Abstract

Summary: Background: The aim of the present study was to examine the contribution of various patient factors to the detection of anxiety and depression within primary care.
Methods: This multicenter survey study was conducted in seven primary care practice settings across three Canadian provinces. Participants included 277 primary health care attendees who were diagnosed with depression and/or an anxiety disorder according to the Mini-International Neuropsychiatric Interview. Binary logistic regressions were conducted to determine which potential patient predictors (demographics, need variables, care related attitudes and disclosure) were significantly associated with correct physician detection of mental health problems.
Results: Findings indicated that patient disclosure was highly related to the probability of primary care physician detection. Patient attitudes toward mental health treatment and patient need variables were also significant determinants of being successfully identified by primary care physicians as suffering from these problems. Positive patient care-related attitudes and higher needs (presence of comorbidity and more physical illnesses) improved physician detection by promoting patient disclosure of anxiety and depression problems.
Conclusion: Future studies should continue to explore the contribution of patient factors leading to detection of psychological problems. As such, interventions to increase treatment access for those with anxiety and/or depression should focus on patient factors such as increasing rates of disclosures and improving needs variables and help seeking attitudes. These findings have important implications for improving treatment access for highly prevalent mental health problems in primary care.
Keywords: Mental health, primary care, disclosure, diagnosis, patient factors.
Citation: Marcus M, Westra H, Vermani M, Katzman MA. Patient predictors of detection of depression and anxiety disorders in primary care. J Participat Med. 2011 Mar 21; 3:e15.
Published: March 21, 2011.
Competing Interests: The authors have declared that no competing interests exist.

Introduction

Various characteristics of primary care physicians and their practices have been suggested as contributing to the under-detection of common mental health problems in primary care.[1][2][3] The literature on improving detection of these issues in primary care settings has predominantly focused on physician skills in assessing mental health problems.[3][4][5]
[6] While physician factors undoubtedly play a role, the authors believe that patient contributions to detection are likely substantive but have not been widely investigated as a potential cause of failure. Patients’ lack of disclosure of their mental health problems has been repeatedly documented in primary care[7][8] and, yet, the relationship to the detection of mental health problems has not been widely investigated. If a patient is not forthcoming about his or her symptoms, it would seriously hamper the physician’s ability to detect the existence of mental health problems and consequently serve to lower observed detection rates.

In an effort to understand patient contributions to detection in primary care, it is important to consider the many models of understanding access to mental health care (eg, Andersen’s behavioral model[9] or Becker’s Health belief model.[10]) According to the frequently cited Andersen model,[9][11] individual predictors of the use of services include predisposing characteristics, enabling resources, and perceived and evaluated need. Predisposing characteristics include demographic characteristics (ie, age, gender, marital status, and education)[4][12] and health beliefs .[13][14] Enabling factors (ie, income level) include social aspects that play a role in access to care. Perceived and evaluated need[15] is the patient’s or professional’s judgment of the severity of the patient’s illness, including symptom severity, comorbid mental health conditions[16] and physical diseases.[4][17][18] Existing research has typically focused on predisposing characteristics such as demographic variables[12] which have limited usefulness since they typically cannot be easily modified in order to increase mental health care utilization.[19]

Another predisposing characteristic, mental health beliefs, has been consistently found to have a substantive influence on help seeking behaviors and services use.[20]
[21][22] and health beliefs .[23][24] Despite their importance, very little research has examined how patient mental health beliefs or attitudes impact primary care physician detection of psychological problems. Predisposing psychological factors, such as patient mental health attitudes, may be of greater potential significance for promoting detection within primary care since there is a greater chance that they might be amenable to change through intervention.

The aim of the present study was to examine the contribution of various patient factors, especially less well-investigated variables, such as disclosure of mental health problems and care related attitudes, to the detection of anxiety/depression within primary care. Factors at each level of Andersen’s model[9] were investigated, together with patient disclosure, as predictors of primary care physician detection. Based on previous studies, the following hypotheses were proposed:

1. Patient attitudes towards mental health care will significantly predict detection beyond patient demographic and need variables, with more positive attitudes being associated with a higher probability of detection;
2. Patient disclosure will be a significant predictor of physician detection even beyond other patient factors (demographic, needs, and care related attitudes). That is, rates of detection will be significantly higher when patients disclose that they are suffering from psychological problems; and
3. Patient disclosure will mediate the relationship between patient factors and primary care physician detection. That is, it is expected that patient disclosure will be a consistent vehicle through which patient characteristics promote detection.

Methods

Sample

Of the 917 individuals who gave informed consent and participated in the study (approximately 75% of those approached), 277 (30%) currently met criteria for a clinically significant anxiety or depressive disorder. The sample thus consisted of these 277 individuals. Depression and anxiety disorders were selected for the present study, since they are among the most prevalent psychological problems presenting to a primary care physician.[18]
[25] Of these 277, 38.3% had Social Phobia (SP), 57.8% had generalized anxiety disorder (GAD), 17.0% had panic disorder (PD) and 61.7% had dysthymia and/or major depressive disorder (MDD). The sample consisted of 210 females and 67 males with an average age of 32 years. The 45.8% of the sample was of European descent and 76.9% had completed some or all of their post-secondary education. The majority of the sample was not married (72.9%) and 33.2% of the sample had an annual family income between $20,000-$60,000. Optimum Ethics Review Board, a Canadian Institutional Review Board, approved the study procedures for research with human subjects.

Methods of Recruitment

This multicenter survey study was conducted in seven primary care practice settings across three Canadian provinces: Ontario, British Columbia and Nova Scotia, between December 2005 and June 2006. All sites were selected by directly contacting the clinic director and meetings were then set up with each physician to enlist their cooperation and interest in the research. The sites that were contacted were based on a convenience sample of primary care clinics. At each participating site, all physicians signed consent forms and agreed to take part in the study. On various days, based on each clinic’s preference, all patients over the age of 18 years presenting for a visit to their family physician’s office who were able to give informed consent, were offered an opportunity to participate in the research. After complete description of the study to these potential participants, written informed consent was obtained.

Procedure and Measures

Prior to seeing their primary care physician, participants completed a demographic questionnaire and a scale assessing distress due to current mental health problems (the Mental Health Distress Scale).[26] They also completed the Inventory of Attitudes toward Seeking Mental Health Services,[27] which assessed their care related attitudes such as psychological openness, help-seeking propensity, and indifference to stigma. Finally, patients responded with “yes” or “no” to the following question: “I have discussed anxiety or mood with my current family physician.” A response of “yes” was considered to constitute disclosure of mood or anxiety problems to the primary care physician.

Following the patients’ visit with their primary care physician, the Mini International Neuropsychiatric Interview (MINI)[28] was conducted. The MINI is a short semi-structured diagnostic interview for major diagnoses within the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the International Statistical Classification of Diseases and Related Health Problems. The MINI has good reliability and validity that is comparable to other longer diagnostic interviews.[29] For example, a previous study demonstrated high reliability for major anxiety and mood disorders on the MINI; ranging from an inter-rater kappa coefficient of 1 for major depression to 0.98 for GAD and test/retest kappa of 0.87 for major depression and 0.78 for GAD.[29] The MINI interviews were conducted by four trained interviewers who each had previous training in conducting DSM-IV based diagnostic interviews.

Following the diagnostic interview, all participants (N = 277) who met current DSM-IV criteria for SP, GAD, PD(A), Dysthymia and/or MDD according to the MINI interview, completed four symptom severity self-report questionnaires. These measures included the Penn State Worry Questionnaire (PSWQ)[30] a measure which assesses the trait of worry, the Beck Depression Inventory II (BDI-II),[31] which assesses the severity of depression, the Anxiety Sensitivity Index (ASI)[32] used as an assessment of fears underlying panic disorder and the Mini Social Phobia Inventory (SPIN),[33] a screening instrument for generalized social anxiety disorder. In order to be conservative in the assignment of diagnoses, patients were only deemed to have a DSM-IV diagnosis of anxiety or depression if it was based on the MINI and had a clinically significant score on the self-report measure corresponding to the diagnosis. Participants diagnosed with SP on the MINI and scoring in the clinical range (two out of three) on the Mini-SPIN were considered to have SP.[33] Participants diagnosed with GAD on the MINI and scoring in the clinical range (score of 55 and above) on the PSWQ were considered to have GAD.[30] Participants diagnosed with PD(A) on the MINI and scoring in the clinical range (score of above 46) on the ASI were considered to have PD(A).[32] Lastly, participants diagnosed with Dysthymia and/or MDD on the MINI and scoring in the clinical range (score of above 15) on the BDI were considered to have a depressive disorder.[31]

Finally, after the diagnostic interview, trained clinical assessors searched the physicians’ notes within the patients’ medical chart and documented any mention of “social anxiety,” “generalized anxiety disorder,” “panic disorder,” “agoraphobia,” “dysthymia,” “depression,” “anxiety disorder,” or “mood disorder” over the past 12 months (not including the current visit). Correct physician detection was determined by agreement between the medical chart of the presence of an anxiety or depressive disorder and the presence of a clinically significant diagnosis, based upon the MINI and the self-report measures.

In order to determine the predictive value of medical comorbidity, the total number of physical illnesses identified in the chart in the past year were tallied. In addition, psychiatric comorbidity was defined by the presence of comorbid depression and anxiety. An overall standard psychiatric severity score was calculated by adding together the standardized severity scores on the ASI, PSWQ, BDI, and SPIN. Employment status was scored as either “yes” (working or in school full or part time) or “no” (not working or in school). Similarly, marital status was coded as “married/co-habiting” or “not married/co-habiting”.

Data analysis

Statistical analyses were carried out with SPSS version 14.0 for Windows. Given that a substantial number of participants had diagnoses of both anxiety and depression (43.5%), and that the main interest was in treatment access for common prevalent mental health problems, all analyses combined these two groups.

Results

Predictors of Primary Care Physician Detection

In a Binary Logistic Regression Analysis to predict accurate detection, patient predictor variables were entered in blocks with the low-mutability demographic variables (education, income, age, gender, marital status, employment and educational status) entered in block one, need parameters (self-reported severity, number of medical illnesses, psychiatric comorbidity, mental health distress) entered in block 2, mutable variables (care-related attitudes) added in block 3, and finally patient disclosure was added in block 4. See Table 1.

Table 1: Predicting Primary Care Physician Detection of Anxiety and Depression.

Being single, having more physical illnesses, the presence of psychiatric comorbidity, more positive attitudes toward help seeking, and having disclosed mental health symptoms to the primary care physician all contributed significantly to successful detection. Demographic variables accounted for the lowest percentage of variance (5.2-7.0%) across the four blocks of predictors. Both patients’ positive care related attitudes and disclosure accounted for a significant amount of the variance in predicting detection (Attitudes: 9.3-12.3%; Disclosure: 9.5-12.7%). Need parameters accounted for the largest amount of the variance in predicting detection (18.6-24.8%).

In summary, positive attitudes significantly predicted primary care physician detection, above and beyond the variance accounted for by demographic and need parameters. Moreover, patient disclosure of mental health problems was a significant predictor of primary care physician detection beyond patient demographic, need, and attitude variables. When care-related attitudes alone were entered separately into a logistic regression analysis, 63.3% of cases were correctly classified as detected and when patient disclosure was entered separately into a logistic regression analysis, 74.0% of cases were correctly classified as detected.

Rates of Primary Care Physician Detection & Patient Disclosure

Patient disclosure and primary care physician detection was also examined together in order to determine an estimate of the probability of detection with and without patient disclosure. The binary variables of patient disclosure (yes, no) and primary care physician detection (yes, no) were found to be significantly related, χ2 (1) = 69.452, p < 0.001; phi = .501. Primary care physician detection was found to be highly unlikely in the absence of patient disclosure as only 16.67% of those who failed to disclose their symptoms were correctly detected. And the probability of detection was substantially greater in the presence of patient disclosure, with 68.57% of those who reported discussing their symptoms with their primary care physician correctly detected.

Mediation Analyses: Care-Related Attitudes, Disclosure, and Detection

Patient factors (being single, increased psychiatric comorbidity, more physical illness, and more positive help-seeking attitudes) may be associated with better primary care physician detection as these factors facilitate patient disclosure. Thus, it was of interest to investigate patient disclosure as a possible mediator of the relationship between patient factors and detection. All mediation analyses were conducted following the steps outlined by Baron and Kenny.[34] Figures 1, 2, and 3 present the results of steps to test mediation for analyses in which mediation was supported. Three of the four significant predictors of detection were found to be mediated by patient disclosure.

Figure 1: Testing Patient Disclosure as a Mediator between Psychiatric Comorbidity and Primary Care Physician Detection.

 

Figure 2: Testing Patient Disclosure as a Mediator between Number of Physical Illnesses and Primary Care Physician Detection.

 

Figure 3: Testing Patient Disclosure as a Mediator between Help Seeking Attitudes and Primary Care Physician Detection.

As shown in Figure 1, step four of the regression analyses indicated that psychiatric comorbidity still significantly predicted detection, when controlling for the mediator, patient disclosure. This indicates partial mediation. Similar results were found for the number of physical illnesses, again supporting patient disclosure as a partial mediation. Patient disclosure was found to fully mediate the relationship between help seeking attitudes and primary care physician detection. In summary, a more severe psychiatric presentation (comorbidity), poorer medical status (higher number of illnesses), and more positive patient care related attitudes, promote primary care physician detection because they each increase the probability of patient disclosure of mental health problems. Moreover, greater comorbidity (psychiatric and medical) continues to be related to detection even beyond its facilitation of patient disclosure.

Discussion

The findings of the present study highlight the significance of patient predictors of primary care physician detection and may in part explain findings of previous studies suggesting relatively modest primary care physician detection rates,[35][36] since studies have generally not taken patient factors into account. As reflected in the present study, when patients were forthcoming about their symptoms, primary care physicians demonstrated high detection rates (68.57%). However, it was only under conditions where patients did not disclose their symptoms, that a drop in the rate of primary care physician detection (16.67%) was observed. Moreover, patient disclosure of mental health problems was a significant predictor of primary care physician detection beyond patient demographic, need, and attitude variables. And finally, factors such as the presence of comorbidity, poor medical status, and more positive care related attitudes were found to be related to increased detection through their impact in facilitating higher rates of patient disclosure of symptoms of anxiety or depression. These findings suggest that increasing patient disclosure of problems with anxiety or depression will increase accurate physician detection of these problems in primary care. That is, efforts to increase detection would do well to focus on facilitating patient disclosure.

There may be at least two ways of promoting patient disclosure of mental health problems in primary care: A focus on patient-centered care and improvement in patient attitudes toward care. Enhanced communication between patients and physicians has been associated with improved detection of patients’ mental health concerns and the quality of primary care.[37]
[38] Thus, one way that patient disclosure could be facilitated is through improvements in patient-centered care and physician-patient communication.[39][40][41] Indeed, engaging patients to be more active participants in their care also leads to increased satisfaction with care and improved access to adequate treatment.[42] A positive doctor-patient relationship may also help to shift patients’ views about the efficacy and value of treatment.[43][44] Additional efforts to improve patients’ attitudes may include interventions such as Mental Health First Aid training,[45][46] social marketing campaigns,[47] and contact with people with mental health problems.[48] These improvements in patients’ attitudes towards care and mental health literacy should also result in increased rates of help seeking, such as patient disclosure.[49][50][51]

In addition to patient disclosure, other patient factors in this study (being single, having more physical illnesses, the presence of psychiatric co-morbidity, more positive attitudes toward help-seeking) all contributed significantly to higher rates of successful detection. Need parameters (psychiatric comorbidity and more physical illnesses), accounted for more than triple the amount of variance compared to demographic variables in predicting detection, suggesting that physician detection is significantly influenced by patient symptom parameters. Findings that more complex patient symptom presentations (psychiatric and medical comorbidity) continue to predict primary care physician detection beyond their impact on patient disclosure further support the importance of symptom parameters in facilitating physician detection of mental health problems. In fact, past research has consistently found that somatic comorbidity and psychiatric comorbidity both result in an increased likelihood of depression being detected by a primary care physician.[52][53] The results of the present study move beyond these findings by demonstrating that, in part, need factors contribute to higher detection because they also promote patient disclosure of mental health symptoms.

As expected, positive patient attitudes toward help seeking were also associated with increased levels of physician detection, beyond the prediction attainable by knowledge of patient demographics and need variables. More positive attitudes were associated with higher rates of patient disclosure of problems with anxiety/depression and thus, higher rates of physician detection. From the present study, it appears that attitudes towards help seeking in particular, or “the extent to which individuals believe they are willing and able to seek professional help,[23]” is relatively more important than stigma or psychological openness. This suggests that a positive view of the value of treatment is essential to facilitating disclosure, and thus promoting primary care physician detection of mental health problems. Positive care-related attitudes are thus key factors to accessing treatment, largely through their facilitation of patient disclosure of anxiety/mood problems.

Limitations and Future Research

A number of limitations of this study are noteworthy. First, all variables were assessed simultaneously. Thus, since attitudes for example, were assessed at the same time as disclosure and detection, it cannot be asserted that attitudes preceded disclosure or detection, or if attitudes improved as a result of disclosing or being detected. Similarly, it is difficult to determine if patient disclosure resulted in physician detection or vice versa, as both actions were assessed concurrently. Future studies using longitudinal designs should attempt to determine the temporal sequence of care related attitudes, disclosure, and detection before more conclusive statements about mediation pathways can be advanced. Also, future studies should assess patient disclosure using other measures, beyond the single retrospectively reported item used in the present study. Lastly, given the lack of validity for the composite measure of psychiatric severity, future studies should ensure inclusion of valid measures of severity.

Conclusions

The findings from the present study highlight a central role for patients being active participants in their care and contributing to primary care physician detection, and consequently access to care. Moreover, the results also suggest a model of the processes involved in gaining access to treatment, which centers on patient disclosure. Future studies should continue to focus on patient factors, especially patient disclosure, need factors and help seeking attitudes, as key to leading toward improved treatment access for those suffering from mental health problems. It is recommended that to improve detection rates of mental health problems, physicians also focus on providing a safe place for patients to become more active participants in their care. This includes improvements in their relationships with their patients, increased continuity of care, and exploring with patients their apprehensions and fears, so that improvements can be made to patients’ attitudes towards care and ultimately to their disclosure.

Acknowledgements

The authors gratefully acknowledge financial support for this project from the Wyeth Pharmaceuticals’ Investigator Originated Proposals and the Canadian Institute of Health Research (CIHR), Graduate Training Award for the first author.

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Copyright: © 2011 Madalyn Marcus, Henny Westra, Monica Vermani, Martin A. Katzman. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the authors, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.