The Cost of Poor Physician-Patient Communication – Depression

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Depression is one of those conditions that patients, particularly men and certain ethnic groups, are reluctant to bring up on their own.  Unfortunately  most physicians also seem reluctant to bring up the subject of depression with their patients.

Depression is a big problem these days.   Four out of every ten patients in  primary care waiting room suffer from moderate to severe depression.  Prevalence rates for depression are highest among women and older patients with chronic conditions.

It costs twice as much to treat a patient with depression ($4,780) as it does to treat a patient without depression ($2,794).  That’s because patients suffering from depression generate more physician visits, medical tests, RX medications and hospitalizations.

Despite its high prevalence and costly nature (medically and socially), depression is significantly under-diagnosed (<50%) and under-treated with medications (50% not prescribed) and/or counseling (90% never referred).

Role of Communication in the Detection and Treatment of Depression

Reasons why most primary care physicians spend little time talking about depression with patients include;  lack of time, competing priorities, perception that the patient will be resistance/non-adherent to therapy, a lack of confidence in treatment efficacy, and uncertainty how best to treat depression.  Whatever the reason, very few physicians 1) routinely ask patients (even high risk ones) if they are depressed, i.e., feel down, loss of interest, etc.  and 2) spend much time educating patients about the condition or treatment options.

On a personal note, during the last six years of my wife’s lung cancer treatment she was never once asked about her emotional or mental health status by her treating or primary physician.

If the subject of depression does come up, it is mostly likely raised by the patient.   Even then patients probably bring it up only when they are in real pain.   Most patients would probably just as soon avoid the subject.   Up to 40% of U.S. adults, particularly older folks, still believe that depression is a personal character flaw and not a biomedical condition.   Many of these people are resistant to a diagnosis of depression from their doctor.   Some believe that anti-depressants are ineffective and addictive, while others simply don’t like taking pills of any kind or cannot afford the medication.

So How can Doctors do a Better Job Talking with Patients about Depression?

  • Screen all patients for depression not just Medicare patients at their mandated initial preventive exam
  • Assess patient attitudes and belief about depression and its causes
  • Ask the patient if they are depressed
  • Help patients understand that depression is not a personal problem but a real biomedical condition that can be effectively treated
  • Provide anticipatory depression guidance for older patients and patients with chronic conditions
  • Prescribe treatments and therapies that are in alignment with the patient’s desires and expectations.
  • Ask patients if they can afford prescribed medication
  • Teach patients how to take medications and what do before stopping their medications

 

Sources:

Depression Among High Utilizers of Medical Care.  Pearson et al.  Journal of General Internal Medicine. 1999: 14:461-468.

Physician attitude toward depression care interventions: Implications for implementation of quality improvement initiatives.  Henke et al.  Implementation Science 2008, 3:40.

Attitudes to depression and its treatment in primary care.  Weich et al.  Psychological Medicine, 2007, 37, 1239–1248.

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