Persistently poor outcomes of undetected major depression in primary care

ELSEVIER

Persistently Depression

Poor Outcomes of Undetected in Primary Care

Kathryn Rost, Ph.D., Minglian Jeff Smith, B.S., James Coyne,

Zhang, Ph.D., John Fortney, Ph.D., Hh.D., and G. Richard Smith, Jr., M.D.

Abstract: Despite its relevance for quality care initiatives, the field of psychiatry has little scientific knowledge regarding the course of current major depression when primary care patients with tke disorder remain undetected. Using statewide telephone screening, we identi$ed and followed 98 adults with current major depression who made one or more visits to a prima y care physician during the 6 months following baseline. Thirty-two percent of primary care patients with current major depression remained undetected for up to 1 year. Almost half of undetected patients developed suicidal ideation. Less than onethird of undetected patients made a visit during the month they reported their worst symptoms. Fifty-three percent of undetected patients reported five or more current symptoms at 2 year follow-up. Prima y care patients with undetected major depression report persistently poor outcomes. Comparison of outcomes with detected patients suggests that quality improvement florts directed at improving detection without improving management of defected patients may not improve outcomes. 0 1998 Elsevier Science Inc.

Introduction Early research showing that primary care physicians fail to detect about half of their patients with major depression [l-12] after a single visit has led to considerable interest in screening as a key component of efforts to improve the quality of care

This research was presented in part at the NIMH Services Research Meeting September, 1995. Research was supported by the National Institute of Mental Health MH49116, MH48197, MH55297, and MH54444. Center for Rural Mental Healthcare Research and the VA Health Services Research and Development Field Program for Mental Health, Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, ArkansasUSA (K. R., M. Z., J. F., G. R. S.) and Department of Family Medicine, University of Michigan School of Medicine, Arm Arbor, MichiganUSA (J. *Cc.). Address reprint to: Kathrvn Rest, Ph.D., Universitv , of Arkansas for Medical Sciences, Centers for Mental Healthcare Research, 5800 West 10th Street, Suite 605, Little Rock, AR 72204.

12 ISSN 0163~8343/98/$19.00 PII SO163-8343(97)00095-9

Major

provided for primary care patients with major depression; however, several lines of research call the value of widespread screening into question. Two investigations 113,141report that over half of undetected patients report mild depression in which attention/placebo treatments are as effective as medication or psychotherapy [ 151. Four observational studies [12,14,16,17] and two randomized trials [4,18] report that detected patients show no more improvement than patients whose major depression remains undetected. We reasoned that increased efforts to identify undetected major depression among primary care patients would be warranted if 1) primary care physicians failed to detect a patient’s major depression ozler muttiple visits rather than after a single visit; 2) undetected patients displayed substantial impairment or suicidal ideation; and 3) undetected patients remained symptomatic over time. We further reasoned that quality improvement efforts might be better directed to improving the manugemenf of recognized major depression if detected patients received poor quality treatment for their depression and had poor outcomes. The longitudinal study we undertook to address these questions had three objectives. The first objective was to identify the proportion of primary care patients in routine care settings whose current episode of major depression remained undetected for up to 1 year. As part of this objective, we examined how the probability of detection changed across multiple visits to the same provider. The second objective was to characterize impairment and remission rates in undetected patients over 1 year. The third objective was to examine quality of depression treatment and remission rates in detected patients over 1 year.

General Hospital Psychiatry 20, 12-20, 1998 0 1998 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010

Undetected Depression

Methods Subject Recruitment Protocol for the study was approved by our Institutional Review Board. We conducted first stage depression screening in telephone interviews in 1992-1993 with randomly selected adults age 18 and over in 11,078 (70.5%) of 15,721 randomly selected Arkansas households with listed and unlisted telephone numbers. We used a stratified sampling design to oversample nonmetropolitan counties to meet the requirements of the original study [19]. We employed a 0.06 cutoff on the Burnam screener [20] to identify 998 (9.0%) household members who screened positive during first stage screening. Excluding 286 bereaved, 54 manic, and 14 acutely suicidal individuals and 8 individuals who denied all depressive symptoms at the inperson interview, 470 (73.9%) of 636 eligible depressed adults agreed to participate in a 3-hour face-to-face baseline interview which most subjects completed within 1 month after the telephone interview. Participants were similar to nonparticipants in all sociodemographic and clinical characteristics (including depression severity) except age and residence. Participants were younger (46.3 years old vs 55.1, p < 0.0001) and less likely to reside in nonmetropolitan areas (74% vs 83%, p < 0.02) than nonparticipants. The 9900 screennegative individuals who completed the telephone interview and were not followed provide a nondepressed comparison group. We weighted the sample so it was comparable in age, gender, education, and region to individuals eligible to participate in the study and so the sample would have a ruralurban distribution comparable to the state’s population. While increasing the generalizability of our findings, weighting results in sample sizes that are not whole numbers; thus, we present weighted n’s rounded to the nearest integer in the Results section.

Follouwp

Data Collection

C)ne hundred sixty-two subjects met criteria for current major depression at baseline. We conducted telephone interviews with 157 of the 162 subjects (96.9%) 6 months after baseline and with 152 subjects (93.8%) 12 months after baseline. The research team successfully collected and reliably abstracted essentially complete medical, pharmaceutical and insurance records for the year following baseline on 148 of the 152 subjects (97.4%) completing follow-

in I’rirnary Care

up. The application of weights increased ber of subjects from 148 to 153.

Operational

Definitions

the num-

of Major Consirwts in

the Study Current A4ajor Depression. We characterized subjects as having current major depression if they met criteria on the baseline interview we administered following screening for lifetime major depression using the Diagnostic Interview Schedule (DIS) 1211 and reported five or more depressive symptoms in the last 2 weeks. The DIS diagnosis required that depressive symptoms have been severe enough during this episode or a previous episode to tell a doctor or other health professional, take medication, or interfere with their activities. Detection. Primary care patients were categorized as having their depression detected if 1) patients reported they had sought help for depression during the previous 6 months from a medical doctor at either the 6- or 12-month follow-up interview; 2) the primary care physician mentioned depression symptoms in the notes or coded depression as a diagnosis in the medical or billing records for any visit during the year following baseline; 3) the primary care physician prescribed an antidepressant medication during the year following baseline; or 4) the primary care physician referred the patient to specialty mental health care during the year following baseline for depression treatment. We included subjects who reported they had sought help even when depression treatment was not initiated fo identzjiy a detected as opposed to a treated s~arnpk Guideline-Cowordanf Care. We operationalized guideline-concordant care as patient reports that they had taken one or more of the antidepressant medications listed in recently released rohlcms.

13

K. Rost et al. Disability days during the past month were measured by adding the number of full bed days in the past month due to either physical health or emotional problems to the number of restricted activity days due to physical health or emotional problems. All impairment measures, coded as greater scores equal greater impairment, were collected at baseline at 6 months and 12 months. We also examined suicidal ideation as a quality of life indicator rather than as a mortality risk indicator. We reasoned that patients who actively contemplated suicide perceived little value to their lives, a conclusion not necessarily true for nonsuitidal individuals with other symptoms of depression. We measured suicidal ideation at 6 and 12 months by a positive response to either of the two most severe DE suicide items which identified subjects who reported thinking about and/or attempting suicide during the past 6 months. We initially compared each patient’s report across all three interviews to select the assessment period when the patient reported the worst functioning over the past month. We call this period the worst assessment although we recognize that both detected and undetected patients may have had periods of even worse impairment than we were able to capture in our three-wave interview. Remission. Subjects met criteria for remission if they reported two or fewer of the nine criteria for major depression within the last 2 weeks. Subjects met criteria for improvement if they reported three or four of the nine criteria for major depression within the last 2 weeks. Subjects who remained currently depressed continued to report five or more of the nine criteria for major depression within the last 2 weeks. These constructs were measured at the 6- and 12-month interviews using the depression section of the DIS modified to collect symptom recency.

Although the major focus of the paper is to describe the course of disorder in undetected patients, we recognized that any descriptive information we provided would be more meaningful if we compared undetected patients with detected patients and nondepressed subjects where warranted. We evaluated two potential analytic methods to make these comparisons: unadjusted comparisons and adjusted comparisons controlling for observed between-group differences at baseline. We elected to present unadjusted comparisons in the tables in this paper because they provide a more clinically meaningful picture of the course of disorder undetected patients actually experience, rather than the impairment they zuo~ln experience if they were comparable in all other relevant ways to detected patients. We report the results of adjusted comparisons in the text to provide assurance that the differences in clinical course observed between detected and undetected patients did not result from differences between the two groups in other factors we could observe. In our adjusted analyses, we used the only sociodemographic or clinical variable that differed between detected and undetected patients; however, the results we report remain stable when controlled for gender, minority status, marital status, education, depression severity, current dysthymia, physical comorbidity, psychiatric comorbidity, primary care visit frequency during the year following baseline, and number of primary care physicians involved in treatment. We used linear regression models in adjusted analyses of between-group differences in physical role limitations, emotional role limitations, and disability days; logistic regression models in adjusted analysis of between-group differences in suicidality; and multinomial logit models to generate adjusted estimates of remission/improvement/no remission for the two groups.

Data Analysis

Results

We used simple descriptive statistics to characterize the proportion of primary care patients whose major depression was detected during the year, and t-tests/Chi-squares to compare how detected and undetected patients differed in sociodemographic and clinical characteristics at baseline. In order to examine whether the probability of detection changed over the course of multiple visits to the same provider, we calculated the probability of detection at a given visit among patients who made at least that many visits to the same provider.

Primary Care Visits by Depressed Community Residents

14

One hundred three of the 153 subjects (64.1%) made one or more visits for any reason to a family practitioner, general practitioner, or general internist during the 6 months following baseline. Subjects who made a primary care visit within 6 months following baseline were more likely to be older (50.1 vs 36.4 years old, p = O.OOOl), less likely to be high school educated (35.7% vs 6&l%, p = O.OOOl),

Undetected Depression and reported more physical comorbidities (3.8 vs 1.9, p = 0.0001) compared with subjects who did not. ‘The two groups did not differ by gender, minority status, marital status, number of major depressive symptoms at baseline, or current dysthymia.

Detection of Major Care Patients

Depression Among

Primary

We excluded from the analysis five primary care patients who received depression treatment from a mental health provider only during the year following baseline because we reasoned that their primary care provider would not alter the depression treatment they received. Sixty-six of the remaining 98 depressed primary care patients (67.5%) were detected during the year following baseline. The sociodemographic characteristics of detected and undetected patients are presented in Table 1. Detected patients were significantly more likely than their undetected counterparts to be older (52.6 years old compared with 44.7, respectively, p = 0.02). Detected and undetected patients were statistically

Table 1. Sociodemographic and clinical characteristics of detected and undetected primary care patients with major depression Sociodemographic characteristics Mean age (SD)” % Female

‘XiMinority ‘%)High school educated or above % Currently

married

Undetected

Detected

(N z 32)

(N = 66)

44.7 (14.6) 73.4 19.8

52.6 (14.8) 80.6 24.3

46.4 64.6

30.6 58.8

6.4 (1.3) 36.3

6.9 (1.6) 41.0

3.1 (1.7)

4.1 (3.0)

7.8 (1.0)

1.7 (1.0)

Clinical characteristics Current mean criteria

for major depression (SD) ‘% Current dysthymia Mean physical comorbidities (SD)

Mean number of primary care physicians

(SD)

isi l’rirnar\

Care

comparable in gender, minority status, education, marital status, severity of depression, comorbid dysthymia, physical comorbidities, primary care visit frequency during the year following baseline, and number of primary care providers seen during the year. Figure 1 illustrates that the probability of detection decreased dramatically after the first visit, after which the probability of detection remained steady but minimal.

Impairment

During

Worst Assessmcrli

Compared with basehne reports of nondepressed subjects, undetected depressed patients reported nine times more role limitations resulting from emotional problems, three times more role limitations resulting from physical problems, and eight times more disability days at their worst assessment (seeTable 2). In unadjusted comparisons with the detected cohort, undetected depressed patients reported somewhat fewer role limitations from physical problems (p = 0.06), comparable role limitations from emotional problems, and similar disability days. An estimated 45.8% of undetected patients report serious suicidal ideation during their worst assessmentcompared with 54.6% of detected patients, a difference that was also not statistically significant. One undetected patient (3.2%) reported a suicide attempt during the following year, compared with four detected patients (5.4%). Adjusting comparisons for age resulted in significant between-group differences in role limitations due to emotional problems (74.5 in undetected group compared with 86.5 in detected group, 1 ~:2.09, ~7= 0.04); all other comparisons remained nonsignificant. We examined the subset of subjects whose worst assessmentwas at either 6 months or 12 months to determine whether undetected patients visited their primary care provider during the same month they reported their worst impairment to us. This analysis demonstrated that only 31.3% 01 undetected patients made a primary care visit during the month they reported their worst assessment compared with 58.5% of detected patients !y2 2;: (3.4, p = 0.01).

Mean number of primary

-

care visits to most frequently visited provider during year following baseline (SD)

Remission of Major Depression in Undetected Depressed Prima y Care Patients 4:3 (3.0)

5.3 (5.0)

As shown in Figure 2, more than half of undetected patients continued to meet criteria for current major

‘15

K. Rost et al.

Figure 1. Absolute probability of detection of depression in depressed patients by visit.

1

2

3

4

5

6

7 or more

Visit

depression (five or more symptoms within the last 2 weeks) at 6- and 12-month follow-up. Overall, 37.5% of undetected patients met criteria for current major depression at both follow-ups; 25.0% of undetected patients failed to meet criteria at either follow-up. Adjusting comparisons for age had virtually no impact on remission rates. Qualify

of Tveafmenf

Depression Cure Patients

and Remission of Major in Detected Depressed Primary

Figure 2 also shows that close to three-fourths of patients with detected major depression continued to meet criteria for current major depression (five or more symptoms within the last 2 weeks) at 6-month follow-up. This figure drops to 61.0% by 12 months. Overall, 51.3% of detected patients met criteria for current major depression at both follow-ups; 18.0% of detected patients failed to meet criteria at both follow-ups. Our examination of process indicators

demonstrated that 52.0% of detected patients received a prescription for antidepressant medication during the year following baseline, although only 27.1% completed a course of antidepressant medication in accordance with recently released guidelines [22]. Seven percent of detected patients also received a referral from their primary care physician to a mental health specialist in addition to a prescription for antidepressant medication; all referred patients made one or more specialty care visits.

Discussion We began this investigation by delineating three reasons that would justify increased efforts to identify patients with major depression in primary care settings. The first reason was that in a large proportion of the patients they treated primary care physicians failed to detect current episodes of major

Table 2. Disease burden during worst assessment in year following baseline Unadjusted

Detected N = 66

Undetected N = 32 Role limitations-physical*

mean (SD)

Role limitations-emotional+ Disability

70.0 (39.7) 82.7 (25.8) 17.0 (9.3) 45.8

mean (SD)

days-(physical

or emotional) in past month mean (SD) % Suicidal ideation + The greater the score, the greater the impairment ** An additional analyzed.

16

180 subjects

were

excluded

from

comparison

84.1 (29.5) (2:) 20.0 (11.5) 54.6

Nondepressed Test statistic t p t p t p $ p

= = = = = = = =

group

N = 9900**

3.70 0.06 0.56 0.45 1.79 0.18 0.665 0.42

21.1 (34.8) (2;:;) (2) Not asked

on O-100 scale.

the nondepressed

group

because

they failed

to provide

complete

data on the variables

12 Months

6 Months

60%

60%

45%

-t i

20% 0% Remission’

Improvement*’

Current

* 2 or fewer symptons for the last 8 weeks ** 3 or 4 symptoms for the last 8 weeks

2. Remission and improvement with major depression at baseline.

Figure

Remission*

Improvement” -.-_--.-.

* 2 or fewer symptoms for the last 8 weeks ** 3 or 4 symptoms for the last 8 weeks

of disorder in detected (N = 66) and undetected (N = 32) primal\:

depression over time rather than in a single visit. This study found evidence that primary care physicians detected 68% of patients experiencing an episode of major depression over the course of multiple visits, with the greatest likelihood of detection at the initial visit. Over time, detection appears to be most likely in older depressed patients, a relationship previously reported [14,25] and contradicted [26]. The second reason justifying the need to increase screening efforts is that undetected patients report serious problems over time. Detected and undetected patients experience highly comparable impairment during their worst assessment, although detected patients may attribute more role limitations to emotional problems. The impairment experienced by undetected patients should not be minimized, given that 28% of depressed primary care patients who contemplate taking their own life do not discuss depression even once with a health professional. The third reason for screening reflects that the choice undetected patients make to manage their major depressive episode entirely without the help of a health professional makes sense only if they in fact get better on their own. However, this study found over half of undetected depressed patients continue to meet criteria for a major depressive episode at 6 or 12 months. Thus, although this

Current . _,

CJR patients

“self-limiting” disorder resolves in some undetected patients without intervention, it does not resolve for most over the course of 1 year. Other studies have found that untreated individuals report greater interpersonal problems, more difficulty enjoying activities, and a decrease in occupational status compared with treated patients at &year follow-up [141. Despite the poor outcomes associated with undetected depression, it is difficult to justify an exclusive emphasis on increasing detection to improve the quality of care because less than 40% of detected patients show remission improvement 6 or 32 months later. Other investigators report 6 month remission/improvement rates of 70X-$5% [ll, 16,271 using virtually identical criteria. We suspect our lower improvement rates paint a more generalizable picture of outcomes for major depression in routine primary care given that our subjjcts were not recruited from clinical settings volunteering to participate in depression research. Remission rates among detected patients should improve if more than 27% of depressed patients receive high-quality care for major depression, which is the proportion we observed in the detected cohort of this study. We think it is inadvisable to compare outcomes between detected and undetected patients until greater progress is made in answering questions about whether and how to control for unobserved

17

K. Rest et al. severity differences between the two groups [[28]]. Without adequate statistical control, it is difficult to interpret conclusions from studies that fail to find that treated primary care patients have better outcomes than untreated patients [12,14,16,17]. Research showing that depressed individuals are more likely to visit a primary care physician than a mental health professional have led to a focus on general medical settings as the key setting to increase detection [29]. Our finding that 103 of 153 community residents with major depression visited a primary care physician within 6 months after baseline compared with 9 who visited a mental health specialist only support this view. However, if the 32 individuals who visited primary care doctors without being detected (table 1) are combined with the 41 who never visited a primary care physician or a mental health specialist, fully 48.0% of community residents with major depression remained undetected over the course of 1 year. This suggests that while primary care medical settings present an important opportunity to improve treatment for depression, they are only part of the solution. If subsequent studies confirm our findings that primary care efforts systematically miss a sizable proportion of younger, more educated, and physically well individuals with major depression because they never make a primary care visit in the first place or fail to return when their condition is not detected, alternative methods of outreach such as workplace screening will need to be developed and evaluated. Concurrent with these efforts, primary care physicians must assume greater responsibility for their patients with major depression if the patients are to get any professional care. Primary care physicians in this sample failed to recognize the condition over time in one of every three depressed patients they saw, particularly younger patients. Younger patients may deny depressive symptoms or physicians may adopt a lower index of suspicion because younger patients report fewer physical limitations. Repeat visits do not meaningfully increase the probability that the doctor will detect the patient’s depression; and many undetected patients fail to make return visits when their condition worsens.

Conclusions This picture leads us to conclude that screening efforts alone will not succeed in improving outcomes in routine primary care for primary care

18

patients with major depression. First, screening needs to be refined or complemented by interventions that increase physicians’ ability to identify true positives from among patients who screen positive to avoid treating many subthreshhold patients who improve over the short term without active treatment [30]. Second, screening needs to be complemented by follow-up interventions that actively monitor patients whose symptoms of major depression remain untreated, without depending on the patient to call for help. Third, because detected patients often receive poor quality treatment and fail to get better, interventions are needed to train primary care physicians to assist patients in completing a course of guideline-recommended treatment [22] in patients whose major depression can benefit from pharmacotherapy or psychotherapy. Our conclusions are strengthened by using a community-based sample to evaluate clinical care, and a well-executed prospective design which allowed us to evaluate detection over time. Other aspects of the methodology cause us to qualify our conclusions, Because we recruited patients in their homes rather than immediately before the visit, we recognize that a small proportion of undetected patients may have no longer met criteria for current major depression when they made their primary care visit, particularly those with less severe symptoms [31]. Our decision not to query physicians about detection immediately after the visit (to avoid the Hawthorne effect) may have resulted in either overestimates or underestimates of actual detection rates, but we suspect that the multi-informant approach we used to measure detection is as sound or more sound than many other commonly used methods. A second limitation of the study is that we do not know how our findings generalize to patients treated outside fee-for-service settings given the predominance of fee-for-service reimbursement in our state when this study was conducted. However, if physicians in capitated settings are less likely to detect depression [32], one might expect greater problems in health maintenance organizations and other managed care settings. In summary, these results suggest that quality improvement efforts that are limited to screening may do little to improve outcomes in routine primary care settings. Screening efforts need to be coupled with or preceded by interventions that teach primary care physicians to assist patients who meet diagnostic criteria in completing an efficacious course of treatment. Multidisciplinary research efforts are needed to assess how comprehen-

Undetected

sive primary care interventions and alternative methods of outreach affect both direct treatment costs and the substantial indirect costs borne by both depressed individuals and society as a whole [33,34]. 7’hc authors wish to acknowledge Linda Delaney, Carl Elliott, Madorma Gautreau. Debbie Hodges. Dnn Hoyt, Mnrki Kimball, Stacy Kimbrel, Phyllis Linkswiler, Cindy Mosley, Cynthia Moton, Blair Tompkins, Ry~m Turk, Chnrlotte Willinms, the men and women who partici/mted irl this stud,y, rind rcvirwers who provided comments 011 mrlkr drnfts of this nf~7rrawipt.

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