Reinvention of Depression Instruments by Primary Care Clinicians

Abstract

PURPOSE Despite the sophisticated development of depression instruments during the past 4 decades, the critical topic of how primary care clinicians actually use those instruments in their day-to-day practice has not been investigated. We wanted to understand how primary care clinicians use depression instruments, for what purposes, and the conditions that infl uence their use.METHODS Grounded theory method was used to guide data collection and analysis. We conducted 70 individual interviews and 3 focus groups (n = 24) with a purposeful sample of 70 primary care clinicians (family physicians, general internists, and nurse practitioners) from 52 offi ces. Investigators' fi eld notes on offi ce practice environments complemented individual interviews. RESULTSThe clinicians described occasional use of depression instruments but reported they did not routinely use them to aid depression diagnosis or management; the clinicians reportedly used them primarily to enhance patients' acceptance of the diagnosis when they anticipated or encountered resistance to the diagnosis. Three conditions promoted or reduced use of these instruments for different purposes: the extent of competing demands for the clinician's time, the lack of objective evidence of depression, and the clinician's familiarity with the patient. No differences among the 3 clinician groups were found for these 3 conditions. CONCLUSIONS Depression instruments are reinvented by primary care clinicians in their real-world primary care practice. Although depression instruments were originally conceptualized for screening, diagnosing, or facilitating the management of depression, our study suggests that the real-world practice context infl uences their use to aid shared decision making-primarily to suggest, tell, or convince patients to accept the diagnosis of depression. Ann Fam Med 2010;8:224-230. doi:10.1370/afm.1113. INTRODUCTIOND epression is a highly prevalent, disabling, and costly public health condition in the United States, 1-3 and more than one-half of people with mental health issues receive care from primary care clinicians. 4 Despite decades of research, there remains a gap between ideal care for depression and actual outcomes in primary care settings. 5,6 One strategy for enhancing depression management has been the development of depression instruments to help diagnose, stratify the severity of, and evaluate the treatment of depression. Since the development of the Hamilton Rating Scale for Depression, 7 the Beck Depression Inventory, 8 and the Zung Self-Rating Depression Scale 9 in the early 1960s, continued work in the development of depression instruments has led to the availability of numerous depression instruments today.It is nearly impossible to identify all the depression instruments available today or to describe each instrument's purposes and performance. Salient dimensions of development efforts, however, have been the testingretesting of performance and comparing the instruments' psychometrics R EINV EN T ION O F DEPR ES SION ...

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