Do patient requests for antidepressants enhance or hinder physicians' evaluation of depression? A randomized controlled trial.
OBJECTIVE
We sought to ascertain whether patients' requests for antidepressants affect visit duration or history taking by primary care physicians (PCPs) for patients with depressive symptoms and a coexisting musculoskeletal disorder and to determine whether more thorough history taking is associated with diagnostic accuracy or with provision of minimally acceptable initial care for major depression.


METHODS
This was a randomized trial using standardized patients (SPs). Six roles involved 2 conditions (major depression and adjustment disorder, both with coexisting musculoskeletal conditions) and 3 patient request types (brand-specific, general, or none). We conducted the study in 152 PCP offices in Northern California and Rochester, New York. Physicians were assigned randomly to see 2 SPs with depression/wrist pain or adjustment disorder/back pain.


METHODS
Physician history-taking for depression and the musculoskeletal condition; depression diagnosis in the medical record; antidepressant prescriptions/samples; referral/follow-up recommendations; visit duration; and provision of minimally acceptable initial depression care.


RESULTS
General antidepressant requests were associated with more depression history-taking (Adjusted Parameter Estimate = 0.80 more questions of 10 (95% confidence interval = 0.31-1.29, P < 0.001); brand-specific requests were marginally associated with more depression history-taking (Adjusted Parameter Estimate = 0.45, 95% confidence interval = -0.04-0.93, P = 0.07). Antidepressant medication requests were not related to musculo-skeletal question asking (P > 0.3) or visit length (P > 0.8). Depression history taking was directly associated with the likelihood of a chart diagnosis of depression and the provision of minimally acceptable initial depression care.


CONCLUSIONS
General antidepressant requests increase depression history taking, including screening for suicide. Patients' requests for medication do not appear to short-circuit history taking for depression or distract the physician's attention from coexisting musculoskeletal conditions.
Feldman
Mitchell D
MD
Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, USA. mfeldman@medicine.ucsf.edu
Franks
Peter
P
Epstein
Ronald M
RM
Franz
Carol E
CE
Kravitz
Richard L
RL
D000275:Adjustment Disorders / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy; D000367:Age Factors; D000928:Antidepressive Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D003625:Data Collection / Q000379:methods; D003865:Major Depressive Disorder / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D008297:Male; D008487:Medical History Taking; D009140:Musculoskeletal Diseases / Q000150:complications / Q000175:diagnosis; D009819:Office Visits; D010358:Patient Participation; D010821:Physicians, Family / Q000523:psychology; D010818:Practice Patterns, Physicians' / Q000458:organization & administration; D012737:Sex Factors
D000928:Antidepressive Agents