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Attitudes, Knowledge, and Behavior of Family Physicians Regarding Depression in Late Life
Joseph J. Gallo, MD, MPH;
Stephen D. Ryan, MD, MPH;
Daniel E. Ford, MD, MPH
Arch Fam Med. 1999;8:249-256.
ABSTRACT
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Objectives To assess self-reported knowledge, attitudes, and behaviors of practicing community family physicians regarding identification and management of depression in late life.
Design We sent a 3-page "fax-back" survey to 768 active physician members of the Maryland Academy of Family Physicians, Baltimore.
Measurements We asked physicians to rate how confident they felt in evaluating several common medical conditions of late life, including depression. The questionnaire included items related to knowledge and treatment practices for depression in older adults.
Results Two hundred fifteen usable surveys were returned. In general, physicians took responsibility for diagnosing and treating depression. Few physicians reported that they routinely referred the older patient to a psychiatrist to treat depression, and only half thought that consultation was helpful. Physicians responding to the survey were generally aware of alternative presentations of depression in elderly persons, and were well informed about the duration of treatment with medications for depression. Most were using selective serotonin reuptake inhibitors as first-line agents to treat depression. Physicians thought that medications for depression were as effective for older patients as for younger patients, but were less optimistic about the effectiveness of psychotherapy. The barriers to identifying and treating depression in older patients most often mentioned by physicians were related to the atypical presentation of depression in older adults. More than half of the physicians rated themselves as "very confident" in evaluating depression. There were few differences in the responses of physicians with and those without a Certificate of Added Qualifications in geriatrics.
Conclusions Depression in late life remains a difficult clinical challenge for primary care physicians. These findings are particularly relevant in the face of recent efforts to increase collaboration between primary care physicians and mental health professionals.
INTRODUCTION
ACCORDING TO the Global Burden of Disease project,1 unipolar depression, which was the fourth leading cause of disability in 1990 worldwide, will be second only to heart disease in 2020. At the same time, a recent consensus report concluded that undertreatment of depression is common.2 To the extent that depression is associated with loss of autonomy, diminished quality of life for older adults and their families, and diminished functional capacity, inadequate treatment of depression results in unnecessary functional impairment and associated costs.3-4 Epidemiologic evidence that depression may be more common among recent cohorts5-6 portends higher rates of depression and suicide when these younger persons reach late adulthood.
Primary care occupies a strategic position in the evaluation, treatment, and prevention of mental disturbances of late life.7-8 Some investigators have suggested that, in the United States, most persons with a mental disorder may seek care from a specialist in mental health care without consulting a general physician; that is, persons with mental disorders tend to "bypass" the general health sector.9-10 However, evidence for a bypass was lacking among persons with incident mental disorders in the Epidemiologic Catchment Area studies.11 With respect to age, Gallo et al12 found that older adults were much less likely than younger adults to visit a specialist in mental health but were more likely to seek care in the general medical sector. Analysis of data from the Baltimore Epidemiologic Catchment Area follow-up study13 replicate the earlier studies in that there was again little evidence that persons with incident depression sought care directly in the specialty mental health services. Rabins14 reformulated estimates derived from prevalence studies of the Baltimore Epidemiologic Catchment Area and concluded that unmet need for mental health services increases with age, with up to 63% of adults aged 65 years and older having an unmet need for mental health care. These results underscore the importance of the general medical setting for older persons with mental disturbances, since older persons with depression are likely to present to a primary care physician, not a specialist in mental health.
To shed light on the issues related to the recognition and treatment of depression among older adults in primary care, we sent a "fax-back" survey to practicing physician members of the Maryland Academy of Family Physicians, Baltimore, that was focused on depression in late life. Our goal was to gauge self-reported attitudes, knowledge, and behaviors of primary care physicians related to depression in older adults. Belief in the efficacy of psychotherapy and pharmacotherapy for older patients was assessed. In addition, we asked the physicians to rate how confident they felt in evaluating depression in late life along with other common medical conditions of late adulthood, such as diabetes mellitis and heart conditions. We included a comparison of self-rated confidence for evaluating depression with other conditions to provide a basis for assessing whether physician reports about difficulties were related to geriatric syndromes in general or specifically to depression in late life. This study differs from other surveys of physicians' attitudes, knowledge, and behavior related to mental health issues in the focus on depression in older adults in primary care; the responses of physicians in community practice, not restricted to a residency program or other academic setting; and how confident physicians feel in evaluating depression in comparison with other medical conditions.
PARTICIPANTS AND METHODS
Our survey consisted of 3 parts, each 1-page long. The first page concerned the perceived effect that managed care would have on primary care practice. The second page asked about self-rated confidence of the physicians to evaluate various conditions common in late life, including depression. Physicians were asked to rate themselves on a scale from 1 (very confident) to 4 (not very confident). The conditions were acute myocardial infarction, dementia and delirium, stroke of carotid origin, urinary incontinence, atrial fibrillation, hearing loss, type II diabetes mellitus, and depression.
The third page focused on depression in late life. We modeled our questionnaire items for page 3 on the survey of Callahan et al15 of academic physicians, which focused on depression in late life. We based our questionnaire on the previous work by Callahan et al to provide a basis for comparison and to employ items that have proven useful in another study. The questionnaire includes items that tap knowledge and treatment practices of primary care physicians with regard to depression among older patients in primary care. The physician is asked to indicate the extent to which they agree or disagree with the statements by circling numbers on the form corresponding to true, mostly true, mostly false, or false (Table 1).
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Table 1. Questionnaire Mailed to Family Physicians, Modeled After Callahan et al*
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STUDY SAMPLE
Our sampling frame was the membership roll of the Maryland Academy of Family Physicians on April 1, 1997, which consisted of 768 active physician members. We excluded from participation retired physicians, residents, and student members. A 3-page survey was mailed to physicians, who were asked to complete the form and fax or mail the survey back to the Maryland Academy of Family Physicians office. We entered names of physicians returning questionnaires into a drawing for tickets to a professional baseball game as an incentive for participation. A second mailing was sent to physicians who did not respond to the first mailing. A total of 215 usable forms were returned, resulting in a 28% response rate. There were no significant differences in age, year of election to the Maryland Academy of Family Physicians, or sex between participants and nonrespondents.
ANALYTIC STRATEGY
Our aim in this study was primarily descriptive. However, we suspected a priori that self-reported attitudes, knowledge, and behavior of physicians might be related to the age of physicians, their self-rated confidence in evaluating depression in older adults, and whether they had obtained a Certificate of Added Qualification (CAQ) in geriatrics from the American Boards of Family Practice and Internal Medicine. For these analyses, we carried out simple comparisons of proportions using 2-tailed  2 tests of significance with a cutoff of .05, recognizing that tests of statistical significance are approximations that serve as aids to interpretation and inference. All analyses were performed with commercial software (SPSS Version 6.0; SPSS Inc, Chicago, Ill).16
RESULTS
CHARACTERISTICS OF THE SAMPLE
The sample of 215 physicians returning a usable questionnaire had a mean (SD) age of 46.8 (13.2) years. In 99 cases (46%), physicians reported that 25% or more of the patients they saw were aged 65 years and older; 21% reported that persons aged 65 years and older accounted for 40% or more of their patients. Of the physicians responding, 78 (36%) reported that they did not devote any hours per week to nursing home patients or to homebound patients. On average, physicians responding to the survey reported that they devoted a mean (SD) of 2.40 (4.66) hours per week caring for nursing home patients or homebound patients. In only 5 cases did the respondent indicate an academic affiliation. With regard to obtaining a CAQ in geriatrics, 24 physicians (11%) reported that they had a current CAQ.
KNOWLEDGE AND ATTITUDES CONCERNING DEPRESSION IN LATE LIFE
The responses to the questionnaire are listed in Table 2. Most physicians thought that depression was more common in elderly patients, that depression was "understandable" given the losses and chronic illnesses that older patients experience, and that when depression coexists with dementia, it is still important to treat depression. Physicians clearly agreed that diagnosing depression and prescribing antidepressants were in their purview. Most physicians agreed that depression in elderly patients often presents with somatic symptoms, not sadness, and that depression can sometimes present with significant cognitive impairment. Few physicians felt that they did not have time to consider the diagnosis of depression in their older patients. In contrast, there was more disagreement among the physicians regarding whether a psychiatric diagnosis is stigmatizing, and whether it is necessary to rule out a physical illness before considering a diagnosis of depression.
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Table 2. Responses to Questionnaire*
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TREATMENT OF DEPRESSION
We found that most physicians thought that medicines for depression were just as effective for older patients as for young patients (86% agreed), but that they were more uncertain about the benefits of psychotherapy for older persons (57% thought that psychotherapy was just as effective for the older patients as for younger patients) (Table 2). Only half the physicians thought that psychiatric consultation was helpful, and only 11% said that they routinely refer their older patients to a psychiatrist to manage depresion in older persons. Somewhat more than one third regarded anxiolytics as helpful in managing depression in older persons. A similar proportion reported that they used a depression questionnaire when they suspected depression in an older patient. Few physicians said that a brain scan was part of their workup for depression in an older patient, but most reported that they assessed suicide risk when depression was suspected.
Physicians were asked to name the medication they considered their "first-line drug for treating depression in older adults," as well as the drug they considered "second-line." The selective serotonin-reuptake inhibitors were by far the most commonly mentioned medications for the treatment of depression in older adults by primary care physicians, comprising almost 80% of first-line medications. Sertraline was mentioned as a first-line medication most often (by 55 physicians) followed closely by paroxetine (48 physicians), fluoxetine (44 physicians), and unspecified selective serotonin-reuptake inhibitors (23 physicians). These medications were the most often mentioned second-line medications as well. A minority of physicians mentioned first-line use of tertiary tricyclics such as amitriptyline (8 physicians) or secondary tricyclics such as desipramine (8 physicians). Consistent with current recommendations,17-18 170 (79%) said that an adequate trial of antidepressants was at least 4 weeks, and 156 (73%) thought that antidepressants should be continued for at least 4 to 9 months for persons who have recovered from a first depressive episode. Of the physicians responding to the survey, 130 (61%) indicated that the medical literature was "very convincing" for "treating depression in elderly patients to reduce morbidity."
BARRIERS TO IDENTIFICATION AND TREATMENT OF DEPRESSION IN LATE LIFE
In open-ended questions, we asked physicians to tell us what they considered barriers to identifying and treating depression in older adults. Patient-related factors were mentioned most commonly by physicians: older patients do not accept the diagnosis (58 physicians), older patients experience atypical symptoms (38 physicians), and older patients do not comply with recommended therapy (29 physicians). Limited time, stigma related to psychiatric diagnosis of depression, the cost of treating depression, and concern related to reimbursement were less commonly mentioned.
RELATIONSHIP TO PHYSICIAN AGE, CONFIDENCE RATING, AND CAQ
Several items of the questionnaire were related to physician age, self-reported confidence in evaluating depression, and CAQ in geriatrics (Table 3). Compared with younger physicians, older physicians tended to think that medications and psychotherapy were less effective for older patients than for younger patients, but were more likely to rate psychiatric consultation as helpful. Older physicians tended to believe that anxiolytics were often helpful in managing older patients with depression and reported that when depression was considered in older patients, physical illness was ruled out first. Most older physicians (81%) felt confident in prescribing antidepressants to older patients, but this proportion was somewhat lower than the percentage of younger physicians who felt confident doing so. Older physicians tended to be less likely to agree that diagnosing and treating depression was their responsibility (P=.055) and tended to disagree that cognitive impairment is often a sign of depression in older persons (P=.071).
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Table 3. Relationship of Attitudes, Knowledge, and Behaviors to Physician Age, Self-rated Confidence in Evaluating Depression, and Certificate of Added Qualification (CAQ) in Geriatrics*
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With regard to self-rated confidence in evaluating depression, physicians who rated themselves as "very confident" in managing depression were more likely to agree that the presentation of depression differs in older adults. Very confident physicians were more likely to say medications were just as effective for older patients and tended to believe that psychotherapy was just as effective also (P=.083). Confident physicians were more likely to report that they assessed suicide risk and felt more comfortable prescribing medication. Treating depression in the context of dementia and use of a depression questionnaire tended to be more commonly reported by physicians who rated themselves as very confident in evaluating depression in older adults.
There were few differences between physicians who said they had obtained a CAQ in geriatrics and those who did not. Physicians with a CAQ were less likely to think that depression was understandable in older persons, were less likely to rule out physical illness first when considering depression, and were less likely to say that anxiolytics are often helpful in managing depression in late life. Physicians with a CAQ tended to be less likely to think that depression was more common in the elderly than in younger adults.
EVALUATING DEPRESSION
On the second page of our survey, before the physicians answered the questions about depression in late life on page 3, we asked the participants to rate themselves on evaluating older patients for several conditions. Figure 1 illustrates the responses of the physicians to these items concerning confidence. Physicians were as likely to rate themselves as "confident" or very confident in evaluating depression in older patients when compared with evaluating other geriatric syndromes. Seventy-eight physicians (36%) rated themselves as confident in evaluating depression, while 115 (53%) rated themselves as very confident.
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Percentage of 215 physicians responding to the survey who reported feeling "confident" or "very confident" in evaluating common conditions of older patients.
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COMMENT
Our study attests to the responsibility and importance that the family physicians who responded to our survey attach to the evaluation and management of depression in older patients, and calls attention to domains that warrant further research. Unlike other studies, our survey was not limited to physicians in academic practices15, 19-20 or to a small number of physicians in general practice (n=36)21 or family practice (n=64).22 Physicians who responded to the survey expressed confidence in prescribing antidepressant medications to older adults and few reported that they routinely refer their older patients with depression to psychiatrists. The participants were aware of differences in presentation of depression in older patients compared with younger patients, consistent with their reservations concerning the evaluation of depression.
Before discussing the findings of this investigation in detail, the limitations need to be discussed. First, we have based our study on self-reports of physician behavior, not on observations of actual practice or on review of patient records. Second, we cannot be sure of the extent to which responses were influenced by what the physicians felt were socially desirable answers. For example, almost all physicians said they assess suicide risk when depression is suspected. Third, our sample may not be representative of all family physicians. Even if we could be assured of proper representation, we have limited our sample to family physicians in Maryland. It is possible that responding physicians are more knowledgeable and have more favorable attitudes toward depression in late life than are physicians who did not respond. Finally, all survey research has the challenge of ensuring full participation of the sample. We did not have the resources to provide further incentives or additional efforts at follow-up to encourage nonresponders to participate in the study. Although there are many reasons for nonparticipation, one might suspect that the nonresponding physicians might be even less interested in depression in elderly patients than the physicians who sent in a completed survey. In that case, our study would be based on the most confident and interested physicians so that our findings may be conservative in the sense that we may be sampling from the "best" or most confident physicians.
Despite limitations, our study calls attention to several issues related to the treatment of depression in late life because we have surveyed community practicing primary care physicians. Most physicians thought that depression was more common in older persons, and that, given the losses of late life, depression was understandable. Clinical lore and studies based on prevalence of symptoms have supported the view that depression is more common in elderly patients, but epidemiologic studies employing standard criteria for major depression have suggested that depression is less common in older adults.23-25 Indeed, the notion of "subsyndromal" depression (ie, significant depression that does not meet full standard criteria for disorder) is a critical issue for identification and treatment of depression in late life in primary care.26 Recent work has highlighted the relationship between vascular lesions of the central nervous system and alternative expressions of depression in older adults.27 Physicians seemed to recognize that alternative presentations of depression in late life, such as denial of sadness28-29 and coexisting cognitive impairment30 were possible, and often mentioned the atypical presentation of depression in older persons as a barrier to identification and treatment. Typical barriers to treatment of depression in primary care (lack of adequate time, stigma of psychiatric diagnoses, and reimbursement31) were not often mentioned. The most commonly mentioned barriers were related to the atypical presentation of depression in older adults.
PHYSICIANS FELT confident in their ability to prescribe antidepressants in older patients with depression (93%) (Table 2), but had more reservations regarding the evaluation of depression in older patients (53% reporting feeling very confident in evaluating depression). These apparently contradictory findings may reflect the physicians' practical experience that the tendency of older adults with depression to have unexplained somatic complaints or cognitive impairment is a difficult clinical problem. Only 61% of the physicians thought that the medical literature provided very convincing evidence for treating depression in elderly patients to reduce morbidity reflecting uncertainty in diagnosis and management of atypical depression in older adults. That most physicians who responded to our survey agreed with the statement that depression in elderly patients was understandable belies a continued need to consider how physician attitudes may relate to treatment practices.
Physicians with a CAQ in geriatrics were less likely to endorse the idea that depression was understandable, to say that they rule out physical illness first, and to endorse the use of anxiolytics; otherwise, there were few differences between physicians with and without a CAQ. That physicians with a CAQ are less likely to say that depression in the elderly is understandable, that they rule out physical illness first, and that they endorse the use of anxiolytics may reflect an overall propensity to consider depression early in the diagnostic process, but this requires further elaboration in other studies of the process of care for depression in late life. In addition, findings may reflect that physicians who obtain a CAQ are interested in the care of elderly patients, not that they have an interest as a result of obtaining a CAQ. Physicians with high self-rated confidence in evaluating depression in older patients seemed to be more knowledgeable and to have more positive attitudes toward depression treatment, lending construct validity to the self-assessment. Older physicians seemed to differ from younger physicians on several items, possibly reflecting changing attitudes toward the evaluation and management of depression in older persons.
Physicians who responded to the survey generally thought that antidepressants were as effective for older persons as for younger persons. By far, physicians reported that their medication of choice for the treatment of depression in older adults was a selective serotonin reuptake inhibitor. Adverse effects of medications were not often mentioned as a barrier to treatment by physicians who mentioned barriers. Physicians were well aware of the recommended periods considered adequate for a trial of an antidepressant and an appropriate course of treatment after an initial depressive episode. More than one third of the physicians thought that anxiolytics were often helpful in depression in late life. Although it is difficult to know how to interpret this response, it may reflect a lack of knowledge. On the one hand, it may be that use of an anxiolytic is a useful adjunct in treating anxiety symptoms associated with depression. However, physicians may focus on anxiety symptoms and fail to consider depression. A community study in the United Kingdom suggested that undiagnosed depression among persons aged 75 years and older was associated with prescription of tranquilizers, hypnotics, and analgesics.32
In contrast with drug therapy for depression, psychotherapy was less commonly thought to be efficacious for the older patient when compared with younger patients, and half of the physicians disagreed with the statement that psychiatric consultation was often helpful. Psychotherapy seems to be as effective for elderly patients as for younger patients.33-34 That few family physicians reported that they referred their older patients to psychiatrists for management of depression was not surprising, but it is disconcerting to consider that only half thought that consultation was generally helpful. Unfortunately, we cannot comment on what factors underlie the feeling that psychiatric consultation is often not helpful. Nonetheless, this raises an important area for future research, particularly in the face of recent efforts to increase collaboration between primary care physicians and mental health professionals.35-36
Shao et al20 assessed resident and faculty physicians associated with 2 university-based medical centers with regard to attitudes and behaviors related to depression, but did not focus on older patients. Of 138 generalists, of whom 111 were residents in training, 58% reported that they prefer to refer depressed patients to a mental health specialist. Also in contrast with our study, almost half of the generalists thought that the diagnosis of depression was stigmatizing. Consistent with our results, however, just 60% of the generalists noted that depressed patients were receptive to the diagnosis and 58% reported that they gave priority to medical problems when considering depression. About 60% of the generalist physicians were able to correctly answer multiple-choice questions about the minimum duration and efficacy of treatment with antidepressants. Callahan et al37 did focus on the diagnosis and management of depression in older primary care patients, but their survey was limited to 118 residents and 35 faculty internists. In that study, 55% of the internists felt confident in diagnosing depression in older patients, but only 35% felt confident in prescribing antidepressants. As expected, faculty physicians who presumably have more clinical experience reported fewer difficulties dealing with depression in older patients. Bowers et al21 found that general practitioners from Australia had limited knowledge of depression in older persons, but conclusions were severely limited by the small sample size of 36 physicians. Glasser and Gravdal22 surveyed 64 physicians in family practice and 66 physicians in internal medicine in Illinois and found that most physicians felt responsible for diagnosing and treating depression in older patients. Of the physicians returning the survey, 85% thought that greater emphasis was needed in medical training on the link between physical and mental health. Older physicians were more likely than younger physicians to agree that inquiring into the emotional status of their patients was intrusive. Attitudes about depression in late life expressed by the Illinois physicians were generally consistent with the responses of Maryland physicians reported here. For example, 50% said they do not focus on depression until they have ruled out physical illness (compared with 58% in our study). Banazak38 reported on a survey of primary care physicians done in Michigan that included 359 family physicians. In that study, failure of patients and their families to follow through with recommended treatment were seen as a major barriers to treating depression in late life. Among the Michigan physicians completing the survey, 41% were unaware of the depression guidelines from the Agency for Health Care Policy and Research.17, 39 Community-based physicians answering our survey seemed to be generally knowledgeable about the guideline-concordant duration of treatment for depression.
The primary care setting plays a key role in the care of older adults with mental disturbances, but identifying and managing depression in late life can be a challenge.26 We need to find ways to increase our effectiveness as primary care physicians in managing depression late adulthood if the disability associated with this important condition is to be limited. A better understanding of alternative presentations and approaches to evaluation and management of depression in older primary care patients are critical elements for future research in primary care settings.26, 40 At the same time, mental health professionals must consider the "ecology"41 of the primary care setting without preconceived notions about diagnosis and treatment based on experience in specialty settings. Family physicians, internists, and others who care for elderly patients strive to provide good mental health care to their patients in spite of the barriers.42 Shepherd et al43 concluded more than 30 years ago that the way to improve treatment for mental disorders in the community is to strengthen the therapeutic role of the general physician, and if the results of our survey among community-based physicians are any indication, such efforts will fall on fertile ground.
AUTHOR INFORMATION
Accepted for publication May 2, 1998.
This study was supported by a grant from the Maryland Academy of Family Physicians, Baltimore, and the American Academy of Family Physicians, Kansas City, Mo. Dr Gallo is a Brookdale National Fellow in Geriatrics.
We thank Esther Barr, executive director, Maryland Academy of Family Physicians, for her assistance.
Corresponding author: Joseph J. Gallo, MD, MPH, Department of Family Practice and Community Medicine, University of Pennsylvania, 3400 Spruce St/2 Gates, Philadelphia, PA 19104-4283 (e-mail: jgallo{at}welchlink.welch.jhu.edu).
From the Department of Mental Hygiene (Dr Gallo), and the Departments of Psychiatry and Behavioral Sciences (Dr Gallo) and Medicine (Drs Gallo and Ford), The Johns Hopkins University, Baltimore, Md; and the Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY (Dr Ryan).
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Psychosom. Med. 2003;65:931-937.
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Depression and Bipolar Support Alliance Consensus Statement on the Unmet Needs in Diagnosis and Treatment of Mood Disorders in Late Life
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Arch Gen Psychiatry 2003;60:664-672.
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Unrecognized Medical Disorders in Older Psychiatric Inpatients in a Senior Behavioral Health Unit in a University Hospital
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J Geriatr Psychiatry Neurol 2003;16:121-125.
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Older Adults' Acceptance of Psychological and Pharmacological Treatments for Depression
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TCAs vs SSRIs: Same Bang for Whose Buck?
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