.03 to 4.81; z = 2.03; P = .042); (3) greater knowledge about counseling (OR, 2.09; 95% CI, 1.63 to 2.68; z = 5.77; P < .001); (4) paid sick leave (OR, 1.59; 95% CI, 1.10 to 2.30; z = 2.48; P = .013); and (5) no recent antidepressant treatment (OR, .39; 95% CI, .27 to .56; z = −5.06; P < .001). Among those who had not had recent counseling, predictors of preference for counseling were the same as for the group overall. Among subjects who had counseling in the 6 months prior to enrollment, those who preferred counseling were less likely to have had recent antidepressant treatment (OR, .39; 95% CI, .19 to .79; z = −2.60; P = .009), had greater knowledge about counseling (OR, 1.6; 95% CI, 1.1 to 2.4; z = 2.35; P = .019), were less concerned about stigma associated with depression treatment (OR, .59; 95% CI, = .42 to .82; z = −3.13; P = .002), and were less likely to have young children in the home (one child compared to none [OR, .36; 95% CI, .17 to .78; z = −2.60; P = .009]; three or more children compared to none [OR, .24; 95% CI, .06 to .98; z = −1.98; P = .047]). Among those who had antidepressant treatment in the past 6 months, those preferring counseling had greater knowledge of counseling (OR, 2.0; 95% CI, 1.4 to 3.0; z = 3.78; P < .001), were less concerned about stigma associated with depression treatment (OR, .63; 95% CI, .49 to .83; z = −3.38; P = .001), and had moderate comorbid medical illness (2 illnesses vs none [OR, 2.5; 95% CI, 1.1 to 5.6; z = 2.22; P = .027]).

Preference varied somewhat between those who had recently received treatment and those who had not. Most important, patients who had recent treatment and no longer met criteria for a current disorder were most likely to say they would want treatment if depressed, suggesting that those who receive inadequate treatment or have incomplete response to treatment may become discouraged and need additional support to remain in care. In the PIC study, those patients in depression care at baseline who were randomized to the intervention which provided education, support, and activation were more likely to remain in care over the study follow-up period compared to those in usual care.²⁴

This study found that of those who preferred active treatment, a majority preferred counseling, regardless of the severity of their symptoms. Predisposing patient characteristics, such as gender, African-American ethnicity, and a greater knowledge of counseling, were significantly associated with a preference for counseling over medication. This suggests that, in addition to cultural and gender differences, treatment preferences may in part reflect selective attention to treatment information or gaps in patient education. Not receiving paid time off from work was associated with a preference for medications over counseling; thus, the time costs of counseling may represent substantial barriers to selecting it. Almost as many patients preferred group to individual therapy, and only predisposing factors, but not disease severity or enabling factors, predicted preference for group counseling. It is understandable that different types of patients in different life circumstances would prefer different treatments, even when their depression was of similar severity. Although the treatments have roughly equal efficacy, especially for those with mild to moderate depressive disorders, they differ in terms of financial and time costs, degree of self-disclosure and interaction with others, and use of psychoactive medications.

Our findings may have implications for practitioners. Because treatment preferences vary among patients and because providers are unlikely to accurately assess patient preferences without asking them directly,²⁵ it is important for clinicians to elicit patient preferences in order to help patients realize their treatment preferences. Patients who are not offered their preferred treatments may be at greater risk for treatment nonadherence,^11–13 and patients who take an active part in clinical decision making may have improved clinical outcomes and satisfaction with care.^26–28 Future studies should explore how clinician treatment preferences affect patient preferences.

Should practitioners honor a patient's autonomy in declining or deferring care for depression, especially when this choice may be associated with poverty or lack of knowledge? This is an important question because untreated depression has serious consequences for the individual, including disability and increased morbidity and mortality from other medical conditions,^1,3,29 and for society, including lost productivity and increased health care utilization.^30–32 The value of active treatment at first may be especially important in primary care where absence of an infrastructure for monitoring patients over time may easily turn “watchful waiting” into no treatment. The alternative is to develop guidelines and practice policies that target treatments to patients who remain depressed after a period of observation.³³ Since treatment knowledge is associated with treatment preference, future studies should examine the role of education in motivating depressed patients to seek active treatment and assisting them in making informed treatment choices.

Our findings also have potential implications for health care policy. Because most patients in this and previous studies prefer counseling, strategies to increase access to counseling from primary care^16,34–37 may increase the proportion of patients entering into depression care. Since specific short-term group therapies³⁸ are efficacious in depression and are often less costly than individual therapy, it is important to note that there is a substantial patient group not only willing to consider group therapy, but preferring it foremost. Health plans and systems which serve diverse populations should aim to provide a variety of effective depression treatments to address the preferences of patients, including ethnic minorities who may have different treatment preferences than the majority³⁹ and who have traditionally had more difficulty accessing health care services.⁴⁰ The association between lower income and the preference for no treatment suggests that the poor may need supplemental resources in addition to education and activation to motivate treatment.

The limitations of our study must be considered when interpreting our findings. Patient treatment preferences are complex and difficult to assess in a questionnaire format. Treatment preferences were elicited with a hypothetical question because the study enrolled patients who screened positive for depressive symptoms, but who did not necessarily consider themselves depressed, nor were they seeking care for depression. Information on costs, side effects, and efficacy were included to make the choice more realistic; however, they may not represent the specific characteristics of the treatments in each of the diverse clinical settings. Thus, actual treatment preferences may differ from the more hypothetical preferences reported here.

Several characteristics of the sample may limit the generalizability of our findings. Conclusions regarding patients who prefer no treatment may be limited because this was a clinical sample that may overrepresent those preferring active treatment. Further, patients who refused the initial screener may have been less likely to prefer active treatment if they had been depressed. Weights used to control for demographic and clinical differences between respondents and nonrespondents may not fully account for differences between these groups. For example, more educated patients were more likely to participate at each step and may also have been more likely to prefer treatment. The rates of patient-reported previous counseling are high compared to previous primary care samples,⁴¹ perhaps because practices with accessible counseling resources were more likely to take part in this study. Although our weighted logistic regression models control for previous treatment experience, patients who prefer counseling may be overrepresented in our sample. Finally, our sample included patients with minor depression. Although it causes significant impairment in functioning and increases in somatization and health services utilization,⁴² there is debate over the effectiveness of treatments for minor depression, and thus the appropriateness of honoring their treatment preferences.