The final sample consisted of 24 primary care physicians. Forty-two percent of the physicians were female and all were family practitioners or internists (Table ). Of the 17 recruited from three health care organizations from the Southeast, West, and Mid-Atlantic regions, ages ranged from 33 to 55 years with a mean of 44 years. Twenty-four percent practiced in multi-specialty clinics, and 69% had five or more physicians in their group. Slightly different demographic information was collected on the DPRP physicians because they did not participate in the data abstraction component of the study. Mean years in practice for the DPRP physicians was 17.3 years, and all DPRP participants were male.
Physician and practice characteristics
Although all physicians were aware of depression care interventions discussed in the interviews, physicians had varied experiences with them. Several physicians worked in practices currently or previously involved in formal quality improvement programs related to use of the CCM. A few practices had selected intervention components such as on-site mental health specialists and/or access to care managers. Several practices facilitated the use of the Patient Health Questionnaire (e.g
., PHQ-9) depression scale [25
]. Other practice differences included the use of electronic medical records and the availability of staff trained to educate patients.
Barriers to care
Our qualitative analysis identified six barriers to depression care:
1. Diagnosing depression is more difficult than diagnosing other conditions.
'There might be times when depressed symptoms are a normal response to circumstances and not clinical depression. It would be nice if we could somehow distinguish those.'
Many physicians reported that diagnosing depression is difficult because there is no standard lab test to quantify severity and patients may not express their symptoms in a clear or predictable way. Physicians expressed concern that patients may underreport symptoms from fear of stigma or exaggerate symptoms to gain attention. Further, some noted that determining whether a patient suffered from an adjustment reaction, bipolar disorder, or symptoms secondary to a medical illness required further evaluation for which they did not have the time or the expertise.
2. Patient resistance and poor compliance.
'As a physician, I only have so much control. I can do my best. I could do all of this! I can ask about substance abuse; I can give them the medication; I can schedule them a three-week follow-up. But if they don't show up I can't go to their home and get them.'
Nearly all physicians reported patient resistance to depression diagnosis and treatment. Physicians noted that the stigma associated with antidepressant use was not as prevalent as it once was, while stigma associated with psychotherapy continued to be a major barrier to referral. Patient failure to continue antidepressant treatment after experiencing symptom relief against recommendations was a source of physician frustration. Physicians also mentioned that low energy levels and motivation associated with depressive episodes led to poor adherence.
3. The mental health system is fragmented and difficult to access.
'There have been several times that I really thought somebody needed to see a psychiatrist and not a counselor, and I picked up the phone with the patient in my office to call the 1–800 number. I tell them I am the physician and I want them to see psychiatry, and they say, "Number one, we can't talk to you, and number two, they have to go to a counselor first." So, the only way that someone can see a psychiatrist is to go through whatever mental health number that the patient has to call and they have to see a counselor first, and then only that person can then send them to psychiatry. So, it's a little bit difficult. You never know when this happens.'
Physicians indicated that managing patients with mental illness was different from caring for those with a physical illness because of the organization of the mental health care system. Noted differences in access to mental health care compared to physical health care included a more burdensome administrative process, a longer waiting period for an appointment, reduced availability of specialists (particularly psychiatrists), and inadequate coordination between physicians and mental health specialists. One obstacle experienced by a few physicians was inability to make mental health specialty appointments on behalf of their patients because of insurance policies. Physicians noted that assisting with referrals was sometimes crucial for patients with depression due to reduced functioning associated with this disorder, yet they had fewer referral options than for those with other conditions.
4. Insurance coverage for depression treatment.
'If you have a Medicaid patient that comes in with an emotional issue you have to tell them, "Sorry, I can't see you for this."'
Insurance coverage was often insufficient to meet the needs of patients with depression. Physicians said that mental health visit limits and high out-of-pocket costs for mental health specialist visits hindered referrals. Physicians also said that treatment options were extremely limited for patients with no or inadequate drug coverage.
Medicaid and Medicare coverage for mental illnesses was described as problematic. Physicians said patients with Medicaid had limited access to mental health specialists because insufficient reimbursement reduced the number of practitioners willing to accept Medicaid, and public mental health clinics often had long waiting lists even for patients with urgent needs. Some physicians were unable to treat patients with Medicaid themselves due to practice and state policies. Physicians noted that patients with Medicare often were deterred by high coinsurance rates for mental health visits. Physicians also expressed concern about reimbursement downgrades from Medicare when billing for depression.
5. Lack of mental health expertise.
'I have a patient that can't get the [psychiatric] care they need and I'm just not sure what to do next. I find it frustrating and I almost don't want to see them any more because, I'm embarrassed to say, I just don't know what to do.'
Physicians felt pressured to provide care for patients with depression despite being stretched beyond their expertise and available resources. Reasons accounting for this barrier include patient preference for seeing a primary care physician rather than a specialist because of the time and financial burden of specialty care, stigma concerns, and greater comfort in seeing a provider with whom they already had a relationship. They also said that lack of specialist availability sometimes prevented them from referring patients who would benefit from it. Consequently, physicians noted patients with severe and complex mental illnesses often were left in their care despite their lack of expertise.
6. Competing demands and other responsibilities as primary care provider.
'If you took a diabetic, heart disease patient with cholesterol, and you did what's recommended for screening, it would take seven hours. So, it's really difficult in primary care to juggle it all and, unfortunately, a person's diabetes and chest pain take precedence in an internal medicine practice.'
Physicians described multiple responsibilities during office visits. When depression is first diagnosed, it is often within the context of a visit for another problem. Further, patients diagnosed with depression may come in for follow-up visits for other chronic conditions or for acute problems in addition to depression. While physicians expressed comfort discussing a series of physical conditions in quick succession, they noted difficulty handling depression this way because of its sensitive and emotional nature. Further, physicians reported patients with co-morbid conditions may require additional motivation and encouragement to ensure therapeutic adherence for both depression and other conditions.
'There's only a certain amount of time and energy that one can devote toward a visit. And anytime you add something, you're probably going to have to subtract something else.'
Beyond troublesome multi-issue visits, physicians were overwhelmed with their responsibilities as primary care physicians in general. They felt they lacked the time to screen for depression and manage the care according to depression guidelines. In particular, they felt they only had enough time to schedule frequent follow-up visits with the most severely depressed patients. Making phone calls as a substitute for in-person visits was not considered a viable alternative because they were not paid for telephone calls and were concerned about the time required to reach patients consistently.
Physician use and attitude toward interventions
In this section, we describe physician attitudes about the usefulness of each intervention.
Experts recommend the use of formal depression screening tools in coordination with effective follow-up and treatment to increase accurate identification of depressed patients [26
]. Screening tools, such as the two-question Patient Health Questionnaire (PHQ-2), can be brief, easy to use, and administered by practice staff. Physicians can then follow up with a complete assessment of patients who screen positive for depression.
Some physicians advocated screening by staff before seeing the physician as a way to make patient visits more efficient. They reported if a patient screened positive, they could address depression with the patient at the beginning of the visit. Physicians felt this was important because depression was often the key to the patient's overall health and should be addressed in conjunction with treatment plans/goals associated with other conditions. Discussing depression first also eliminated the possibility that the patient would bring it up at the end of the visit, thereby prolonging the visit.
One physician who worked in a practice with a co-located mental health specialist noted that the presence of this individual made 'screening easier' because patients who screened positive would be seen by someone on site (the co-located mental health specialist) and managed appropriately.
Physicians were comfortable screening new Medicare patients for depression as mandated by the Centers for Medicare and Medicaid Services in the initial preventive physical exam questionnaire. However, few physicians endorsed screening all patients for depression because screening was time consuming and may encounter resistance from patients who already must complete multiple pre-exam forms. There was also concern that screening all patients may prompt discussions unrelated to the purpose of the visit among patients who were not depressed.
'You're going to get a lot of people who will [screen positive] and that's really not what they're here for. And some people like to have illness. I mean, I don't know how to explain that, but I think a lot of people will put a half a check, or "sometimes," and then it's hard to ignore it. And you just get everybody that way. And maybe in the real world, that's OK, but I think that's just going to open a Pandora's box, and you're going to get everybody who's ever felt depressed, or everybody who isn't sleeping, and every day would be like that.'
Instead of screening everyone, some supported targeting screening to at-risk populations, such as those with chronic conditions.
Experts recommend that physicians use structured assessments such as the PHQ-9 to facilitate diagnosing depression [25
]. Use of the assessments has been found to yield a detection rate almost double that of routine physician diagnosis of depression [28
]. The PHQ-9 can also be used to monitor patient response to treatment because it is a valid measure of treatment outcomes [28
'Where I personally find standardized questionnaires helpful is when the person comes in and says, "Oh, I'm just fatigued. Things just don't go right. There must be something wrong with my thyroid." I think then getting them a standardized questionnaire is helpful, because I can say, "look at your answer and look at your score. This really is in the depressed range."'
All physicians were familiar with structured assessments, but few used them routinely to detect and monitor depression. More often, physicians used these tools selectively with patients for whom they thought they would be helpful. Notably, all providers who worked in the organization where the use of PHQ-9 was encouraged and easily integrated into the electronic medical record were routine users of the PHQ-9. Routine users reported many benefits including improved communication with patients about depression, enhanced patient involvement in symptom monitoring, simplified diagnostic process, and reduced burden of convincing patients of their depression diagnosis (patients perceived the severity score calculated from responses to structured assessments as more objective than clinical judgment). Routine users did not find the assessments cumbersome or time-consuming to use.
'If it's somebody you've known for ten years, and they've got disturbance in sleep and appetite and they're not enjoying their usual activities, and they are getting worse and worse for more than six weeks, eight weeks, you know this person is probably developing major depression and so you don't need to say, let me leave the room so you can fill out this survey, you just don't do that – if you went to a doctor that you've known for ten years and they use that, you would probably be like, "No, I'm telling you, I'm depressed"'
Many physicians who did not routinely use structured assessments wanted more information before incorporating them. Others chose not to use assessment tools or used them selectively because they remained unconvinced of their usefulness. Physicians described a tension between using assessment tools and asking questions for diagnosis. Some felt patients preferred not to respond to structured inventories because they viewed them as impersonal and thus may not be truthful or clear in their response to items. Others suggested that using structured assessments was redundant and inefficient because they typically probe for cardinal depression symptoms during patient interviews with open-ended questions and 'small talk'[29
'Now, I do use a formalized screening tool when I'm seeing possible bipolar. It's normally helpful with that. But, as far as depression, I see a lot of it and it's fairly easy to detect with just nine basic questions.'
Practice guidelines recommend educating patients to overcome patient resistance to screening and treatment and to ensure treatment adherence [30
]. Providing information about the cause, symptoms, and natural history of depression, treatment options including risks and benefits, anticipated outcomes, potential difficulties with compliance, and early warning signs of relapse is likely to improve adherence and outcomes [31
Most physicians reported educating patients to some degree about the prevalence and biological basis of depression to reduce treatment resistance. One physician said telling patients about a billboard quote 'Depression is a chemical – it is not part of your character' attenuated stigma concerns. Other physicians noted that using structured depression assessments were useful in educating patients about the symptoms, engaging patients in treatment, and demonstrating progress. Except for physicians who had access to care managers, education appeared brief and oriented toward convincing the patient of their diagnosis and describing treatments because of time constraints. Further, education appeared limited to the first visit because physicians said they had limited time to provide extensive follow-up visits. Physicians with care managers relied on them to provide most or all of the education after making a diagnosis.
'Depression requires a lot of time. The [counselor] gets one hour with patients each time and can talk about different social things that could help with the depression and can go over other behavioral modifications and so forth, and I barely have time to get the diagnosis and to write a script.'
Mental health integration
Experts recommend that primary care practices integrate on-site mental health specialists to enhance coordination of care [13
]. Physicians who had access to on-site mental health professionals relied extensively on them, reporting greater information sharing, increased referral completion rate, and promotion of comprehensive and consistent treatment. Problems with co-located mental health specialists included long wait for appointments, availability limited to one or two days a week, and non-acceptance of Medicaid.
'Before [the co-located mental health specialist] came, it was very challenging to call the outpatient psychiatrists to get appointments, and then once the patient goes there, it mainly seems like they are seen by the residents, and then each time they go, there's a different doctor, so, patients don't like that, and ended up coming back here. So, I think we are very blessed and lucky [to have the co-located mental health specialist].'
All physicians who did not have access to on-site professionals indicated a need for it. To cope with not having on-site professionals, some physicians created their own 'integrated system' by making personal connections with therapists to help matching patients to available therapists when issuing referrals. Physicians also used their connections with mental health specialists to reduce delays in obtaining care for their patients. Some physicians tried to improve referral completion by activating the patient and telling the patient what to expect from a therapy visits to reduce apprehension.
Primary care physicians said they rarely received reports from specialists after patient referral. Some depended on patients to tell them if their mental health specialist had recommended a new or changed medication prescription. Those who did not feel comfortable collecting this information from patients had to make special efforts to contact specialists directly with variable success.
Mental health consults
Facilitating primary care physician communication with psychiatrists for advice with complex cases has the potential to increase physician comfort in providing evidence-based depression care. Only a minority of primary care physicians in our sample had access to psychiatrists for advice; some through a telephone hotline set up by the insurance company, others through 'curbside consultations', informal meetings with co-located mental health specialists [33
]. Of those with access, few utilized this resource. Those who contacted psychiatrists for consult indicated that it allowed them to become more educated and comfortable delivering depression treatment.
'If we have somebody that we're really concerned about, and don't know what to do, we can page him. He'll call us right back, help us to know what to do with that patient right then, and then pick up the pieces later.'
Of those without access, none expressed interest in it as a way to reduce the effect of barriers. Resistance to increasing access can be illustrated by one physician's report that when her practice implemented a telephone consultation system, few used it, despite initial concern about high volume of calls. While the reasons for physician lack of interest in obtaining consultations were unclear, time constraints or perceived inefficiency may be one factor.
'It's complicated [to use consults] because the patient you are going to run into trouble with is somebody that needs two or three drugs or that has failed things in the past. It's never just, "They didn't do well on this. Can we do this?" It's always this mish-mash of things. [Consults] may be helpful occasionally, but in general, they are almost going to have to see the person and hear the whole long Gone with the Wind story.'
Current literature has stressed the benefits of non-physician follow-up monitoring to facilitate care coordination, symptom monitoring, and informational support to ensure compliance and efficacy in achieving self-care [10
]. Care managers, whose role is coordinating disease management for patients, can improve depression outcomes by increasing rates of treatment, speeding response to treatment failure, and reducing the likelihood of patients' prematurely discontinuing care.
'We used to have a care manager – we could send her a note and she would call them at one week, and three weeks, and four weeks and get feedback if they're having side effects. That was excellent because she'd get back to me right away and tell me they're having a little side effect – something that might have made them stop their medicine, or they're feeling bad on this. And I could adjust things before I had time to see them again I really miss it. That was really a help for my practice. It was a huge part of the load of dealing with depression, actually.'
Physicians universally recognized the benefit of care managers. Most physicians with access to care managers regularly used them to contact patients between visits to answer questions, facilitate referrals, monitor adherence and side effects, and assess symptoms. Reasons for not using care managers included not knowing them personally and dissatisfaction with past performance.
'I never found it helpful when some nurse I don't know [provided care management for] somebody. It doesn't give me a picture of anything, so I don't use it. But [I do have access to] that service. If my nurse had time to do it that might be nice, because they know her, and they would tell her what was going on, but she doesn't have time to do it either.'
Also, physicians reported that while they regularly offered to connect patients with care managers, some patients were not interested or were not responsive to care manager contacts. Physicians who had care managers located within their practice (rather than off-site) tended to endorse their benefits more strongly. Physicians who used an electronic medical record system that allowed them to view care management notes including severity assessments appeared to work more closely with and receive more benefits from care managers.