title: Clinician burden and depression treatment: disentangling patient- and clinician-level effects of medical comorbidity.
abstract: BACKGROUND
  Efforts to improve primary care depression treatment have assessed strategies across heterogeneous groups of patients, but few have examined clinician-level influences on depression treatment.
  
  
  OBJECTIVE
  To examine clinician characteristics that affect depression treatment in primary care settings, using multilevel ordinal regression modeling to disentangle patient- from clinician-level effects.
  
  
  METHODS
  Secondary analysis from the Quality Improvement in Depression Study dataset.
  
  
  METHODS
  The participants were 1,023 primary care patients with depression who reported on treatment in the 6-month follow-up and whose clinicians (n = 158) had at least 4 patients in the study.
  
  
  METHODS
  Primary outcome variable was depression treatment intensity, derived from assessment of concordance with AHCPR depression treatment guidelines based on patient-reported data on their treatment. Primary independent variable was clinical practice burden for treating depression, derived from patient- and clinician-reported composite measures tested for significant association with clinician-reported practice burden.
  
  
  RESULTS
  Clinicians who treat patients with more chronic medical comorbidities perceive less burden from treating depressed patients in their practice (Spearman's rho = -.30, p < .05). Clinicians who treat patients with more chronic medical comorbidities also provide greater intensity of depression treatment (adjusted OR = 1.44, p = .02), even after adjusting for the effects of patient-level chronic medical comorbidities (adjusted OR = 0.95, p = .45).
  
  
  CONCLUSIONS
  Clinicians who provide more chronic care also provide greater depression treatment intensity, suggesting that clinicians who care for complex patients can integrate depression care into their practice. Targeting interventions to these clinicians to enhance their ability to provide guideline-concordant depression care is a worthwhile endeavor and deserves further investigation.
authors.affiliation: Department of Family Medicine, University of Colorado Denver, Aurora, CO, USA. Miriam.dickinson@uchsc.edu
authors.forename: L Miriam
authors.initials: LM
authors.lastname: Dickinson
authors.forename: W Perry
authors.initials: WP
authors.lastname: Dickinson
authors.forename: Kathryn
authors.initials: K
authors.lastname: Rost
authors.forename: Frank
authors.initials: F
authors.lastname: DeGruy
authors.forename: Caroline
authors.initials: C
authors.lastname: Emsermann
authors.forename: Desireé
authors.initials: D
authors.lastname: Froshaug
authors.forename: Paul A
authors.initials: PA
authors.lastname: Nutting
authors.forename: Lisa
authors.initials: L
authors.lastname: Meredith
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D002908:Chronic Disease / Q000523:psychology / Q000628:therapy*; D015331:Cohort Studies; D003866:Depressive Disorder / Q000150:complications / Q000628:therapy*; D037001:Directive Counseling / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010817:Physician-Patient Relations; D010821:Physicians, Family; D011320:Primary Health Care; D011785:Quality Assurance, Health Care; D016032:Randomized Controlled Trials as Topic; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012044:Regression Analysis; D016526:Workload