Family doctors and other primary care physicians are often the first health professionals to learn that a patient is depressed, but that doesn’t mean they identify all of the depression cases that walk through their offices.
Far from it: A new survey of California adults has found that 43% of people would keep their depression symptoms to themselves during a doctor’s appointment, because they feel their emotional difficulties are off-topic, they don’t want to be prescribed antidepressants, or they’re afraid a record of the conversation will be seen by employers.
The results aren’t especially surprising, but they do highlight the need to educate patients, doctors, and nurses about the importance of discussing mood problems during checkups and other routine appointments, says study coauthor Richard Kravitz, MD, a professor of internal medicine at the University of California, Davis.
“The primary care sector cares for a majority of patients with mental health conditions in America, and we know that depression is undertreated everywhere,” Dr. Kravitz says. “The number one reason for that is because recognition of depression starts with disclosure from the patient.”
Gerard Sanacora, PhD, a professor of psychiatry at the Yale University School of Medicine, says this study offers more evidence that the stigma surrounding mental illness is still an obstacle that prevents many people from seeking effective, timely treatment.
“I was actually surprised that even more people didn’t feel that it was a burden to talk to their doctor,” says Sanacora, who was not involved in the study. He suspects that if the survey hadn’t been conducted in California—one of the states most accepting of mental illness, he says—the patients would have been even more hesitant to discuss depression.
The National Institute of Mental Health funded the survey and analysis. The results were published today in the Annals of Family Medicine.
Kravitz and his colleagues surveyed 1,054 adults over the phone about their general health, access to doctors and insurance, demographics, and family and personal histories of mental health problems. The researchers then asked the respondents whether 11 potential reasons for not wanting to talk with a doctor about depression applied to them a little, a lot, or not at all. (The reasons were gathered from focus groups in a related study.)
The most common concern, which 23% of respondents said applied a lot to them, was that the doctor would recommend antidepressants. Other popular reasons were that it’s not a primary care physician’s job to deal with emotional issues (16%) and that their medical records could fall into the hands of an employer or another outside party (15%). Respondents also expressed fear about being referred to a specialist or being labeled a “psychiatric patient.”
The people who had the most to gain from talking with their doctor—individuals with moderate to severe depression symptoms at the time of the phone survey—subscribed to the most beliefs that would prevent them from doing so.
This reluctance among patients is crucial to overcome, Sanacora says, because the longer depression goes undiagnosed, the harder it can be to treat and the more permanent damage it can do. “There’s increasing evidence that the state of being depressed could actually be injurious to the brain,” he says. “Delaying treatment is probably the worst thing a patient can do for their mental health.”
Primary care physicians need to actively promote mental-health treatment in their offices, Dr. Kravitz says. “Putting pamphlets in the waiting rooms, using appropriate posters, or providing questionnaires to patients are all ways to show that depression lies within the scope of their practice,” he says.
Dr. Kravitz and his colleagues are also developing a public service announcement targeted toward high-risk demographic groups. In the survey, for instance, people who were female, Hispanic, had no family history of depression, and had less education or lower household income were all more likely than their peers to express reluctance about talking with their doctors.
Sanacora says that doctors can also do a better job at picking up on physical signs of depression that patients may be more vocal about, such as chronic pain, lack of appetite, and sleep problems.
“The emotional aspect is only a small part,” he says. “Physicians need to consider these other symptoms, and ask some pointed questions. That may eventually lead to more diagnoses.”