title: Barriers to initiating depression treatment in primary care practice.
abstract: OBJECTIVE
  This study used qualitative and quantitative methods to examine the reasons primary care physicians and nurses offered for their inability to initiate guideline-concordant acute-phase care for patients with current major depression.
  
  
  METHODS
  Two hundred thirty-nine patients with 5 or more symptoms of depression seeing 12 physicians in 6 primary care practices were randomized to the intervention arm of a trial of the effectiveness of depression treatment. Sixty-six (27.6%) patients identified as failing to meet criteria for guideline-concordant treatment 8 weeks following the index visit were the focus of this analysis.
  
  
  METHODS
  The research team interviewed the 12 physicians and 6 nurse care managers to explore the major reasons depressed patients fail to receive guideline-concordant acute-phase care. This information was used to develop a checklist of barriers to depression care. The 12 physicians then completed the checklist for each of the 64 patients for whom he or she was the primary care provider. Physicians chose which barriers they felt applied to each patient and weighted the importance of the barrier by assigning a total of 100 points for each patient. Cluster analysis of barrier scores identified naturally occurring groups of patients with common barrier profiles.
  
  
  RESULTS
  The cluster analysis produced a 5-cluster solution with profiles characterized by patient resistance (19 patients, 30.6%), patient noncompliance with visits (15 patients, 24.2%), physician judgment overruled the guideline (12 patients, 19.3%), patient psychosocial burden (8 patients, 12.9%), and health care system problems (8 patients, 12.9%). The physicians assigned 4,707 (75.9%) of the 6,200 weighting points to patient-centered barriers. Physician-centered barriers accounted for 927 (15.0%) and system barriers accounted for 566 (9.1%) of weighting points. Twenty-eight percent of the patients not initiating guideline-concordant acute-stage care went on to receive additional care and met criteria for remission at 6 months, with no statistical difference across the 5 patient clusters.
  
  
  CONCLUSIONS
  Current interventions fail to address barriers to initiating guideline-concordant acute-stage care faced by more than a quarter of depressed primary care patients. Physicians feel that barriers arise most frequently from factors centered with the patients, their psychosocial circumstances, and their attitudes and beliefs about depression and its care. Physicians less frequently make judgments that overrule the guidelines, but do so when patients have complex illness patterns. Further descriptive and experimental studies are needed to confirm and further examine barriers to depression care. Because few untreated patients improve without acute-stage care, additional work is also needed to develop new intervention components that address these barriers.
authors.affiliation: Center for Research Strategies, Suite 1150, 225 E 16th Avenue, Denver, CO 80203, USA. Paul.Nutting@CRSLLC.org
authors.forename: Paul A
authors.initials: PA
authors.lastname: Nutting
authors.forename: Kathryn
authors.initials: K
authors.lastname: Rost
authors.forename: Miriam
authors.initials: M
authors.lastname: Dickinson
authors.forename: James J
authors.initials: JJ
authors.lastname: Werner
authors.forename: Perry
authors.initials: P
authors.lastname: Dickinson
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Smith
authors.forename: Beth
authors.initials: B
authors.lastname: Gallovic
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000928:Antidepressive Agents / Q000008:administration & dosage*; D001291:Attitude of Health Personnel; D016000:Cluster Analysis; D015331:Cohort Studies; D003625:Data Collection; D003866:Depressive Disorder / Q000175:diagnosis / Q000188:drug therapy*; D005194:Family Practice / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D017408:Guidelines as Topic; D006801:Humans; D008875:Middle Aged; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care / Q000379:methods; D012720:Severity of Illness Index; D014481:United States
chemical_list: D000928:Antidepressive Agents