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ORIGINAL RESEARCH |
From the Group Health Cooperative, Eastside Hospital, Redmond, Washington.
Address reprint requests to: Anna LaRocco-Cockburn, Group Health Cooperative, Eastside Hospital, 2700 152nd Avenue NE, Mailstop D105, Redmond, WA 98052; E-mail: laroccocockburn.a{at}ghc.org.
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: A total of 282 obstetrician–gynecologists completed a 36-question mail survey that assessed attitudes regarding depression screening, training to treat depression, psychosocial concern, professional influence, and ease of screening.
RESULTS: Depression screening (employed regardless of signs or symptoms) was reported by 44% of physicians. Positive attitudes toward depression screening, high psychosocial concern, high ease of screening, and adequate training to treat depression were significant independent predictors of depression screening practices.
CONCLUSION: The majority of obstetrician–gynecologists are concerned about depression, believe depression screening is effective, and perform some degree of depression screening with their patients. However, they perceive depression screening as difficult to carry out in everyday practice, and some question whether screening improves outcomes
Depression is a common and disabling psychiatric disorder that is diagnosed two to three times more frequently in women than in men.1–4 Approximately one fourth to one third of women will experience a clinically significant depression during their lifetime, with depression being particularly common in women of childbearing age.5–8
Depression is often a recurrent illness and poses a significant public health burden because of increased morbidity and mortality in patients with depressive symptoms. Unrecognized depression can be especially serious, causing unnecessary medical evaluation, disability, medical illness, and increased mortality due to suicide or accidental death.9–11 Recent research has revealed associations between maternal depression and poor mother–child attachment and between maternal depression and impaired child cognitive development.12–14
Several authors have recommended screening of primary care patients for depression,15,16 and a number of studies have shown that depression screening leads to increased recognition of depression.15,17–20 However, the use of depression screening continues to be debated. Although some studies show improvement in patient outcomes with implementation of screening programs, others show measurable differences only in conjunction with collaborative care or quality improvement programs.21–25 Despite this controversy, the United States Preventive Services Task Force recently recommended screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up.26
Because of the high lifetime prevalence of depression in women, obstetrician–gynecologists will encounter depressed patients regularly in their practices.5,27 As women increasingly identify obstetrician–gynecologists as their primary physicians28–30 and are seen often during their reproductive years, this specialty may provide a suitable avenue for screening. The aims of this study were to estimate the frequency of depression screening, describe current attitudes regarding depression screening, and identify factors that positively or negatively affect the use of depression screening by obstetrician–gynecologists. We hypothesized that the following characteristics would determine the use of depression screening: attitudes toward depression screening, training to treat depression, general interest in psychologic and social aspects of patient health, professional influence such as American College of Obstetricians and Gynecologists (ACOG) recommendations and professional literature, and ease of screening measured by factors such as time constraints.
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MATERIALS AND METHODS |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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For the purpose of this study, depression screening was defined as follows: asking one’s own chosen questions about mood and/or mental health; using a validated set of screening questions; using a patient self-report screening tool; or using a structured clinical interview in patients regardless of signs or symptoms. A cross-sectional survey of practicing obstetrician–gynecologist members of Washington State ACOG was performed. Questionnaires were mailed to all 615 ACOG obstetrician–gynecologist members in April 2001. Second and third mailings of the questionnaire were sent to those who did not respond initially. We included all physicians who had a current office practice. We excluded physicians who were retired, exclusively administrative, exclusively surgical (no office practice), and those who actively refused to participate. The study protocol was approved by the University of Washington Human Subjects Division.
Variables for five characteristics hypothesized to be predictive of depression screening (attitude, psychosocial concern, professional influence, training, and ease of screening) were created by computing additive scores from Likert scales and creating cutoff points based on a median split. Scores above the median were indicative of positive attitudes, high psychosocial concern, positive professional influence, adequate training, and high ease of screening. A Cronbach 
was computed for each scale. The fifth variable, attitude toward appropriate training to treat depression, was measured by a single statement to which participants responded using a Likert scale.
Results of the questionnaire were analyzed using the Statistical Package for the Social Sciences 10.0 (SPSS, Chicago, IL). Descriptive statistics were used to characterize the overall population and groups based on self-reported screening practices (screen versus do not screen). Bivariate tests were used to examine associations between the five variables (attitude toward depression screening, psychosocial concern, professional influence, ease of screening, and training to treat depression) and depression screening. Differences in these variables between groups based on screening practices were examined using 
2 tests. Logistic regression analysis was used to determine the relationship between the five variables and depression screening. Age and primary care physician status were entered as covariates. Odds ratios (ORs) were derived for the probability of practicing depression screening given positive attitude compared with neutral/negative attitude, high psychosocial concern compared with neutral/low psychosocial concern, positive professional influence compared with neutral/negative professional influence, high ease of screening compared with neutral/low ease of screening, and adequate training compared with neutral/inadequate training to treat depression.
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RESULTS |
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Respondents had a (mean ± standard deviation) length of practice of 12.6 ± 9 years and age of 45 ± 9 years. Forty-nine percent of respondents practice in a private group partnership, and 68% reported they had attended a continuing medical education course in the last 5 years that included education on depression. Forty-one percent reported they considered themselves primary care physicians, and 6% of the respondents were medical residents. Seventy-seven percent lived in metropolitan areas, whereas 23% lived in small urban or rural areas.
Respondents were asked whether they conducted depression screening (regardless of signs or symptoms). Respondents could choose from four responses: never, sometimes, often, or always. Forty-four percent of respondents reported they often or always practice depression screening, 41% reported they sometimes screen for depression, and 15% reported they never screen for depression. When asked how they screen for depression, physicians were allowed multiple responses. Eighty-one percent reported they ask their own questions about mood or mental health, 32% reported they use a short, validated tool, 16% reported they use a validated patient self-report paper and pencil test, and 7% reported they use a validated interview.
Attitudes regarding the practice of depression screening were generally positive. Ninety percent of respondents agreed that screening "will improve the detection rate," and 79% agreed that screening "will result in early diagnosis and treatment" of depression. Eighty-four percent agreed that treatment for depression is effective; however, only 58% agreed that depression screening leads to improved treatment outcomes. Sixty-five percent of respondents agreed that obstetrician–gynecologists should screen for depression, and 73% agreed that depression in women is common enough to screen for in a systematic way. These six items constituted the scale measuring attitudes toward depression screening. Participants answered each question according to a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). A Cronbach of .8260 was computed, confirming a strong relationship between scale components.
Psychosocial concern varied among respondents. Physicians generally reported that patients desired their psychosocial problems be addressed, with only 24% stating that "my patients do not want me to investigate psychosocial problems" and only 13% stating that "my patients feel questions about the psychosocial aspects of their lives are irrelevant." Forty-eight percent, however, feared that "patients will become more dependent on me if I open up with psychosocial concerns," and 56% agreed that "consideration of psychosocial concerns requires more effort than I have to give." Half of respondents agreed with the statement, "I do not focus on psychosocial concerns until I have ruled out organic disease." These five items constituted the scale measuring psychosocial concern. Participants answered each question according to a 5-point Likert scale, and all questions in this scale were reverse scored. A Cronbach of .7438 was computed, confirming a strong relationship between scale components.
Physicians had varying beliefs regarding whether various professional factors have influenced them to engage in depression screening. More than 50% reported they were "neither influenced to screen or not to screen" by medical school training, residency training, discussion with colleagues, policy of employer or practice, and recommendation of professional organizations other than ACOG. Fifty-seven percent reported that ACOG influenced them to conduct depression screening, and 69% cited the professional literature as a supportive influence regarding depression screening. These seven items (medical school training, residency training, discussions with colleagues, professional literature, policy of employer or practice, recommendations of ACOG, and recommendation of other professional organizations) constituted the scale measuring professional influence. Participants answered each question according to a 5-point Likert scale. A Cronbach of .6787 was computed, confirming a moderately strong relationship between scale components.
Physicians generally agreed that ease of screening was a major factor in the decision whether to practice depression screening. Fifty-six percent of respondents agreed that screening all their patients for depression would be difficult. Seventy-three percent reported that time constraints or other demands would likely interfere with screening all patients for depression. Forty-seven percent agreed that depression screening in all of their patients would take too much time away from the patient appointment. These three items constituted the scale measuring the individual’s perception of ease or difficulty in performing depression screening. Participants answered each question according to a 5-point Likert scale, and two questions in this scale were reverse scored. A Cronbach of .8229 was computed, confirming a strong relationship between scale components.
Respondents were asked whether they agreed with the statement, "I feel I’ve had the appropriate training to treat depression." Forty-five percent disagreed with this statement, 24% neither agreed nor disagreed, and 32% agreed with this statement. This statement was used as an indicator of the respondent’s training to treat depression. Respondents answered this question according to a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree).
Associations between demographic characteristics and depression screening were examined using 2 tests. No demographic characteristics (years of practice, type of physician, practice setting, primary care provider status, continuing medical education course taken, age, or regional setting) were significantly associated with screening behavior (Table 1
). However, bivariate analyses showed that each of the five characteristics (attitude, psychosocial concern, professional influence, ease of screening, and training) was significantly related to depression screening (Table 2).
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). For this analysis, all significant variables (P < .05) from the bivariate analysis were entered into the regression as dichotomous variables. Age (continuous) and primary care physician status (dichotomous) were entered as covariates. Positive attitude toward depression screening, high ease of screening, high psychosocial concern, and adequate training were found to be significant independent predictors in the analysis. Professional influence was not a significant independent predictor of screening. After adjusting for age and primary care physician status, the probability of conducting depression screening by physicians with positive screening attitudes was OR = 2.9 (95% confidence interval [CI] 1.5, 5.4) as compared with physicians with neutral/negative screening attitudes; by physicians with high psychosocial concern was OR = 2.6 (95% CI 1.5, 4.7) as compared with physicians with neutral/low psychosocial concern; by physicians reporting high ease of screening was OR = 3.1 (95% CI 1.6, 5.8) as compared with physicians reporting neutral/low screening feasibility; and by physicians reporting adequate training to treat depression was OR = 2.2 (95% CI 1.1, 4.1) as compared with physicians reporting they did not have adequate training to treat depression.
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DISCUSSION |
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This study demonstrates that even though obstetrician–gynecologists recognize depression as a serious health issue and feel a responsibility to diagnose it, they are limited by time constraints, a lack of training to treat depression, and some uncertainty that screening improves outcomes. In a population of Washington State ACOG members who are practicing obstetrician–gynecologists, roughly half (44%) of the respondents reported they screen for depression. Respondent attitudes toward depression screening support this practice. The majority reported positive attitudes toward depression screening and agreed that obstetrician–gynecologists should routinely screen for depression. This is interesting in light of the fact that ACOG and other professional organizations have never made a formal recommendation that obstetrician–gynecologists conduct depression screening and that controversy exists in the literature regarding the usefulness of depression screening.20,21 When we compared screening practices with attitudes regarding depression screening, psychosocial concern, professional influence, and ease of screening, important differences arose. Physicians with positive attitudes toward depression screening, high psychosocial concern, and high ease of screening were significantly more likely to conduct screening than those with negative/neutral attitudes toward depression screening, low/neutral psychosocial concern, and low/neutral ease of screening. The findings that attitude regarding depression screening and psychosocial concern predicted screening practices is consistent with other studies that found physician attitudes predicted physician behavior.31,38,39 These data also support other study findings in which physician-perceived barriers, especially time constraints, made depression diagnosis and treatment difficult.38,40 The theme of time constraints was also strongly reflected in several qualitative comments made regarding depression screening.
Adequate training to treat depression was a significant predictor of depression screening. Though not significantly related to depression screening, younger age was significantly related to having received training to treat depression. Physician confidence to assess for and treat depression has been previously associated with training.41 With the advent of safer medications for the treatment of depression and a move toward primary care physicians as providers of comprehensive care, assessment and treatment of mood disorders has become a part of many medical school training programs. This may account for a significant relationship between younger age and training to treat depression.
In addition to training programs, the use of collaborative care programs that utilize physician extenders (such as nurses or mental health professionals to proactively follow patients, monitor outcomes, and help with scheduling return visits for patients with adverse outcomes) is key to improving treatment for depressed patients and may be one way to facilitate depression screening and effective treatment of depression in women of reproductive age. Further research should explore the optimum models of collaborative care that would be most effective in an obstetrician–gynecologist’s office as opposed to a primary-care setting. Given the unique needs of women and their higher rates of depression, the question arises whether screening for and treating depression based on a primary-care model is desirable. Education of obstetrician–gynecologists and development of a screening/treatment model will need to be tailored to the unique depression characteristics of women of reproductive age, especially given the risks and consequences of postpartum depression and depression during adolescence.
Until health systems evolve to a point where providers have the time, appropriate resources, and training to adequately identify and treat or refer depressed patients, provider uncertainty that routine depression screening leads to positive patient-level treatment outcomes will remain. Still, this study showed that the majority of obstetrician–gynecologists believe they have a responsibility to identify depression in practice, and nearly half already screen for it.
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Footnotes |
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doi:10.1016/S0029-7844(03)00171-6
Received August 5, 2002. Received in revised form November 8, 2002. Accepted November 13, 2002.
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REFERENCES |
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2. Myers J, Weissman MM, Tischler GL. Six-month prevalence of psychiatric disorders in three communities: 1908 to 1982. Arch Gen Psychiatry 1984;41:959–67.[Abstract]
3. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of psychiatric disorders in the United States: Results from the National Comorbidity Survey. Arch Gen Psychiatry 1994;51:8–19.[Abstract]
4. Weismann MM, Olfson M. Depression in women: Implications for healthcare research. Science 1995;269: 799–801.
5. Stotland NL, Stotland NE. Depression in women. Obstet Gynecol Surv 1999;54:519–25.[Medline]
6. Kemper KJ, Babonis TR. Screening for maternal depression in pediatric clinics. Am J Dis Child 1992;146:876–8.[Abstract]
7. Zuckerman BS, Beardslee WR. Maternal depression: A concern for pediatricians. Pediatrics 1987;79:110–7.
8. Desai HD, Jann MW. Major depression in women: A review of the literature. J Am Pharm Assoc 2000;40: 525–37.[Medline]
9. Fawcett J. The morbidity and mortality of clinical depression. Int Clin Psychopharmacol 1993;8:217–20.[Medline]
10. Wells KB, Steward A, Hays RD, et al. The functioning and well being of depressed patients: Results from the medical outcomes study. JAMA 1989;262:914–9.[Abstract]
11. Murphy JM, Monson RR, Olivier DC, Sobol MA, Leighton AH. Affective disorders and mortality: A general population study. Arch Gen Psychiatry 1987;44:473–80.[Abstract]
12. Murray L. The impact of postnatal depression on infant development. J Child Psychol Psychiatry 1992;33:543–61.[Medline]
13. Easterbrooks MA, Biesecker G, Lyons-Ruth K. Infancy predictors of emotional availability in middle childhood: The roles of attachment security and maternal depressive symptomatology. Attach Hum Dev 2000;2:170–87.[Medline]
14. Carter AS, Garrity-Rokous FE, Chazan-Cohen R, Little C, Briggs-Gowan MJ. Maternal depression and comorbidity: Predicting early parenting, attachment security, and toddler social-emotional problems and competencies. J Am Acad Child Adolesc Psychiatry 2001;40:18–26.[Medline]
15. Rucker L, Frye EB, Cygan RW. Feasibility and usefulness of depression screening in medical outpatients. Arch Intern Med 1986;146:729–31.[Abstract]
16. Magruder-Habib K, Zung WW, Feussner JR. Improving physicians’ recognition and treatment of depression in general medical care. Results from a randomized clinical trial. Med Care 1990;28:239–50.[Medline]
17. Iliffe S, Mitchley S, Gould M, et al. Evaluation of the use of brief screening instruments for dementia, depression and problem drinking among elderly people in general practice. Br J Gen Pract 1994;44:503–7.[Medline]
18. Gold I, Baraff LJ. Psychiatric screening in the emergency department: Its effect on physician behavior. Ann Emerg Med 1989;18:875–80.[Medline]
19. Zung WW. Role of rating scales in the identification and management of the depressed patient in the primary care setting. J Clin Psychiatry 1990;51:72–6.
20. Georgiopoulos AM, Bryan TL, Wollan P, Yawn BP Routine screening for postpartum depression. J Fam Pract 2001;50:117–22.[Medline]
21. Schade CP, Jones ER, Wittlin BJ. A ten-year review of the validity and clinical utility of depression screening. Psychiatr Serv 1998;49:55–61.
22. U.S. Preventive Services Task Force. Screening for depression in adults: Summary of the evidence. Ann Intern Med 2002;136:765–76.
23. Wells KB, Sherbourne C, Schoenbaum M, Duan N, Meredith L, Unutzer J, et al. Impact of disseminating quality improvement programs for depression in managed primary care: A randomized controlled trial. JAMA 2000; 283:212–20.
24. Katzelnick D, Simon G, Pearson S, Manning W, Kobak K Depression management programs. Arch Fam Med 2000; 9:689–70.
25. Lin EH, Katon WJ, Simon GE, Von Korff M, Bush TM, Rutter CM, et al. Achieving guidelines for treatment of depression in primary care: Is physician education enough? Med Care 1997;35:831–42.[Medline]
26. Agency for Healthcare Research and Quality. U.S. Preventive Services Task Force now finds sufficient evidence to recommend screening adults for depression.
27. Schmidt LA, Greenberg BD, Holzman GB, Schulkin J Treatment of depression by obstetrician-gynecologists: A survey study. Obstet Gynecol 1997;90:296–300.[Abstract]
28. Johns L. Obstetrics-gynecology as primary care: A market dilemma. Health Aff (Millwood) 1994;13:194–200.
29. Bell H. Showcasing primary care. Minn Med 1995;78: 8–14.
30. Hale RW. Women, obgyns and primary care: An essential relationship. J Med Assoc Ga 1994;83:559–62.[Medline]
31. Taylor VM, Montano DE, Koepsell T. Use of screening mammography by general internists. Cancer Detect Prev 1994;18:455–62.[Medline]
32. Ashworth CD, Williamson P, Montano D. A scale to measure physician beliefs about psychosocial aspects of patient care. Soc Sci Med 1984;19:1235–8.
33. Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemiol 1997;50:1129–36.[Medline]
34. Asch DA, Christakis NA, Ubel PA. Conducting physician mail surveys on a limited budget. A randomized trial comparing $2 bill versus $5 incentives. Med Care 1998;36: 95–9.[Medline]
35. Donaldson GW, Moinpour CM, Bush NE, Chapko M, Jocom J, Siadak M, et al. Physician participation in research surveys. A radomized study of inducements to return mailed research questionnaires. Eval Health Prof 1999;22:427–41.
36. McPhee SJ, Bird JA, Jenkins CNH, Fordham D. Promoting cancer screening. A randomized controlled trial of three interventions. Arch Intern Med 1989;149:1866–72.[Abstract]
37. Bandura A. Social learning theory. Englewood Cliffs, New Jersey: Prentice Hall, 1977.
38. Main DS, Lutz LJ, Barrett JB, Matthew J, Miller RS. The role of primary care clinician attitudes, beliefs, and training in the diagnosis and treatment of depression. Arch Fam Med 1993;2:1061–6.[Abstract]
39. Millstein SG. Utility of the theories of reasoned action and planned behavior for predicting physician behavior: A prospective analysis. Health Psychol 1996;15:398–402.[Medline]
40. Rost K, Humphrey J, Kelleher K. Physician management preferences and barriers to care for rural patients with depression. Arch Fam Med 1994;3:409–14.[Abstract]
41. Kaplan MS, Adamek ME, Martin JL. Confidence of primary care physicians in assessing the suicidality of geriatric patients. Int J Geriatr Psychiatry 2001;16:728–34[Medline]
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