Primary care clinicians' recognition and management of depression: a model of depression care in real-world primary care practice.

BACKGROUND: Depression is prevalent in primary care (PC) practices and poses a considerable public health burden in the United States. Despite nearly four decades of efforts to improve depression care quality in PC practices, a gap remains between desired treatment outcomes and the reality of how depression care is delivered. OBJECTIVE: This article presents a real-world PC practice model of depression care, elucidating the processes and their influencing conditions. DESIGN: Grounded theory methodology was used for the data collection and analysis to develop a depression care model. Data were collected from 70 individual interviews (60 to 70 min each), three focus group interviews (n = 24, 2 h each), two surveys per clinician, and investigators' field notes on practice environments. Interviews were audiotaped and transcribed for analysis. Surveys and field notes complemented interview data. PARTICIPANTS: Seventy primary care clinicians from 52 PC offices in the Midwest: 28 general internists, 28 family physicians, and 14 nurse practitioners. KEY RESULTS: A depression care model was developed that illustrates how real-world conditions infuse complexity into each step of the depression care process. Depression care in PC settings is mediated through clinicians' interactions with patients, practice, and the local community. A clinician's interactional familiarity ("familiarity capital") was a powerful facilitator for depression care. For the recognition of depression, three previously reported processes and three conditions were confirmed. For the management of depression, 13 processes and 11 conditions were identified. Empowering the patient was a parallel process to the management of depression. CONCLUSIONS: The clinician's ability to develop and utilize interactional relationships and resources needed to recognize and treat a person with depression is key to depression care in primary care settings. The interactional context of depression care makes empowering the patient central to depression care delivery.

Health disparities or data disparities: sampling issues in hepatitis B Virus infection among Asian American Pacific Islander studies.

Hepatitis B virus (HBV) infection in Asian American Pacific Islanders (AAPIs) is an important health problem that must be recognized and addressed by the U.S. public health policy. However, AAPIs have been to a large degree invisible in public health data and debates and their interests have been disregarded. Moreover, an estimation of HBV infection rates reported from the National Nutritional and Health Survey Examinations III was 1.25 million; however, an estimate based on AAPI-targeted studies places the number at almost 2 million. This article discusses the perils of application of textbook methods of sampling coverage, selection, and nonresponse in studies related to AAPIs and the importance to note that some rapidly increasing racial/ethnic groups such as AAPIs have linguistic and cultural differences and these differences often cause such groups to be omitted from data collection.

Conditions that influence a primary care clinician's decision to refer patients for depression care.

The objective of this study was to identify conditions that influence primary care clinicians' referral decisions related to depression care. Forty primary care clinicians (15 general internists, 10 nurse practitioners, and 15 family practice physicians) were included in this study. The clinicians participated in semistructured interviews and completed two quantitative instruments (with 33 items on depression treatment decision making and 32 items on provider attitudes toward psychosocial care). Data analysis revealed that several conditions influence a clinician's decision to refer a depressed patient to a mental health specialist: the patient's resources, the clinician's comfort in prescribing antidepressants and counseling patients with depression, and familiarity with a mental health specialist and practice environment. The decision to refer a patient with depression to a mental health specialist is a complex process involving the clinician, patient, and practice-related issues. Understanding these relationships may provide strategies to improve depression care management and lead to the design of depression care quality-improvement interventions that accommodate primary care practice context. The findings from this study suggest a need to increase mental health training opportunities for primary care clinicians to strengthen their skills and comfort level in managing depressed patients and encourage the development of relationships between primary care clinicians and mental health specialists to facilitate timely and accessible mental health care for patients.

Reinvention of depression instruments by primary care clinicians.

PURPOSE: Despite the sophisticated development of depression instruments during the past 4 decades, the critical topic of how primary care clinicians actually use those instruments in their day-to-day practice has not been investigated. We wanted to understand how primary care clinicians use depression instruments, for what purposes, and the conditions that influence their use. METHODS: Grounded theory method was used to guide data collection and analysis. We conducted 70 individual interviews and 3 focus groups (n = 24) with a purposeful sample of 70 primary care clinicians (family physicians, general internists, and nurse practitioners) from 52 offices. Investigators' field notes on office practice environments complemented individual interviews. RESULTS: The clinicians described occasional use of depression instruments but reported they did not routinely use them to aid depression diagnosis or management; the clinicians reportedly used them primarily to enhance patients' acceptance of the diagnosis when they anticipated or encountered resistance to the diagnosis. Three conditions promoted or reduced use of these instruments for different purposes: the extent of competing demands for the clinician's time, the lack of objective evidence of depression, and the clinician's familiarity with the patient. No differences among the 3 clinician groups were found for these 3 conditions. CONCLUSIONS: Depression instruments are reinvented by primary care clinicians in their real-world primary care practice. Although depression instruments were originally conceptualized for screening, diagnosing, or facilitating the management of depression, our study suggests that the real-world practice context influences their use to aid shared decision making-primarily to suggest, tell, or convince patients to accept the diagnosis of depression.

What comprises clinical experience in recognizing depression?: the primary care clinician's perspective.

PURPOSE: Depression is a highly prevalent condition in primary care settings. In our previously reported work, we investigated the processes and conditions that influence primary care clinicians' recognition of depression. Three conditions influence the recognition of depression: familiarity with the patient, time available, and clinical experience. This article further describes the role of clinical experience in depression care. METHODS: The grounded theory method was used to guide data collection and analysis. In-depth, in-person interviews were conducted with a purposeful sample of 8 clinicians. All interviews were audiotaped and transcribed. RESULTS: We identified 3 areas that comprise clinical experience relevant to depression care: (1) knowing one's professional role, (2) knowing oneself, and (3) knowing one's patients. In knowing one's professional role, 4 subdimensions were identified: (1) becoming familiar with illness patterns and clinical skills, (2) learning what works in the real world, (3) understanding what being a doctor is about, and (4) thinking of the whole person. The analysis indicated that clinical experience results from professional and personal growth during interactions with patients. The outcome of this developmental process was the achievement of comfort with depression care, a critical mediating variable that influenced primary care clinicians' recognition of depression. CONCLUSIONS: The developmental process of attaining comfort in managing depression warrants further exploration. Developing interventions to speed this process offers another approach to enhancing care for the management of depression.

The recognition of depression: the primary care clinician's perspective.

PURPOSE: The purpose of this study was to explore the responses of primary care clinicians to patients who complain of symptoms that might indicate depression, to examine the clinical strategies used by clinicians to recognize depression, and to identify the conditions that influence their ability to do so. METHODS: The grounded theory method was used for data collection and analysis. In-depth, in-person interviews were conducted with a purposeful sample of 8 clinicians. All interviews were audiotaped and transcribed. RESULTS: This study identified 3 processes clinicians engage in to recognize depression-ruling out, opening the door, and recognizing the person-and 3 conditions-familiarity with the patient, general clinical experience, and time availability-that influence how each of the processes is used. CONCLUSIONS: The likelihood of accurately diagnosing depression and the timeliness of the diagnosis are highly influenced by the conditions within which clinicians practice. Productivity expectations in primary care will continue to undermine the identification and treatment of depression if they fail to take into consideration the factors that influence such care.