Among patients with chronic CHD, we found that depressive symptoms were strongly associated with patient reports of poor doctor-patient communication, as measured on two subscales from the established Interpersonal Processes of Care questionnaire. Depressive symptoms were independently associated with poor reported explanations of condition and poor reported responsiveness to patient preferences, after adjustment for demographic factors, medical comorbidities and disease severity. In contrast, common medical comorbidities and objective measures of cardiac disease severity were not associated with reported doctor-patient communication. These findings raise questions about whether self-reports of doctor-patient communication are in part a reflection of the psychological state of the patient.
Several studies have explored the relationship between depression and doctor-patient communication. Patients with underlying mental disorders may be more likely to have unmet patient expectations,31
less likely to have their symptoms understood by their physicians,32
less involved in shared decision making33
and less satisfied with their care.34
To our knowledge, only one prior study has evaluated the influence of depressive symptom severity on patient reports of doctor-patient communication across different domains.24
This study, conducted in a cohort of adults with diabetes, found that depressive symptoms were associated with worse reports of doctor-patient communication on four out of seven subscales from the same Interpersonal Processes of Care instrument. However, it was unclear how the association of depressive symptoms with poor reports of doctor-patient communication compared with medical comorbidities and objective measures of disease severity. Our study extends these important findings by reporting an association of depressive symptoms with reports of poor explanations of condition and responsiveness to patient preferences in a cohort of adults with chronic CHD and by demonstrating that the association is not explained by medical comorbidities or worse cardiac function in depressed patients.
Consistent with previous data, we found a high prevalence of depressive symptoms in patients with chronic coronary disease.21,35,36
Depression is a significant risk factor for adverse outcomes in this population. Patients with CHD and concomitant depression are at increased risk for recurrence of cardiac events and for adverse cardiovascular outcomes after coronary artery bypass grafting surgery,21
independent of baseline cardiac disease severity.37
Depression is associated with poor health-related quality of life in patients with chronic CHD and more strongly predicts health status outcomes than objective measures of disease severity.25
Our findings suggest that patients with depression are at increased risk for experiencing poor communication with their physicians. Poor experiences of doctor-patient communication—similar to poor perceived health status—may also lead to depressive symptoms.
The lack of association between medical comorbidities or disease severity and reports of poor communication implies that medical complexity may not compromise patients’ experiences of communication with their doctors to the same extent as depressive symptoms. In addition to interventions focused on clinician communication skills, efforts to improve doctor-patient communication should include increased screening and treatment of patients with depressive symptoms. Referral to mental health services, when available, may assist primary care physicians in such evaluation and treatment. Physicians may also wish to explore different strategies for communicating information and sharing decisions with patients who are depressed. Poor experiences of communication in this population may signal a need for alternative communication models.
Why patients with depressive symptoms experience poor communication is not clear. Swenson hypothesized that differences in content, process or recall among patients with depression may result in poor communication.24
Content refers to the challenge of dealing with multiple issues during a medical visit, which could lead to less time-sharing information. Our findings do not support the content explanation because communication was not associated with medical comorbidities or cardiac function. The fact that sicker patients did not report worse communication suggests that visit content did not interfere with information exchange or shared decision making. Process refers to differences in the way physicians interact with their patients. Depressed patients may have difficulty discussing their health problems with physicians,22
have a more negative affect, be less well-liked by their doctors38
and/or make physicians feel more frustrated or less engaged,18
thereby placing a strain on interpersonal relationships, which may impede physician-patient communication. Visit recall means that depressed patients may have inaccurate or skewed recollections of what happened during a visit. Depressed patients may report poor communication in part because they view everything in a negative light. Alternatively, difficulty with concentration, a symptom of major depression,39
may impair patient recall of communication during the medical visit.
While the process of communication may be objectively worse in patients with depressive symptoms, it is also possible that patients with depression perceive the same interactions differently. Depressive symptoms are associated with poor reports of doctor-patient communication, and the perceived quality of doctor-patient communication predicts patient satisfaction.40
Thus, if patients with depressive symptoms report lower satisfaction with their physicians, is this because depressed patients perceive things differently or because their physicians are actually providing poorer quality care? The possibility that patients with depressive symptoms view clinical encounters through different lenses raises questions about the validity of patient self-report questionnaires used as measures of health-care quality.
Several limitations must be considered in interpreting our results. First, we evaluated two aspects of doctor-patient communication, explanations of condition and responsiveness to patient preferences, using two subscales from the Interpersonal Processes of Care instrument. Our study did not address other important components of doctor-patient communication including empathy, respectfulness, listening or empowerment.2,3,41
While explanations of condition and responsiveness to patient preferences are critical aspects of care, it is possible that the inclusion of additional measures of doctor-patient communication would have provided different results. Second, we studied patients with coronary heart disease, so our results may not generalize to patients with other illnesses. However, CHD is a common chronic illness requiring frequent physician visits and associated with multiple medical comorbidities and high rates of depression. Third, it is possible that depression itself may have presented a barrier to participation in this study. However, we found a high prevalence of depressive symptoms consistent with previous data.36
Fourth, our participants spoke English, and the majority were male and white. Although the Interpersonal Processes of Care instrument was designed to compare doctor-patient communication across diverse racial/ethnic groups, our study sample did not allow us to make such comparisons. Fifth, we did not collect information about individual physicians. While previous work has demonstrated an association between physician characteristics and patient reports of doctor-patient communication,42
we were unable to evaluate physician predictors of communication or account for clustering at the physician level. Sixth, the Interpersonal Processes of Care instrument is a patient self-report questionnaire; we did not observe doctor-patient communication directly. While patient perceptions of communication are important in and of themselves, direct observation might have allowed us to examine whether perceived differences in communication were more strongly associated with visit process or recall. Finally, this was a cross-sectional study; thus, we were unable to evaluate causality.