From the Editors’ Desk: Challenging Problems, Challenging Patients

Abstract

According to the World Health Organization, depression affects more than 120 million persons worldwide and is a significant cause of disability. In fact, as assessed by disability adjusted life years (or DALYs), depression now ranks 2nd for men and women in the 15–44 age group. Along with other mental and behavioral disorders, it is also one of the most common problems seen in primary care, and is a frequent accompaniment to many chronic illnesses. In this issue of JGIM, several papers examine depression and other mental/behavioral health disorders from a variety of perspectives. Sorkin et al. report on a study of the mental health needs and barriers to care among older Asian Americans in the US. They found that while expression of emotional distress and utilization of mental health services varied among the six Asian subgroups studied, several groups continue to underutilize care, possibly because of stigma and other cultural barriers. This study reminds us that our patients continue to confront more barriers to access quality care for mental and behavioral health conditions than for most of the other medical problems we manage. Access to care does not guarantee satisfactory outcomes. Prior research has shown that many patients with depression continue to have significant symptoms despite an adequate trial of antidepressant medication. How to manage patients with ‘treatment resistant depression’ has been an ongoing challenge for clinicians and researchers. Trivedi et al. report on a systematic review of psychotherapy for patients with treatment resistant depression to determine if the evidence supports the use of psychotherapy to augment or substitute for drug therapy. They conclude that while there is insufficient evidence to draw any firm conclusions, psychotherapy (primarily cognitive therapy) is likely underutilized by primary care providers and should be considered as an option for patients with treatment resistant depression. Also in this issue, a study by Bayliss et al. reminds us that primary care patients with depression usually also have other medical co-morbidities that complicate their care. In contrast with some prior research, they found that incident depression did not worsen clinical outcomes in a cohort of patients with diabetes. Patients with underlying mental disorders such as depression areoftenchallengingforphysicianstocareforandaremorelikely to be perceived as “difficult”. In this issue, Hinchey and Jackson present findings from a fascinating study that examined predictors and outcomes of difficult patient encounters in primary care. As they point out, most of the previous work in this area has focused on patient behavior. This study adds to our understanding of difficult encounters by more closely examining physician factors that are associated with difficult encounters and by looking at outcomes. They found that physicians with feweryearsofclinicalexperienceandthosethatratedloweronthe