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Competing Demands From Physical Problems
Effect on Initiating and Completing Depression Care Over 6 Months
Paul A. Nutting, MD, MSPH;
Kathryn Rost, PhD;
Jeffrey Smith, BS;
James J. Werner, MS;
Carl Elliot, MS
Arch Fam Med. 2000;9:1059-1064.
ABSTRACT
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Objective and Design To evaluate a cohort of patients with major depression to examine the effect of competing demands on depression care during multiple visits over 6 months.
Participants and Setting Ninety-two patients with 5 or more symptoms of depression and no recent depression treatment were evaluated by 12 primary care physicians in 6 practices in the usual-care arm of an effectiveness trial of the Agency for Health Care Policy and Research Depression Guidelines.
Main Outcome Measure Treatment was considered to be initiated if the patient reported starting a guideline-concordant antidepressant medication or making a visit for specialty counseling. Treatment completion was defined as either a 3-month course of guideline-concordant antidepressant use or completion of 8 or more specialty counseling visits.
Results Among the 92 patients reporting no recent treatment at study enrollment, 57% reported starting and 17% reported completing a course of guideline-concordant antidepressant medication and or specialty counseling at the 6-month interview. The severity of physical problems among patients with high enthusiasm for depression treatment decreased the odds that patients would initiate depression therapy. Severity of physical problems had no observable effect on completing depression therapy in the group of patients who initiated treatment.
Conclusions Physical problems compete with depression for attention over multiple visits in untreated patients who are enthusiastic about getting care for their emotional problems. Interventions are needed for this high-risk group, because depression treatment could potentially enhance patients' treatment of their physical problems.
INTRODUCTION
MOST DEPRESSION care is provided in the primary care setting, and there is ample evidence that patient outcomes can be improved with enhanced mental health care. Although there are a number of important barriers related to patient, physician, and health care system characteristics, there is also evidence that emotional problems often do not compete successfully for time and attention during the primary care visit.1 Primary care patients often present with multiple problems and concerns, all of which logically cannot be addressed in a single, time-constrained visit. There is little information on how physicians and patients implicitly make decisions about which problem(s) to address in a given visit, or which problems are addressed over a sequence of visits.
The construct of "competing demands" has been proposed to guide an understanding of how physicians and patients interact and address certain problems in primary care.1-5 The "competing demands" model suggests that patients and physicians bring an implicit agenda of issues to the primary care visit. In their interaction, they address some problems and leave other problems to subsequent visits, if addressed at all. The specific dynamics of the competing demands relationships for depression care have not been well studied, but represent a fruitful area of research that could lead to more effective and efficient strategies for providing evidence-based care for depression.
We have previously reported data from the "usual care" practices of an effectiveness trial of the Agency for Health Care Policy and Research Depression Guidelines in which we observed a strong competing effect of chronic physical problems as well as a new problems presenting during an index visit.1 To address the limitations inherent in the early study's cross-sectional design, we expanded the analysis to examine the effect of competing demands on initiating and completing depression treatment during a series of primary care visits over the first 6 months after enrollment. In this conceptualization, the severity of the physical problems the patient perceives competes with the severity of the emotional problems the patient perceives when deciding what problems need to be addressed during the visit. We hypothesized that in primary care patients with major depression the severity of physical problems would diminish, and the severity of emotional problems would enhance, the likelihood of initiating depression care. We further hypothesized that patient preferences for depression treatment would mediate the effects of both physical and emotional problems on the initiation of depression care. Lastly, because competing demands from physical problems may be less of an issue once depression is "on the radar screen," we hypothesized that severity of physical problems would not predict completion of depression treatment among those who initiated treatment.
MATERIALS AND METHODS
STUDY DESIGN
This report analyzes data from 6 primary care practices (12 participating physicians) in the usual-care arm of a study examining the effect of a primary care–based intervention to increase care of patients with major depression according to the Agency for Health Care Policy and Research Depression Guidelines.6-7 The study used stratified randomization to assign 12 primary care practices, each with 2 participating physicians, to an enhanced or usual-care condition. Administrative staff in each practice used a 2-stage screening process to recruit 20 depressed patients from a consecutively identified cohort of the patients visiting each of 2 participating physicians. The first-stage screening required 2 minutes for the patient to complete; patients who screened positive completed a second-stage screening that determined if the patient experienced 5 or more of the 9 symptoms of major depression over the past 2 weeks. Patients visiting a participating physician were eligible if they (1) reported 5 or more of the 9 criteria for major depression in the past 2 weeks on the Inventory to Diagnose Depression8; (2) screened negative for lifetime mania; (3) screened negative for alcohol dependence with current drinking9; and (4) did not meet Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)10 criteria for a bereavement-related depression. Patients were excluded if they were pregnant, postpartum, or breastfeeding, because the study tested an intervention addressing antidepressant medication treatment. In addition, practical considerations forced us to exclude a small number of patients with severe cognitive impairment, patients whose physical illness was too severe to complete screening, patients who could not read the screening test, patients with no telephone access, and patients who planned to seek most of their health care elsewhere during the next year. Immediately after patients were identified as eligible, the administrative staff invited them to participate in a longitudinal study seeking to understand more about what people who feel sad or uninterested in things decide to do about their condition.
The practices achieved a 77.4% participation rate of eligible, identified patients. Two hundred forty patients were enrolled in the usual-care condition, and 96 patients reported no recent depression treatment (antidepressant medication in the past month or psychotherapy within previous 6 months) at the baseline interview. Of these, 92 patients participated in the 6-month interview and provided the data for this analysis.
Physicians in the usual-care condition were not informed when their patients met criteria for major depression, but in some cases patients may have asked their physician questions about the study. All data reported in this manuscript were collected from patients using a structured telephone interview conducted immediately after the index visit, and 6 months later. Study enrollment procedures, including treatment of suicidal intent, were approved by the Human Research Advisory Committee of the University of Arkansas for Medical Sciences and the Colorado Multi-Institutional Review Board. An extensive description of the parent study's methods has been published.11
STUDY SETTING
Twelve primary care practices from 3 practice-based research networks (Ambulatory Sentinel Practice Network, Wisconsin Research Network, and the Minnesota Academy of Family Physicians Research Network) participated in the study. Eligibility criteria included (1) 2 primary care physicians willing to participate in the study; (2) a nurse willing to deliver the nursing intervention if randomized to the enhanced care condition; and (3) administrative staff willing to screen primary care patients for major depression as part of routine care. Practices in which primary care physicians could routinely refer patients with depression to on-site mental health specialists for treatment were excluded. Participating practices included 8 located in metropolitan and 4 located in rural areas. The 12 practices were located in Colorado, Michigan, Minnesota, New Jersey, North Carolina (n = 2), North Dakota, Oklahoma, Oregon, Virginia, and Wisconsin (n = 2). Although the physicians volunteering to participate in the study cannot be assured of being typical of the larger community of primary care physicians, studies from Ambulatory Sentinal Practice Network Inc have demonstrated no differences in patient characteristics12 or the clinical behavior of their primary care physicians, compared with the national probability sample of family physicians reported in the National Ambulatory Care Survey.13
DEFINITION OF MAJOR VARIABLES
Independent Variables
From patient-reported data, we developed 3-item scales to assess severity of both physical and emotional problems. Severity of physical problems was assessed by patient report of (1) the physical role functioning using the 36-Item Short-Form subscale,14 (2) the number of bed-days plus restricted activity reported caused by physical problems, and (3) the total number of physical comorbidities from a list, including diabetes, high blood pressure, arthritis, respiratory conditions, recent cancer, neurological conditions, stroke, congestive heart disease, coronary artery disease, back problems, irritable bowel disorder, thyroid disease, kidney failure, and eye disease. Severity of emotional problems was assessed by patient report of (1) their emotional role functioning using the 36-Item Short-Form subscale, (2) the number of bed-days plus restricted activity for emotional problems, and (3) depression severity as measured using a 23-item version of the Center for Epidemiological Studies Depression Scale,15 which was modified to measure DSM-IV10 symptoms for major depression during the past week.
Scales for both physical (Cronbach  = .64) and emotional (Cronbach = .69) problems were developed by standardizing each of the component variables on a 0 to 100 scale, and constructing the scale as a linear combination of the 3 components. Within each of the 2 scales, the correlation among the variables exceeded 0.30.
Patients' acceptance at baseline of both specialty care counseling and antidepressant medication was assessed by patient report using 4-point scales. Patients responded to the stems "How acceptable is it to you to use antidepressant drugs" and "How acceptable is it to you to seek one-on-one counseling from a mental health professional" with 1 of 5 response categories, including "definitely acceptable," "probably acceptable," "probably not acceptable," "definitely not acceptable," and "don't know." Values for these variables were imputed in 6 subjects who failed to answer the questions by assigning these subjects the most prevalent response. An acceptability of depression therapy variable was created for the analysis that distinguished those patients for whom either antidepressant medication or specialty counseling was reported as "definitely acceptable."
Dependent Variables
Two dependent variables were computed based on patient report at the 6-month interview. Treatment was considered to be initiated if the patient reported taking a guideline-concordant antidepressant medication or making a visit for specialty counseling. Treatment completion was defined as either a 3-month course of guideline-concordant antidepressant or completing 8 or more specialty counseling visits.
Covariates
The model included continuous measures of age and education, and dichotomous measures of sex, minority status, and marital status.
DATA ANALYSIS
We used a hierarchical approach to test the relationship of patient characteristics to whether depression treatment was initiated to during the time frame in clustered hierarchical linear models, nesting patients within providers and providers within practices. These models indicated that there were no significant differences among providers or practices, most likely a result of the limited variation among 12 physicians in 6 practices. The insignificant clustering effects allowed us to employ weighted logistic regression models to test the hypothesized relationships. We tested the mediating effect of acceptability of depression therapy on treatment initiation by introducing interaction terms into the model. We used the parameter estimates from the regression model to graph the relationship between the independent and dependent variables for each value of acceptability of depression therapy when the interaction term proved significant.
RESULTS
The 12 board-certified family physicians participating in the usual-care condition of study had a mean (SD) age of 43.3 (5.9) years, and were 67% male (n = 8) and 92% nonminority (n = 11). The 92 patients reporting no previous depression treatment at baseline had a mean (SD) age of 43.9 (12.8) years, and were 84% female (n = 77), 89% high school–educated (n = 82), and 14% minority (n = 13). Patients reported a mean (SD) of 6.7 (1.4) symptoms of major depression and 2.2 (1.8) physical comorbidities. After the index visit, patients reported that antidepressant medication (17% [n = 16]) and specialty care counseling (20% [n = 18]) were definitely acceptable. Over 6 months, the patients made on average 5.7 visits to their primary care physician. Among the 92 patients reporting no recent treatment at study enrollment, 57% (n = 52) reported initiating and 17% (n = 16) reported completing guideline concordant care by the 6-month interview. Of the 92 patients, 33 (36%) reported that either antidepressant medication or psychotherapy was definitely acceptable, and of these 22 (67%) initiated treatment and 9 (27% of total or 41% who initiated treatment) completed a course of guideline-concordant medication or psychotherapy. Among the 59 patients (64%) who reported less enthusiasm for depression thera py, 30 (51%) initiated and 6 (10% of total or 20% who initiated treatment) completed a guideline-concordant course of therapy.
Logistic regression models examining the main effects of physical and emotional comorbidity controlling for covariates identified no significant effects of physical or emotional problem severity on treatment initiation or completion. Logistic regression models testing the interaction of treatment acceptability with physical and emotional problems are shown in Table 1. The results confirmed our hypothesis that physical problems reduced the likelihood of initiating depression care over a 6-month period, but only for patients who reported depression treatment to be acceptable. The model failed to reach significance for completing treatment among those patients who initiated depression care. Educational level predicted completing, but not initiating therapy. It is reassuring to observe no racial disparities in the probabilities of either initiating or completing therapy in these multivariate models. Severity of emotional problems had no effect, independently or in interaction with treatment acceptability, on treatment initiation. Figure 1 demonstrates that as physical problems increase, the probability of initiating depression treatment falls, but only for patients who report that depression treatment is acceptable. A logistic regression model run separately for the patients reporting low acceptability of depression treatment failed to reach significance (P = .27).
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Logistic Regression Models Examining Predictors of Initiating and Completing Depression Therapy
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Figure 1. Mediating effect of acceptability of depression therapy on the relationship between concern for physical problems and probability of initiating and completing depression care.
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COMMENT
Our previous report demonstrates that physical comorbidity exerts strong competition for discussing or modifying depression care on a single visit. In this analysis, we observed a strong competing effect of physical comorbidity on initiating, but not completing, depression therapy during sequential visits over a 6-month period of observation. Physicians and patients make some progress working through competing demands over a sequence of visits (comparative data with previous report not shown), although the presence of physical comorbidities continues to impede initiation of depression care for many patients. Physical comorbidity exerted detrimental effect only in patients who report depression care is acceptable. Among patients less enthusiastic about depression treatment, increased physical comorbidity seemed to exert little additional competing effect. In contrast, physical comorbidity has no observable effect in completing a course of depression treatment in those patients who initiate care.
The competing demands model suggests that patients and physicians bring an implicit agenda of issues to the primary care visit. Their interaction, modified by patient, physician, visit, and health system factors, results in attention to some problems with other problems left to subsequent visits if addressed at all. We propose an expansion of the model to emphasize the effect of critical components of the patient's agenda as depicted in Figure 2. The patient's perceived severity of the depression will increase initiation of depression care, while the patient's perceived severity of comorbid physical problems will decrease it. Patient beliefs about depression (eg, whether the emotional problem is a "legitimate medical concern," whether the primary care physician is a logical source of advice and care, and whether available treatments for depression are acceptable) will mediate the competition between physical and emotional problem severity. In our data, patient lack of enthusiasm for antidepressant or psychotherapy effectively shortened the lever arm against which patient perceptions of their physical and emotional problems could exert their influence on the likelihood of depression care.
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Figure 2. The competing demands model, showing the relationships among patient preferences and perceptions of emotional and physical problem severity.
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We had expected that patients' perception of the severity of emotional problems would enter the logistic regression model as well by enhancing likelihood of depression care. In our data, however, emotional problem severity had no effect on treatment initiation. We constructed a scale to capture emotional problem severity that was similar to and would seem to be as robust as that constructed for physical problems, but failed to observe a direct effect or an interaction with acceptability of depression therapy. Similarly, our previous report1 and other studies have not observed a direct effect of depression severity during a single visit. We suspect that we have not conceptualized important indicators of this relationship, or measured those indicators we have conceptualized with sufficient precision. Further research should examine these relationships more carefully to better inform the development of interventions for those most in need.
In the absence of further research data, we acknowledge we may not have captured the most salient features of physical problems. For example, sudden onset or acuity of a single physical problem may be a much more important predictor of diversion of physician and patient attention than the number of comorbid conditions as measured in our study. While physical problems potentially increase the number of visits a depressed patient makes, and thus provide greater opportunity for patients and physicians to address the problem of depression, it is important to note that greater numbers of visits do not increase the probability that depression treatment will be initiated.16-17 Further research that clarifies the mechanisms by which physical problems seem to compete with depression care can inform interventions that assist physicians and patients in setting rational priorities among multiple health care needs. Although our data suggest competition between care for physical problems and depression, future work should seek to reveal win-win intervention opportunities. For example, the co-occurrence of diabetes and major depression18 might afford opportunities to develop interventions that address depressive symptoms with accompanying improvements in diabetes outcomes.
The strengths of this study include the ability to evaluate over time a cohort of previously untreated depressed patients who were not selected into the study based on willingness to participate in a treatment protocol. The study also used a newly emerging method that allows us to distinguish between untreated and treated cases of depression19 in examining the relationship of competing demands on the initiation and completion of high-quality depression treatment. We do, however, acknowledge the study's limitations, associated with the relatively small patient sample, exclusion of a small number of patients too ill to participate, imputation of treatment acceptability data for 6 subjects, and the possibility of selection bias among the physicians and practices volunteering to participate in the study that may present a "best case" scenario for depression care.
A better understanding of how patients and physicians set agendas for primary care among a number of competing health issues is needed to develop interventions that improve depression care in the context of the patient's total need for health services.20 Effective interventions will require a better understanding of how patients and physicians set priorities for services, how patient preferences are elicited and negotiated, how priorities are identified and determined during the primary care encounter, and how a large number of disparate issues are addressed sequentially over a series of visits. We would hope that strategies that assist physicians and patients in being more explicit in negotiating an agenda of care issues to be addressed would lead not only to improved depression care, but to improvements in care for a broad spectrum of chronic health problems.
AUTHOR INFORMATION
Accepted for publication September 14, 2000.
Supported by grants MH49116, MH54444, and P50 MH48197 from the National Institute for Mental Health, Rockville, Md, and a grant from the John D. and Catherine T. MacArthur Foundation, Chicago, Ill (Dr Rost).
We thank Marcia Blake, Nancy Burris, Byron Burton, Naihua Duan, Carl Elliott, Linda Freeman, Debbie Hodges, Barbara Howard, Joylyn Humphrey, JoAnn Kirchner, Kathryn Magruder, Susan Moore, Cynthia Moton, Jody Rath, Becky Saddler, Melonie Shelton, and Margaret White; and the the physicians, nurses, office staff and patients of the participating primary care practices: Chatham Primary Care, Siler City, NC; Dunes Family Health Care, Reedsport, Ore; Eau Claire Family Medicine, Eau Claire, Wis; Enid Family Medicine Clinic, Enid, Okla; Fergus Falls Medical Group, Fergus Falls, Minn; Health East Eastside Medical Center, St Paul, Minn; Lynchburg Family Practice, Lynchburg, Va; Mile Bluff Clinic, Mauston, Wis; Mountain Area Family Health, Asheville, NC; Northern Colorado Family Medicine, Greeley; Oakwood Health Care Center, Westland Family Practice, Westland, Mich; Somerset Family Practice, Somerville, NJ; and University of North Dakota Center for Family Medicine, Minot.
Corresponding author: Paul A. Nutting, MD, MSPH, Center for Research Strategies, Suite 1150, 225 E 16th Ave, Denver, CO 80203 (e-mail: Paul.Nutting{at}JFamPract.com).
From the Department of Family Medicine (Drs Nutting and Rost and Messrs Smith and Elliot), Program in Health and Behavioral Science (Mr Werner), University of Colorado Health Sciences Center, and the Center for Research Strategies (Dr Nutting), Denver, Colo.
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