Williams J W, Rost K, Dietrich A J, Ciotti M C, Zyzanski S J, Cornell J
Audie Murphy Division, South Texas Veterans Health Care System, San Antonio 78284, USA.
Arch Fam Med. 1999 Jan-Feb;8(1):58-67. doi: 10.1001/archfami.8.1.58.
Because primary care physicians (PCPs) are the initial health care contact for most patients with depression, they are in a unique position to provide early detection and integrated care for persons with depression and coexisting medical illness. Despite this opportunity, care for depression is often suboptimal.
To better understand how to design interventions to improve care, we examine PCPs' approach to recognition and management and the effects of physician specialty and degree of capitation on barriers to care for 3 common depressive disorders.
A 53-item questionnaire was mailed to 3375 randomly selected subjects, divided equally among family physicians, general internists, and obstetrician-gynecologists. The questionnaire assessed reported diagnosis and treatment practices for each subject's most recent patient recognized to have major or minor depression or dysthymia and barriers to the recognition and treatment of depression. Eligible physicians were PCPs who worked at least half-time seeing outpatients for longitudinal care.
Of 2316 physicians with known eligibility, 1350 (58.3%) returned the questionnaire. Respondents were family physicians (n = 621), general internists (n = 474), and obstetrician-gynecologists (n = 255). The PCPs report recognition and evaluation practices related to their most recent case as follows: recognition by routine questioning or screening for depression (9%), diagnosis based on formal criteria (33.7%), direct questioning about suicide (58%), and assessment for substance abuse (68.1%) or medical causes of depression (84.1%). Reported treatment practices were watchful waiting only (6.1%), PCP counseling for more than 5 minutes (39.7%), antidepressant medication prescription (72.5%), and mental health referral (38.4%). Diagnostic evaluation and treatment approaches varied significantly by specialty but not by the type of depression or degree of capitation. Physician barriers differed by specialty more than by degree of capitation. In contrast, organizational barriers, such as time for an adequate history and the affordability of mental health professionals, differed by degree of capitation more than by physician specialty. Patient barriers were common but did not vary by physician specialty or degree of capitation.
A substantial proportion of PCPs report diagnostic and treatment approaches that are consistent with high-quality care. Differences in approach were associated more with specialty than with type of depressive disorder or degree of capitation. Quality improvement efforts need to (1) be tailored for different physician specialties, (2) emphasize the importance of differentiating major depression from other depressive disorders and tailoring the treatment approach accordingly, and (3) address organizational barriers to best practice and knowledge gaps about depression treatment.
由于初级保健医生（PCP）是大多数抑郁症患者最初接触的医疗保健人员，他们处于为抑郁症患者及并存的躯体疾病患者提供早期检测和综合治疗的独特位置。尽管有这样的机会，但抑郁症的治疗往往不尽人意。
为了更好地理解如何设计干预措施以改善治疗，我们研究了初级保健医生对识别和管理抑郁症的方法，以及医生专业和按人头付费程度对三种常见抑郁症治疗障碍的影响。
向3375名随机选择的受试者邮寄了一份53项的问卷，这些受试者在家庭医生、普通内科医生和妇产科医生中平均分配。问卷评估了每位受试者最近被诊断为患有重度或轻度抑郁症或心境恶劣障碍的患者的报告诊断和治疗方法，以及抑郁症识别和治疗的障碍。符合条件的医生是那些至少一半时间从事门诊纵向护理工作的初级保健医生。
在2316名已知符合条件的医生中，1350名（58.3%）回复了问卷。受访者包括家庭医生（n = 621）、普通内科医生（n = 474）和妇产科医生（n = 255）。初级保健医生报告了与他们最近病例相关的识别和评估方法如下：通过常规询问或抑郁症筛查进行识别（9%）、基于正式标准进行诊断（33.7%）、直接询问自杀情况（58%）以及评估药物滥用情况（68.1%）或抑郁症的躯体原因（84.1%）。报告的治疗方法仅为观察等待（6.1%）、初级保健医生咨询超过5分钟（39.7%）、抗抑郁药物处方（72.5%）和转介至心理健康专业人员（38.4%）。诊断评估和治疗方法因专业不同而有显著差异，但不因抑郁症类型或按人头付费程度而异。医生障碍因专业不同比因按人头付费程度不同更为明显。相比之下，组织障碍，如获取充分病史的时间和心理健康专业人员的可及性，因按人头付费程度不同比因医生专业不同更为明显。患者障碍很常见，但不因医生专业或按人头付费程度而异。
相当一部分初级保健医生报告的诊断和治疗方法符合高质量护理要求。方法上的差异更多与专业相关，而非与抑郁症类型或按人头付费程度相关。质量改进工作需要：（1）针对不同医生专业进行调整；（2）强调区分重度抑郁症与其他抑郁症并相应调整治疗方法的重要性；（3）解决最佳实践的组织障碍以及抑郁症治疗方面的知识差距。
