The 15-Minute Visit: How Can Primary Care Better Identify and Treat Depression?
ABSTRACT: A physician’s ability to recognize depression depends almost entirely upon their interactions and communication with patients. Understanding the ways that patients and physicians discuss symptoms of depression can help explain why depression is often underrecognized in primary care. This article describes patterns observed in regular clinical encounters with physicians and depressed patients to help paint a picture of the attention currently given to the psychosocial symptoms of depression. The goal is to provide suggestions for primary care physicians and to make an argument for systemic change in the larger health care system that would allow for more comprehensive, collaborative, and patient-centered care for depression.
Research indicates that 71% of people with depression or depressive symptoms seek help first from their primary care physician.1,2 Yet, depression in primary care clinics is correctly identified in only 50% of depressed patients.3 Because technology cannot detect depression via a blood test, urine analysis, or other lab work, the way that physicians and their depressed patients discuss psychological, emotional, and social concerns can markedly influence the practitioner’s ability to appropriately detect, diagnose, and treat this common and often chronic condition.4
The failure to diagnose is compounded by the fact that nearly half of depressed patients do not report their social or psychological problems to their doctor, but instead complain only of their somatic symptoms.5,6 This may be due to the patient’s own expectations for their doctors7 or because the traditional in-office visits are often quick-paced and focus on solving the most urgent biomedical problems.8,9 Even when patients do provide information about their behaviors, thoughts, emotions, and relationships, these psychosocial issues are generally not verbally explored unless physicians believe it important to do so.10 Finally, time constraints—driven by productivity expectations—can limit the ability of a physician to attend to these emotional and behavioral needs.11,12
Even when correctly diagnosed, most patients do not receive treatment in accordance with recommended guidelines,13 and patients frequently do not adhere to a recommended treatment plan.14 This wide-ranging, underrecognition, and undertreatment of depression in primary care has been repeatedly demonstrated,3,7,15 and many have sought to explain it.8,16
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Physicians have different approaches to responding to their patients’ expressed mental health needs and emotional distress.17 Emotion-related communications (ie, giving and receiving of nonverbal messages and emotional self-awareness) are viewed as important elements of high-quality care,18 but the patients’ affective responses are sometimes neglected in communication with care providers.19
Note: A physician’s communication style can improve clinical outcomes, treatment adherence, desire to take antidepressant medication, and patient satisfaction—yet patients often report a shortage of quality communication with their primary care providers.20,21 Primary care physicians must discuss the biological, psychological, and social aspects of the patients’ lives to make an accurate diagnosis. Descriptive qualitative research on how this actually happens in practice is limited and often based on after-the-fact recollections from the perspective of either the doctor or patient.16 As a result, directly observing clinical encounters can increase our understanding of how doctors and patients discuss these problems during regular primary care visits.
An Observational Study
We observed 6 male and 3 female physicians interacting with 22 random patients from their practice. They were not informed of our specific interest in studying depression so there was no influence on their interactions with the patients. Through these observations, we recognized patterns in the ways depressed patients and their physicians discussed psychosocial issues.
The patients in this observational study visited their doctors for a variety of reasons—including acute illness visits, diabetes maintenance, hypertension, sleep apnea, physical exams for work release, chronic pain, and various other conditions and symptoms typically seen in primary care. All patients had screened positive for moderate or severe depressive symptoms on the Patient Health Questionnaire (PHQ-9)22 and in nearly every visit, the patient brought up psychosocial concerns and depressive symptoms. These most often included low energy, lack of interest in pleasurable activities, sleep disturbance, dissatisfaction with mood, trouble concentrating, and relationship difficulties.
No Psychosocial Concerns Addressed
A few minutes prior to their visit, each patient was asked to fill out a questionnaire and all 22 respondents had indicated that they do experience depressive symptoms. Yet, in 7 of the visits, neither the doctor nor the patient brought up any concerns related to the psychological or social aspects of the patient's life. As we know, depression cannot be diagnosed or managed if its symptoms are not discussed. We speculate that one possible reason may be that patients believe it is not a primary care physician’s role to address psychosocial concerns, and hence they only bring up their physical symptoms. Acknowledging that patients may be reticent to disclose psychosocial symptoms, physicians may still be able to better assist depressed patients by asking a variety of direct and open-ended questions about the patient’s behaviors, beliefs, emotions, thoughts, and relationships. These questions can also help the patient increase insight into their own thoughts, emotions, and mood-related behaviors—and may help inspire motivation for change.23
Psychosocial Concerns Not Adequately Addressed
In 10 of the visits, we observed the patient and physician discussed psychosocial symptoms, but not adequately enough to ensure effective treatment in accordance with recommended guidelines. According to the American Psychiatric Association, recommended guidelines for the treatment of depression include acknowledging the patient’s emotional needs, assessing the patient for thoughts of suicide and safety, suggesting lifestyle and behavioral changes, prescribing and managing appropriate medications, and coordinating care with other care providers.24
We observed 3 major patterns that help explain why these concerns were not addressed adequately. When psychosocial concerns were expressed by the patient, physicians either:
• Chose to not acknowledge them, thereby missing the opportunity to discuss these complaints with the patient. We saw some physicians simply not address the patient’s concerns about psychosocial difficulties.
For example, a diabetic patient mentioned that he had recently been having very low energy and great difficulty sleeping. He indicated that he would be participating in a sleep study that night and said he was looking forward to a good night’s sleep since it had been a while. The physician acknowledged the importance of sleep and then went on to talk about blood pressure.
After briefly discussing hypertension medications the patient mentioned motivation problems and low energy, saying he used to go to the gym several times a week and does not have the energy to do so for the past year. Rather than explore possible causes for these issues that are affecting the patient’s quality of life, the physician simply changed the topic to ask if the endocrinologist had checked his feet. The patient did not bring up his psychosocial symptoms again.
Physicians in this group were not providing inappropriate or unrelated patient care, but they clearly forfeited opportunities to explore and discuss psychological and social factors related to the patient’s problem. Although the patient had scored moderately to severely depressed on the depression screening measure, the physician did not factor in the psychological and social aspects of their problems during these clinical visits.
• Chose to physiologically define psychosocial concerns by ascribing them to a physical cause, a medication side effect, or some other biological origin. For example, when asked about his mood, one patient said, “I just don’t feel like doing anything.” The physician’s immediately attributed the condition to the blood sugar levels being out of the normal range.
In another scenario, another patient shared, “I'm a basket case. Up, down, up down.” The physician began describing neurotransmitters and the way SSRIs are believed to influence serotonin reuptake. The patient expressed frustration at the inability of biochemical agents to treat her psychological and relational concerns.
In these instances, treatments for hyperglycemia and serotonin reuptake were indicated and appropriate; however, the patients’ symptoms of depression were not adequately assessed or addressed by the treatments offered. Depression is a biopsychosocial condition, yet a pattern of physicians attending solely to the biological component emerged after observing several clinical visits.
• Acknowledged and discussed the problems, but skimmed over these concerns and chose not to explore them further, provide additional guidance, suggest any lifestyle or behavioral changes, or make a referral. For example, one patient who was 5 months postpartum indicated interest in returning to her pre-pregnancy antidepressant, and asked if that was possible while still breastfeeding. During the visit, she complained of lower back pain, sleeping difficulties, low energy, and emotional disturbance related to new parenting roles and adjusting to pumping breast milk at work. The physician asked if the current antidepressant was keeping her fairly balanced or if it wasn’t working. The patient responded: “It’s really hard to say because I was really worried about postpartum depression and that didn’t happen luckily, but I mean it just seems like being new parents, my husband and I both feel like it’s just kind of an ongoing adjustment. I don’t feel like I have that much energy, but it’s like how much of that would be, you know, new parent, overwhelmed, you know, that kind of a thing, so I mean I can’t really say, but I mean, I guess the medicine is working okay.”
Immediately before the encounter, this patient scored a 19 on the PHQ-9 indicating moderate to severe depressive symptoms. The physician recognized and noted the patient’s biological, psychological, and social complaints but chose not to explore these concerns any further. Instead, the physician just said to let him know if she wants to go back on the original antidepressant once she is done breastfeeding.
This pattern of physicians acknowledging and sometimes discussing psychosocial concerns, but then moving the conversation elsewhere, was observed several times.
Who Is Responsible?
In some cases, physicians appeared to view treatment for psychosocial concerns as someone else’s responsibility. For example, one patient informed the physician that he was on many anti-anxiety medications. The physician simply asked the patient if his psychiatrist was aware of all the drugs. When the patient said yes, the physician moved on to physiological inquiries.
Physicians in this group acknowledged the patient’s mental health needs, but did not suggest or prescribe any behavioral or lifestyle changes. They sometimes noted the involvement of other care professionals but did not attempt to coordinate care nor follow-up on any previous referral. When they did refer to mental health counseling or therapy, they did not provide specific names or agencies to the patient as they would in a referral to radiology, nephrology, or another medical specialty.
Following the Protocol
In 5 of the 22 visits, we did observe care being provided in accordance with recommended treatment guidelines.24,25 Despite time constraints, these physicians were able to identify the patient’s emotional needs, assess for thoughts of suicide and safety, suggest behavioral changes, prescribe appropriate medications, and help the patient access appropriate care through other professionals.
In these scenarios, we frequently noted signs that the physician and patient had a meaningful relationship extending beyond just this one visit. For example, one physician did a follow-up on a past referral to have the patient assessed for ADHD. The patient described her difficulty controlling emotions and stress related to moving away for college, and indicated this would likely be her last visit. The doctor validated her emotions, empathized with her fears, and asked the patient to send a letter in 6 months with an update.
The common thread in these interactions was that the physician was asking the patient about psychosocial behaviors, rather than waiting for the patient to express concern. For example, while checking a patient’s blood pressure, the physician casually asked how the patient was doing emotionally. The patient, when prodded, expressed frustration with side effects from the medication, which made him feel “foggy” and voiced feelings of disappointment about his psychiatrist frequently switching treatments. The physician empathized, discussed exercise and eating habits with the patient, and then even asked how the patient and his romantic partner were doing.
What’s the Take-Away?
We hope to draw attention to the ways that patients and their physicians interact regarding biological, psychological, and social depression concerns during actual outpatient primary care clinical encounters. The goal here is to point out the need for changes in the way depression is identified and treated. Based on our observations, we make the following suggestions:
•Because many of the symptoms of depression may be attributable to biomedical conditions (eg, fatigue with diabetes or anemia), physicians should remember to specifically assess the presence of psychological and/or social concerns. To better distinguish whether symptoms are connected to a biological versus biopsychosocial condition, use tools such as the PHQ-2.26 This simple and quick two-question screener assesses the presence and severity of the 2 primary symptoms of depression—anhedonia and dysphoria.
•Physicians are under time constraints and productivity expectations, but rushing an appointment can hinder effective depression recognition and treatment.16 In fact, this might be a reason we saw some doctors miss, ignore, skim over, only treat biological symptoms, or consider psychosocial concerns as someone else’s job. However, the clinical visits where we observed a physician engaged in psychosocial behavior per the recommended guidelines did not run any longer than an average clinical visit (15-20 minutes).
•Physicians should use the collaborative team approach when it comes to treating a complex condition, such as depression, as it produces better outcomes,27-29 reduces the overall cost of healthcare,30 lowers the burden on healthcare providers, and increase both patient and physician satisfaction.28,31 ■
Daniel S. Felix, PhD, is a faculty member in the family medicine department of the Indiana University School of Medicine and focuses primarily on educating resident physicians in behavioral science and collaborative care.
W. David Robinson, PhD, is an associate professor and director of the marriage and family therapy program at Utah State University and focuses his efforts in collaborative health care and rural practice.
Jenenne A. Geske, PhD, is a faculty member, specializing in research methods and statistics, in the University of Nebraska Medical Center Family Medicine department.
Paige W. Toller, PhD, is an associate professor in the School of Communication at the University of Nebraska-Omaha. Her primary areas of research and teaching are in interpersonal and health communication.
Elisabeth Backer, MD, is a clinical associate professor in the department of family medicine at the University of Nebraska Medical Center, with research interests in behavioral health, patient–physician communication, preventative care, and women's health.
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