A third of all patients who have major depression remain undiagnosed by their primary care physicians for as long as a year, a new survey shows, and the consequences can be grave: among other things, at least half of them entertain thoughts of suicide.
Kathryn Rost, PhD, of the Center for Mental Healthcare Research at the University of Arkansas, and colleagues followed a group of 98 adults who had been culled from random telephone interviews with 11,078 Arkansans and three-hour follow-up interviews with 470 of them.
All 98 were diagnosed by the study team as having major depression, but for 32 percent of them, their depression went undetected by their own primary care doctors. Writing in the journal, General Hospital Psychiatry, the researchers also report that if the depression was not discovered in the first visit to a physician, the likelihood that it would be detected in visits during the following year was very low.
Earlier research shows that the consequences of undetected depression included increased use of health care services, impaired personal relationships and decreased occupational status. A year after the study began, 53 percent of the patients whose depression went undetected by their primary care physicians were reporting five or more current systems of depression.
They also reported nine times more role limitation from emotional problems than community residents without depression.
The problem is compounded, the research team writes, because younger, more educated patients tend not to go to their doctors for depression.
"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."
The researchers also urge that "primary care physicians...assume greater responsibility for their patients with major depression." Among their other recommendations:
- That screening be refined to increase physicians' ability to identify those who need care.
- That follow-up interventions monitor patients without requiring patients to call for help.
- That primary care physicians be trained to help patients complete recommended treatments.
In the same issue of the journal, Myrna M. Weissman, PhD, of Columbia University, and colleagues from several universities describe a new computer-based program to screen for depression and other mental disorders in primary care offices. The team tested the system on about 1,000 Kaiser Permanente patients in California. Patients were asked to complete a form and then were interviewed briefly by a nurse, who recorded their symptoms and a preliminary diagnosis, later reviewed by the primary care doctor.
The researchers concluded their system could greatly speed diagnosis without compromising the validity of results, but does not relieve the physician of the increased time required for follow-up and management of previously undetected cases.
But detection was not the only problem Rost's research team found. Even among patients whose depression was diagnosed, less than 40 percent showed substantial improvement as long as a year later, leading the team to conclude that improved recognition alone, without improved depression management, would not improve outcomes.
Rost's research was supported by grants from the National Institute of Mental Health. Weissman's research was supported by the Pharmacia Upjohn Company.
Journal
General Hospital Psychiatry