Comorbid Chronic Illness and Depression in Primary Care Settings
Objective: To estimate the impact of chronic medical conditions on depression diagnosis, treatment, and follow-up care in primary care settings.
Design: This was a cross-sectional study that used interviewer-administered surveys and medical record reviews. Three hundred fifteen participants were recruited from 3 public primary care clinics. Depression diagnosis, guideline-concordant treatment, and follow-up care were the primary outcomes examined in individuals with depression alone compared with individuals with depression and chronic medical conditions measured using the Charlson Comorbidity Index (CCI).
Results: Physician diagnosis of depression (32.6%), guideline-concordant depression treatment (32.7%), and guideline-concordant follow-up care (16.3%) were all low. Logistic regression analysis showed no significant difference in the likelihood of depression diagnosis, guideline-concordant treatment, or follow-up care in individuals with depression alone compared with those with both depression and chronic medical conditions. Participants with severe depression were, however, twice as likely to receive a diagnosis of depression as participants with moderate depression. In addition, participants with moderately severe and severe depression received much less appropriate follow-up care than participants with moderate depression. Among participants receiving a depression diagnosis, 74% received guideline-concordant treatment.
Conclusion: Physician depression care in primary care settings is not influenced by competing demands for care for other comorbid medical conditions.
One hundred and twenty-five million people in the United States suffer from a chronic physical condition, and approximately 60 million of these have more than one chronic conditions. Chronic physical conditions also account for considerably disproportionate health care utilization and cost among affected individuals. Depressive disorders are associated with chronic physical conditions 20% to 50% of the time, with such co-occurrence reported to predict higher morbidity and worse treatment outcomes.
Primary care settings are important for the treatment of many mental health conditions, and primary care providers are often the sole contacts for more than 50% of patients with a mental illness. These settings are also important health care delivery platforms for individuals with chronic physical conditions, particularly minority Hispanic and African-American populations. However, the quality of depression care in these settings is often poor; depression is under-diagnosed and under-treated close to 50% to 65% of the time in these settings. Many factors have been attributed to this poor quality of depression care, including provider-related factors such as disposition, skills, attitudes, and practice toward mental health care as well as patient-related factors including perceived stigma associated with mental disorders and treatment, preponderance of somatic symptomatology, and a lack of patient awareness of psychological distress.
There is some evidence that multiple competing demands affect the quality of care provided in primary care settings for many medical conditions, with some studies beginning to examine the effects of these demands on mental health care. However, the evidence is mixed regarding the relative effects of comorbid physical conditions on depression care. In 2000, 2 studies reported that chronic physical comorbidity decreased the probability of depression being discussed or noticed during a clinic encounter. Another study in 2002, however, reported similar rates of treatment of patients with depression alone when compared with patients with depression and comorbid physical conditions but worse depression outcomes in the later group. Similarly, a more recent study also found that depressed people with chronic medical conditions were significantly more likely to receive guideline-level care for depression than were depressed people without chronic medical conditions. In another study, Harman et al reported that competing demands did not result in lower quality of depression treatment in older people. There is a strong need for further clarity regarding the role of comorbid chronic conditions on the quality of depression care observed in primary care settings, particularly public safety-net settings serving underserved Hispanic and African-American populations.
Abstract and Background
Abstract
Objective: To estimate the impact of chronic medical conditions on depression diagnosis, treatment, and follow-up care in primary care settings.
Design: This was a cross-sectional study that used interviewer-administered surveys and medical record reviews. Three hundred fifteen participants were recruited from 3 public primary care clinics. Depression diagnosis, guideline-concordant treatment, and follow-up care were the primary outcomes examined in individuals with depression alone compared with individuals with depression and chronic medical conditions measured using the Charlson Comorbidity Index (CCI).
Results: Physician diagnosis of depression (32.6%), guideline-concordant depression treatment (32.7%), and guideline-concordant follow-up care (16.3%) were all low. Logistic regression analysis showed no significant difference in the likelihood of depression diagnosis, guideline-concordant treatment, or follow-up care in individuals with depression alone compared with those with both depression and chronic medical conditions. Participants with severe depression were, however, twice as likely to receive a diagnosis of depression as participants with moderate depression. In addition, participants with moderately severe and severe depression received much less appropriate follow-up care than participants with moderate depression. Among participants receiving a depression diagnosis, 74% received guideline-concordant treatment.
Conclusion: Physician depression care in primary care settings is not influenced by competing demands for care for other comorbid medical conditions.
Background
One hundred and twenty-five million people in the United States suffer from a chronic physical condition, and approximately 60 million of these have more than one chronic conditions. Chronic physical conditions also account for considerably disproportionate health care utilization and cost among affected individuals. Depressive disorders are associated with chronic physical conditions 20% to 50% of the time, with such co-occurrence reported to predict higher morbidity and worse treatment outcomes.
Primary care settings are important for the treatment of many mental health conditions, and primary care providers are often the sole contacts for more than 50% of patients with a mental illness. These settings are also important health care delivery platforms for individuals with chronic physical conditions, particularly minority Hispanic and African-American populations. However, the quality of depression care in these settings is often poor; depression is under-diagnosed and under-treated close to 50% to 65% of the time in these settings. Many factors have been attributed to this poor quality of depression care, including provider-related factors such as disposition, skills, attitudes, and practice toward mental health care as well as patient-related factors including perceived stigma associated with mental disorders and treatment, preponderance of somatic symptomatology, and a lack of patient awareness of psychological distress.
There is some evidence that multiple competing demands affect the quality of care provided in primary care settings for many medical conditions, with some studies beginning to examine the effects of these demands on mental health care. However, the evidence is mixed regarding the relative effects of comorbid physical conditions on depression care. In 2000, 2 studies reported that chronic physical comorbidity decreased the probability of depression being discussed or noticed during a clinic encounter. Another study in 2002, however, reported similar rates of treatment of patients with depression alone when compared with patients with depression and comorbid physical conditions but worse depression outcomes in the later group. Similarly, a more recent study also found that depressed people with chronic medical conditions were significantly more likely to receive guideline-level care for depression than were depressed people without chronic medical conditions. In another study, Harman et al reported that competing demands did not result in lower quality of depression treatment in older people. There is a strong need for further clarity regarding the role of comorbid chronic conditions on the quality of depression care observed in primary care settings, particularly public safety-net settings serving underserved Hispanic and African-American populations.
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