Patients want PCPs to treat depression
Yet, study finds few achieve full recovery
Twice as many people first turn to their primary care physician (PCP) for help with depression and general anxiety disorder (GAD) than to a psychiatrist, according to a survey by the National Mental Health Association (NMHA) in Alexandria, VA. Unfortunately, although PCPs have made great strides in recognizing and treating these mental health disorders, few patients report reaching a full recovery.
The NMHA survey clarifies that patients want their PCPs involved in depression treatment. "More than 70% of patients surveyed wanted their primary care physicians more involved in their depression care," says Jeremy Kisch, PhD, a clinical psychologist and senior director of clinical education at NMHA.
"In most cases, patients have seen their primary care physicians for years and have established a level of comfort and trust with them," explains Michael Faenza, president and chief executive officer of NMHA. "Thus, they want their physicians to be more involved in detecting depression and GAD and in helping them recover so they can return to previously enjoyed activities."
The NMHA survey included more than 3,200 adults over age 18. Participants were interviewed by telephone about their awareness and understanding of clinical depression and GAD as well as their awareness of available treatments and expectations of the results of treatment. A total of 1,495 interviews were conducted in more depth. Of those, 980 participants had experienced depression or GAD, and 515 had not.
The survey revealed that PCPs are at the front line for diagnosing and treating mental illness and are having some success. Findings include:
• Among patients diagnosed with clinical depression, 42% were diagnosed first by their PCP, compared with 34% by a psychiatrist.
• Among patients diagnosed with GAD, 47% were diagnosed first by their PCP, compared with 31% by a psychiatrist.
• Among patients with clinical depression, 47% gave their treatment a grade of "A" in terms of enabling them to fully carry out daily responsibilities.
• Among patients with GAD, 44% gave their treatment an "A" in terms of enabling them to fully carry out daily responsibilities.
• Only 28% of patients with clinical depression and 32% of patients with GAD gave their treatment an "A" for returning them to previously enjoyed activities.
Kisch notes that far too few patients reported achieving full recovery. "The ability to carry out daily responsibilities is not the same as a full recovery. The field is beginning to differentiate and understand that there is a difference between relief from symptoms and a return to full quality of life," he explains.
The NMHA survey results support that statement. Consider the following findings:
• Only 36% of patients with clinical depression and 21% of patients with GAD reported reaching full recovery.
• Slightly more than 50% of patients with clinical depression and 56% of patients with GAD reported a limited recovery.
• The remaining 11% of patients with clinical depression and 23% of patients with GAD reported no recovery at all.
• Patients who saw their PCP first had higher recovery expectations than patients who saw a psychiatrist first. In fact, 50% of patients first seen by their PCP expected a full recovery, compared with 40% of patients who first saw a psychiatrist.
The survey also revealed important clues and uncovers some troubling findings about how to achieve full recovery from clinical depression and GAD. Among those clues are:
• The majority of patients treated for clinical depression reported difficulty coping with the side effects of medication and often had to change medication.
• More than 50% of patients sampled asked their physicians to switch them to other medications. Efficacy was cited as the reason for medication change by 30% of patients, and side effects were cited as the reason by 50% of patients.
• Despite difficulties with medication, 76% of those diagnosed with clinical depression reported believing that antidepressants were as effective as antibiotics.
• Even when symptoms improved, many patients experienced only partial recovery.
• Few patients take medication alone for either clinical depression or GAD. More than 60% of patients with depression reported being treated with a combination of medication and psychotherapy, and only 20% took medication only.
• Nearly 40% of patients with clinical depression reported noticing recovery within a few weeks.
• Nearly 70% of patients with clinical depression reported improvement within two months. That figure rose to 89% after two months.
• Only 6% of patients with clinical depression reported no improvement.
• Roughly 30% of patients with GAD experienced progress within a few weeks.
• About 50% of patients with GAD reported improvement within one month. That figure rose to 62% within two months and 78% after two months.
• Only 10% reported no improvement, while 13% reported not knowing how long it took them to first notice improvement.
• More than 30% of patients with GAD were treated with medication only.
Kisch says the vast majority of patients in the NMHA study participated in some form of talk therapy. "Studies in the literature support the finding of the NMHA study that patients treated with a combination of antidepressants and psychotherapy often achieve fuller recovery from depression than patients receiving either therapy alone," he says. "For example, a study of 681 patients with depression reported in the New England Journal of Medicine1 found that 85% of patients receiving a combination of nefazodone and psychotherapy responded to treatment, compared to 55% of patients receiving nefazodone alone and 52% receiving psychotherapy alone.
"An editorial in that same issue2 identifies that there is still a strong need to develop a more effective therapeutic approach to effective depression treatment in general clinical settings," says Kisch. "The whole issue of how to move from a partial to full recovery has also not yet been well-identified."
Kisch says other recent studies suggest that case managers have a role to play in improving depression outcomes. "A study of depression outcomes in a managed primary care setting reported in the Journal of the American Medical Association3 found patients and providers who received counseling and education from specially trained social workers and nurses achieved better outcomes," he notes. In fact, 50.9% of patients who received counseling and education responded well to treatment, compared with 39.7% of patients who didn’t receive these interventions. "It’s an improvement. It’s not good enough, but it’s an improvement."
Which components of a treatment plan contribute to full recovery from clinical depression still must be better identified, he stresses. "How much difference does it make to participate in a quality improvement [QI] process which includes nursing or social work interventions? Would a better QI process lead to better results, or is the difference in cost not justified? Does every patient with clinical depression require psychotherapy plus medication, or do some do just as well with medication alone? We simply don’t have the evidence we need."
The findings, Kisch says, should motivate health plans to use less costly providers such as nurses and social workers to support patients during treatment of depression and GAD. "There’s no hard evidence, but there is a strong sense that patients who want more primary care involvement are reaching for more support and help. This can be provided by social workers and nurses working with the physician."
The road to recovery may be difficult, he says. "Along that road, PCPs play a valuable role in both identifying individuals who need treatment and often providing that treatment themselves. The key is for some provider to be in a position to make a diagnosis, and most often that is a PCP."
References
1. Keller MB, McCullough JP, Klein DN, et al. A comparison of nefazodone, the cognitive behavioral analysis system of psychotherapy and their combination for the treatment of chronic depression" N Engl J Med 2000; 342:1,462-1,470.
2. Scott J. Editorial: Treatment of chronic depression. N Engl J Med 2000; 342:1,518.
3. Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care. JAMA 2000; 283:212-220.
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