The principal finding of this study is that despite increasing recognition of primary care as the de facto
source of mental health services for the majority of Americans[30
], increased emphasis on the evaluation and treatment of mental health conditions in primary care residency training[31
], and the emergence of effective models for the delivery of high quality depression care[33
], many participants reported gaps in care and regarded the primary care paradigm for diagnosis and treatment of depression with some skepticism. Part of the reason (not emphasized in this article) is surely the inability of many patients to successfully negotiate systemic and organizational barriers such as lack of health insurance and poor access to care. However, our data suggest that less tangible factors also represent formidable obstacles to depression care-seeking. If primary care is to deliver on the promise of first-line care for patients with common mental disorders such as depression, these relational barriers must also be addressed.
Overcoming relational barriers related to competence, openness, and trust will require altering both patient/family factors (e.g. perceptions of their physicians, willingness to raise their concerns assertively) and physician factors (e.g., knowledge gaps, communication skills). For example, patients’ beliefs that primary care physicians as a group lack sufficient knowledge to treat depression may result from lack of familiarity with the scope of primary care training – but also the reality that post-graduate medical training in the United States (particularly in internal medicine) favors biomedical illnesses and underemphasizes the longitudinal follow up that is necessary to ensure good care of depression. A campaign to improve perceptions requires: (1) continuing to educate physicians about recognition and treatment of depression; (2) building communication skills to overcome social distance and distrust; (3) educating patients about the role of PCPs in depression diagnosis and care; (4) activating patients to help them bring their concerns to medical attention; and (5) helping physicians learn about community resources.
Primary care is the de facto delivery system for the majority of mental health care in the United States. Thus it was surprising that many participants in this U.S. study – the majority of whom were quite experienced with care-seeking for depression – regarded depression as falling outside the primary care domain. Similar beliefs have been described among patients in the United Kingdom.[36
] For these individuals, bringing problems with mood, morale, and interest in usual activities to the attention of their PCP felt inappropriate, off-topic, or a potential boundary violation. Changing these perceptions may require a combination of social marketing, physician education, and restructuring of the primary care environment to reward listening without interruption as a valued activity leading to deeper understanding of patients’ concerns.[37
] Physicians should be aware that some patients may be reluctant to speak of mood symptoms out of the belief that it is not the physician’s job to deal with these issues. Such misconceptions may leave patients stuck in the position of choosing between specialized mental health services (which may be stigmatizing)[38
] and not seeking care at all.
Beyond concerns about PCPs’ ability and willingness to address depression, patients were deterred by social, economic, and cultural factors that undermined trust. Social distance has been identified as a mediator of health care disparities and an obstacle to effective and satisfying care.[18
] Low-income participants in our study were particularly concerned that primary care physicians seemed aloof from the day-to-day struggles attached to poverty, unemployment, and stigma. By contributing to a sense of hopelessness and futility among the most vulnerable, such perceptions might disrupt healing and deepen health disparities. Possible systemic solutions include supporting continuity of care (which allows for formation of long-term, trusting relationships),[39
] fortifying community health centers,[40
] and diversifying the socioeconomic composition of the health care workforce.[41
] In addition, communication skills training can enhance physician-patient communication and may reduce socioeconomic disparities.[42
] Finally, considerable evidence suggests that system-based strategies for improving depression quality of care can improve outcomes for diverse populations.[44
These results bolster confidence that the results of several smaller studies apply to the contemporary care environment in the United States. Cape et al. conducted interviews with 83 patients receiving care from nine general practices in the United Kingdom; 45% said they hesitated to seek care for psychosocial issues in primary care due to psychological embarrassment or hesitation to trouble the general practitioners (GP), and 19% were mainly deterred by the doctors' interview behaviors.[46
] Similarly, in a qualitative study of 27 urban English patients with “stress,” Kadam et al. found that many had reservations about approaching their GP with psychosocial problems, found it difficult to access a counselor/listener, and harbored important reservations about pharmacotherapy.[47
] In the United States, Cooper-Patrick et al. interviewed 16 patients and seven health care professionals, identifying four sets of concerns that overlap with data presented here: importance of openness, empathy, and trust; the fragility of access; and the shadow of stigma.[48
] In a small interview study, Saver et al. also identified missed opportunities for diagnosis and suboptimal patient education.[8
The unique contribution of the current study is three-fold. First, the work is part of a formative research program including focus groups, conjoint analysis (a regression technique borrowed from marketing), and a population-based survey, specifically aimed at identifying educational and marketing themes to be addressed by the planned interventions.[49
] Second, the results were obtained from a relatively large number of focus groups in multiple U.S. locations, increasing confidence in their robustness and generalizability. Third, the findings elevate the importance of perceived competence and interest as a critical psychological gateway to care-seeking for depression and perhaps other stigmatized conditions. It is a testable hypothesis that patients are less likely to divulge symptoms indicative of depression if they harbor doubts that the treating clinician has the requisite knowledge, skills, and attitudes to handle the problem. In a single study of 314 patients, Lewis et al. found that 65% thought that specialists were better able to care for depression.[51
] More research is needed to understand the critical links among actual competence, perceived competence, and care seeking.
Our findings, while derived from a large, diverse qualitative research sample, should be interpreted in light of several limitations. First, the experiences of participants were likely different from the general population of depressed patients seen in primary care. In particular, due to self-selection, our patients may have been more seriously depressed, more likely to have been hospitalized, and more prone to complications. Second, histories of depression were self-reported; medical records were not reviewed and structured psychiatric interviews were not conducted, so the validity of their depression diagnoses is unconfirmed. Third, many themes could not be explored in the kind of depth that would have been afforded by individual interviews. In addition, focus groups may foster collective thinking which can lead to reinforcement of some themes and avoidance of others. Nevertheless the focus group format permitted dynamic engagement with the issues and generated hypotheses to be tested in future research, including a population-based survey currently underway. More broadly, our sampling strategy may have limited our ability to understand the experiences of depressed individuals who never sought or received diagnosis and treatment. However, many of our participants went months and years before seeking care; their pre-treatment experiences arguably offer an important window into the experiences of those who never sought care at all.