Depression symptomatology and diagnosis: discordance between patients and physicians in primary care settings

Chizobam Ani,Douglas Bell,Francis Yemofio,Michael Rodriguez,Muhammad A Farooq,Richard Baker,Mohsen Bazargan,David Hindman,Lutful Akhanjee

doi:10.1186/1471-2296-9-1

Abstract

BackgroundTo examine the agreement between depression symptoms using an assessment tool (PHQ-9), and physician documentation of the same symptoms during a clinic visit, and then to examine how the presence of these symptoms affects depression diagnosis in primary care settings.MethodsInterviewer administered surveys and medical record reviews. A total of 304 participants were recruited from 2321 participants screened for depression at two large urban primary care community settings.ResultsOf the 2321 participants screened for depression 304 were positive for depression and of these 75.3% (n = 229) were significantly depressed (PHQ-9 score ≥ 10). Of these, 31.0% were diagnosed by a physician with a depressive disorder. A total of 57.6% (n = 175) of study participants had both significant depression symptoms and functional impairment. Of these 37.7% were diagnosed by physicians as depressed. Cohen's Kappa analysis, used to determine the agreement between depression symptoms elicited using the PHQ-9 and physician documentation of these symptoms showed only slight agreement (0.001–0.101) for all depression symptoms using standard agreement rating scales. Further analysis showed that only suicidal ideation and hypersomnia or insomnia were associated with an increased likelihood of physician depression diagnosis (OR 5.41 P sig < .01 and (OR 2.02 P sig < .05 respectively). Other depression symptoms and chronic medical conditions had no affect on physician depression diagnosis.ConclusionTwo-thirds of individuals with depression are undiagnosed in primary care settings. While functional impairment increases the rate of physician diagnosis of depression, the agreement between a structured assessment and physician elicited and or documented symptoms during a clinical encounter is very low. Suicidality, hypersomnia and insomnia are associated with an increase in the rate of depression diagnosis even when physician and self report of the symptom differ. Interventions that emphasize the use of routine structured screening of primary care patients might also improve the rate of diagnosis of depression in these settings. Further studies are needed to explore depression symptom assessment during physician patient encounter in primary care settings.

Highlights

To examine the agreement between depression symptoms using an assessment tool (PHQ-9), and physician documentation of the same symptoms during a clinic visit, and to examine how the presence of these symptoms affects depression diagnosis in primary care settings
We utilized the following validated interpretation of Kappa values [37]:
Patient characteristics A total of 2321 patients were screened for depression using the Patient Health Questionnaire-2 (PHQ-2) [34]

Summary

Introduction

To examine the agreement between depression symptoms using an assessment tool (PHQ-9), and physician documentation of the same symptoms during a clinic visit, and to examine how the presence of these symptoms affects depression diagnosis in primary care settings. About 16% of a random sample of primary care patients were estimated to have sub-syndromal depression associated with some functional impairment [4]. Depression is associated with marked impairment in psychosocial function, reduced productivity, increased suicide attempts, and increased health care utilization [7]. Minority populations utilize outpatient specialty mental health services for psychiatric symptoms and disorders at much lower rates than non-Hispanic white persons, and are more likely to receive care in general medical settings without seeing a specialist [11,12,13,14,15]. Efforts aimed at increasing the appropriate diagnosis and treatment of depression in minority populations have, met with mixed success and depression still goes under-recognized and under-treated, especially in primary care settings [16,17,18,19,20]

Objectives

Results

Conclusion