Why depression continues to go undiagnosed and untreated in primary care

What medical condition is the most costly to employers?  I’ll give you a hint.  It is also a medical condition that is likely to go unrecognized and undiagnosed by primary care physicians.

If you guessed depression you are correct.  If you mentioned obesity you get a gold star since that comes in right behind depression for both criteria … at least in terms of cost and the undiagnosed part.

Four out of every ten people at work or sitting in the doctor’s waiting room suffer from moderate to severe depression.  Prevalence rates for depression are highest among women and older patients with chronic conditions.  Yet despite its high prevalence and costly nature, depression is significantly under-diagnosed (<50%) and under-treated by physicians.

Why depression continues to go undiagnosed and untreated in primary care

For employers, the cost of depression far exceeds the direct costs associated with its diagnosis and treatment    As the graphic above indicates, the cost of lost productivity for on the job depressed workers (presenteeism) and lost time for depressed workers that are absent from the job (absenteeism) far exceed the cost of cost of treatment (medical and medication cost).

I have identified what I believe to be the central reason why depression continues to go undiagnosed and untreated in primary care.   The reason is that physicians are uncomfortable talking to patients about it.   Even when patients provide “cues” suggesting evidence of depression in the opening statement (“I haven’t been sleeping well,” or, “I haven’t been myself lately”), evidence suggests that physicians are likely to simply not recognize or ignore the cues.   Physicians themselves admit that their training predisposes them to be more comfortable dealing with biomedical versus psychosocial issues.

Now think Accountable Care Organizations and Medical Homes.  Both of these concepts, one a payment reform model and the other a delivery model, are predicated upon the notion that the medical services offered have real value to the payer.  But what kind of value are primary care physicians providing when they fail to diagnose and treat the biggest problem facing the people that ultimately pay for their service?

Tying this all back to physician-patient communication, physicians need to begin employing more patient-centered communication techniques in their dealing with patients.  In particular, physicians need to do a better job listening to what their patients are trying to tell you, even if it is outside your comfort zone.   At the very least you can refer the patient to a counselor for help.  In so doing you will be clearly helping the patient and adding real value to the people who ultimately pay for your valuable service.

Steve Wilkins is a former hospital executive and consumer health behavior researcher who blogs at Mind The Gap.

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  • MassachusettsPCP

    The other reason is that the treatments are limited. Antidepressants tend to help only the moderate to most severe depressed patients (and then again, not all as 60% of patients ‘fail’ the first drug or combination). There are studies out there that indicate that for most garden-variety mild to low grade depression that antidepressants produce little effect. Psychotherapy? Many insurance companies have restrictions on the number of visits for psychotherapy, and patients tend to reject it for a variety of reasons (no time off work, co-pay costs, stigma). I find myself often telling patients that we have medications to help the symptoms of depression, and they often find out on their own that it doesn’t make them happy. It’s a crucial difference.

  • pheski

    There will be little motivation to diagnose unless there is optimism about the opportunities for improvement with treatment. As noted by MassachusettsPCP, there is little evidence that medication helps the mild-moderately depressed. Counseling is less risky and probably somewhat more effective in this group, but too often not available. In our community in central Maine, the wait for an insured patient with moderate-severe depression (major impact on functioning but not actively suicidal) is 4 months. For a MaineCare or uninsured patient, it is twice that – if I can even make it happen. If referred for counseling, they must go through the non-medical triage system – usually on the phone – of their payor and then make multiple attempts to make an appointment (in our community, counselors insist on scheduling directly with the patient) which is a major barrier in any setting, but especially so with a depressed patient. And then there is the time pressure. The standard 15 and 20 minute slots have not changed much in my 30 years, but what I have to pack in that time has grown immensely. Instead of rapid dictation, I spend 20% of the visit or more doing data entry. There are multiple items I must do to satisfy my employer’s need to collect data to qualify for this or that certification. The amount of clinical data to review and the number of clinical choices are both exponentially greater.

    In my setting, I often note mild to moderate mood disorders during the course of preventive and disease management visits. I document this in my note and usually on the problem list. I may or may not overtly address it under a psych diagnostic label with the patient – most often not – instead talking to them about issues of stress/coping/impact/outlook. And since referral for counseling is usually not an option and medication is usually not indicated, I do indeed ‘treat’ it but with the appropriate and available tools – with supportive counseling, with an earlier than medically needed or longer than medically driven follow up, with a phone call in a couple days from me or my nurse to see if they are handling today’s agenda ok. This would not show up in Mr. Wilkins’ data, I’m sure, but is of equal efficacy, probably more effective and certainly more cost-effective than the treatments that would show up on his chart.

    I agree with Mr. Wilkins that depression is under diagnosed. I am not as certain that it is under treated. But I note that he provides absolutely nothing to support his contention that the reason is that physicians are uncomfortable talking about it. Where is the data to support this speculation? And where is the data that increased effort for diagnosis results in better outcomes for a population?

    Sorry to take this so personally, but one of my gripes is non-clinicians who know little or nothing about what a PCP like myself does, and then writes an article not just about what I do, but about why I do it.

    Peter Elias, MD

  • pcp

    Most of the major plans in my area have completely carved out mental health benefits.

    If I discuss depression with a patient, include that in my note, and list that as a diagnosis, I am paid nothing, even if I treat five other problems during that visit.

    If I prescribe an anti-depressant, it’s not covered.

    If I make a referral to a counselor or psychiatrist, it’s not approved.

    So, sure, I’ll agree that it’s my fault that depression is not being diagnosed often enough. Starting tomorrow, I’ll provide better “value” and treat those “4 out of 10″ (aka 2 out of 5) patients for free.

    The poster’s enthusiasm for blaming primary care docs for all the problems of our health care system remains quite impressive.

    • http://bizsavvytherapist.com Susan Giurleo

      So you will only diagnose it if you’re paid. I get the frustration, I’m a psychologist and often get unpaid by the carved out MH benefit, but I figure out what I need to do to get reimbursed. Just not diagnosing sounds a bit unethical to me.

  • ninguem

    Primary care.

    Last in pay, first in blame for all the ills of society.

    • ManAlive

      Exactly correct, Ninguem.
      You have a fan.

  • http://www.healthecommunications.wordpress.com Steve Wilkins

    Drs. Elias and PCP

    First thanks for your comments. A couple of basic observations.

    As a patient going to my physician I have every reason to expect that he/she will provide care when needed and in my best interest. If you fail to provide me with the quality of care I expect then whose is at fault…me for expecting it or you for not telling me you don’t have time or resources to provided it.

    Using your logic, since health plans outsource mental health issues, just like they outsource diabetes, CAD, COPD, and asthma care to disease management vendors, you should have lots of free time to spend with your patients. I know that not how it works and so do you.

    Can you clarify for me just exactly what care your patients can expect from you for their “co-pay” and what care you withold because you aren’t paid to provide it?

    Come on, people like me end up doing what we do because people in your profession spend too much time complaining and grousing. I don’t enjoy railing against anyone…but my wife almost died because busy PCPs overlooked her radiology report indicating a Stage 1 lung CA tumor…which wasn’t doagnosed for another 2 years when it was Stage 4. .I hate to see people die unnecessarily as do you.

    Dr. Elias…I don’t make this stuff up. Below are some citations which address the issues your raised with my post.

    References:

    Main DS, Lutz LJ, Barrett JE, Matthew J, Miller RS. The Role of Primary Care Clinician Attitudes, Beliefs, and Training in the Diagnosis and Treatment of Depression. Archives of family medicine. 1993.

    Adelman RD, Greene MG, Friedmann E, Cook MA. Discussion of depression in follow-up medical visits with older patients. Journal of the American Geriatrics Society. 2008;56(1):16-22. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18184203 [Accessed December 31, 2010].

    Henke RM, Zaslavsky AM, McGuire TG, Ayanian JZ, Rubenstein LV. Clinical inertia in depression treatment. Medical care. 2009;47(9):959-67. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19704353.

    Schwenk TL, Evans DL, Laden SK, Lewis L. Treatment outcome and physician-patient communication in primary care patients with chronic, recurrent depression. The American journal of psychiatry. 2004;161(10):1892-901. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15465988.

    • Primary Care Internist

      Mr. Wilkins, you are part of the growing army of healthcare execs who routinely irritate docs who know what they’re doing but constantly battle uphill against other bureaucrats and execs who really DON’T KNOW what the obstacles are.

      Did you know that medicare reduces payment by half for mental health diagnoses? And that private insurers generally follow suit? So even the many many times my colleagues and i diagnose and treat depression, if we list that as one of the relevant diagnoses, we get dinged. If we don’t, it’s technically fraud. But still we’re to blame. Ridiculous, isn’t it? Maybe you and your other exec colleagues can relate this to the geniuses at CMS since they seem to only listen to the Obamas and other non-doctors who have never diagnosed or treated anyone with anything.

      And this misperception that we docs, especially in primary care, are somehow incapable of communicating with our patients??? On the contrary, every one of my colleagues are much much more adept at communicating with out patients than are their nurses, psychologists, and even social workers. This may sound surprising, but only because bureaucrats and analysts constantly drill this false notion into the public’s collective head that doctors don’t talk to their patients.

      Really guys, ninguem and everyone else reading, let’s start sticking up for ourselves for a change!

      PCI, MD MPH (yes i too have an MPH and no, i don’t think that qualifies me as a healthcare exec, not nearly as much as the MD and residency and practice experience does).

  • http://glasshospital.com GlassHospital

    I think this is a strong post–well argued and backed with evidence.

    I’ll echo the non-aggressive counterexamples in the comments and offer my own:

    I see and diagnose depression all the time. The problem I find with some patients is an unwillingness to consider treatment for fear of being labelled. This applies to both therapy (for which there is indeed a lack of availability–it would be greatly optimized by having mental health providers IN our practice rather than in a separate location) and to medication.

    For those that accept the diagnosis or are willing to trial a medication, improvement often follows.

    -Dr. John

  • pcp

    “If you fail to provide me with the quality of care I expect then whose is at fault”

    If you come to my office with insurance that specifically states you have to go elsewhere for treatment of disease X, I think it’s pretty clear where the problem is.

    “since health plans outsource mental health issues, just like they outsource diabetes, CAD, COPD, and asthma care to disease management vendors . . . Can you clarify for me just exactly what care your patients can expect from you for their “co-pay” and what care you withold because you aren’t paid to provide it?”

    I’m paid to diagnose and treat all the other conditions you list, and I do.

    With the major payers in my area, if I spend 90 minutes with a patient (which I frequently do) and list six diagnoses, one of which is depression, I am paid nothing for the ENTIRE visit. I’m not going to spend my time trying to come up with a difficult and high-liability diagnosis that I can’t even write a prescription for! It’s a TERRIBLE system, for patients and doctors, but I don’t make the rules.

    I’m truly sorry for what sounds like a nightmarish experience for you and your wife, but you come across as very hostile towards primary care. Do you also expect neurosurgeons, dermatologists, and radiologists to diagnose and treat mental disease in their patients? Do you expect psychiatrists to treat obesity, DM, and hypertension? Seems like there’s a big double standard here.

  • http://www.healthecommunications.wordpress.com Steve Wilkins

    Gentlemen,

    I really do appreciate your participation in this dialog. Please understand that the only agenda I have is that of helping patients navigate and survive the US health care system. I agree with you all that the system is broken and among other things, pay for PCPs needs to be fixed and pronto. By the way I am not a high powered/high paid health executive. A good deal of what I do is patient advocacy.

    Actually I don’t not understand or appreciate all the insurance issues surrounding depression/mental health or other areas that you have to deal with in your practices. I learn from forums like this. But then there’s probably things that you don’t understand or appreciate about us “patients” either…so I guess we are equal in terms of needing to be open to listening and learning.

    In the interest of getting your side of the story out, I have an offer for any and all takers (and talkers lol) here. Who would be willing to be interviewed by me as part of a series of blog postings dealing with the challenges and joys of being a PCP today? We would jointly develop the interview guide (agree to the questions so no surprises) and then post the interviews here on KevinMD. Maybe we could get Kevin Pho to be the moderator.. Hint Hint. If by better understanding what PCPS have to deal with patients can get better care…its all good.

    Any takers?

    Steve Wilkins

    • http://glasshospital.com GlassHospital

      Steve-

      I’d be interested.

      -John

      • http://www.healthecommunications.wordpress.com Steve Wilkins

        John,

        Deal. Now let’s see if any of the other physicians want to join in and make a contribution….

        Contact me via http://www.healthecommunications.wordpress.com to talk about details.

  • http://www.dialdoctors.com Dial Doctors

    Depression is a terrible illness which affects productivity the most. It’s true it’s undiagnosed most of the time but I don’t think that doctors choose to ignore the cues. In most settings, doctors have only a few minutes with the patient and all cues are not alike. A good idea might be implementing a BDI screening whenever a patient comes in. It’s incredibly easy and quick both to administer and assess. Think of it as an add on to what patients already get. It’s cost effective because you don’t have to purchase it and the only cost would be the photocopy. It’s so common it’s available online. If patients are already going to complete 5 gazillion papers just to be seen by the doctors, I don’t see why one more which can help diagnose such a sneaky condition. Any patient with high scores gets reffered.

    • ninguem

      “…….Any patient with high scores gets reffered……”

      Interesting thought.

      There IS a “medical” marijuana clinic down the street…..

      I bet they’ll feel better.

  • Angela Caffaratti, MD

    As a family doctor, I feel very well- trained in psychiatry. I fail to see how one can medically treat anyone without consideration of the psychology of the complaint. I do see patients floridly psychotic and wish I had the luxury of referral. I also wish I had psychological counseling easily available. I do my best, and I do quite well.

  • Sideways Shrink

    This discourse is well articulated and civilized covering intelligently the same territory that almost exploded in response to the guest post of Dr. Raina, a psychiatrist, titled “How to be heard by your psychiatrist”. (This post appears to have been removed.) I will not comment on her post except to say that, I and others interpreted the post as giving tips on how to cope with the FOREGONE reality that your psychiatrist was not going to be listening or responsive.
    I am glad PCP and Primary Care Internist brought up the restrictions against or penalties for billing psychiatric diagnostic codes.
    Imagine how much money you would NOT make
    billing those codes for a living? Between CMS RVUs and private insurance following suit there has been a downward pressure medical students choosing to match to psychiatry, especially child and geri psych for a long time. AMA data pegs mean ages of psychiatrists at 62 and 64.
    Another cost saving mechanism of the insurance industry set up through the credentialing process is that if a patient happens to present or develop an acute or sub-acute physical state in my office and needs an physical exam by me so I can decide the correct disposition for the patient (instead of just calling an ambulance which would be much more expensive for the insurance company–but that is not what I think a out what I think about when I think someone might be having a CVA.
    The big picture is we are all in patient care together and we all have different styles of engaging our patients to care for them. Mixing it up amongst ourselves stops us from advocating for all care be reimbursed equally because we all overlap in what we do sometimes more than we would like…

  • http://www.myheartsisters.org Carolyn Thomas

    Am I getting this straight? Are some of you docs saying that because there’s no money involved in appropriately diagnosing depression, it just doesn’t get diagnosed? Given what we know about depression’s devastating influence on longterm outcomes of other disease diagnoses, how is this possible? For example, as Emory University’s Dr. Susmita Mallik reported in the Archives of Internal Medicine last April: “Both doctors and patients should be aware that depression following a heart attack is an important risk factor for adverse outcomes in cardiac event survivors.”

    And as Glass Hospital (comment #8) reminds us, the overwhelming stigma for patients in even accepting a mental health diagnosis is hard enough to accept, never mind finding a physician who’s not watching the clock during such a truly dreadful time in any person’s life. Somehow, Dr. John apparently manages to successfully make this diagnosis for his own patients… For those of you who honestly seem to have no clue, consider reading “Depressing News About Depression and Women’s Heart Disease” at: http://myheartsisters.org/2009/07/03/depression/

  • Leo Holm MD

    Some many erroneous assumptions, so little space to deal with them.
    Is depression really a “disease”? I guess if you trust the consensus opinion in the DSM-n+1. The definition can be changed at any time through a vote or new version. The definition has become evermore inclusive over time. You know you are truly abnormal if there is not a condition in the DSM that describes you. It may remain “unrecognized” for many reasons…when you try to make the whole world “depressed”, as drug companies are doing, it simply becomes the new normal. Makes it a little hard to recognize. Perhaps there are people who recognize depression just fine but don’t believe that everything in the world needs to have pills thrown at it. Depression can arise from a spiritual problem or a situational problem. Some people actually want to work through things on their own before they turn to drugs to solve their problems.
    Undertreated? Really? What are you looking at? Certainly not PhARMA profits, the endless stream of commercials on TV or almost every patient I see on these medications. Levels of antidepressants are actually detectable in municipal water supplies.
    Not to suggest that these medications actually work. Although they do increase the risk of suicide, which I thought might be useful to prevent. Also contribute to obesity, which is also strangely “under diagnosed and undertreated”. Because that is a medical problem too, that the Family Physician has ignored. Lucky for us corporate food producers and our government are right on the case and we should be slender fairly soon.
    Employers have a lot of nerve talking about how much depression “costs” them. Many “depressed” patients are under tremendous pressure at work, financial strain, long working hours, unable to get reasonable amounts of time off, etc. Perhaps employers should examine their working environment instead of whining about health care costs. Although, perhaps with appropriate therapy and medication, employers can become more accepting of their losses and rising health care costs.
    “I have identified what I believe to be the central reason why depression continues to go undiagnosed and untreated in primary care.”
    Yeah, so have I. It is because it is being over diagnosed and over treated on talk shows, health magazines and in commercials by the people who stand to profit the most: the pharmaceutical companies and academic psychiatry. And of course the occasional “plant” doesnt hurt either. Oh well, back to work for a day of ignoring things.