Requests for Antidepressants Can Influence Physician Evaluation of Depression

Patients who initiate a general discussion about the need for antidepressant medication with their primary care physician are more likely to be thoroughly evaluated for depression than those who make a brand-specific request or no request, according to a new study in the December issue of Medical Care.

The study also found that general requests for antidepressants increased the likelihood that patients would be screened for the existence of suicidal acts or impulses.

The research was led by an investigator at the University of California, San Francisco (UCSF) in collaboration with researchers from the University of California, Davis and the University of Rochester.

In a previous study, the first controlled investigation of its kind, the research team had examined the clinical behavior of physicians faced with a patient request for antidepressant treatment. From this earlier study and others, the scientists found that patients' requests had a profound effect on physician prescribing habits regarding both major depression and the psychological condition known as adjustment disorder, which involves depression and anxiety in response to pain or a major event, such as illness or divorce, according to lead author Mitchell Feldman, MD, MPhil, professor of medicine at UCSF, and an internist at UCSF Medical Center.

"Our new research extends those findings by examining the impact of patient requests on the level of history-taking carried out by the physician and by exploring the association of history-taking with diagnostic accuracy as well as provision of acceptable initial care for depressed patients," he said.

The study was conducted with 18 "standardized patients" -- actors who are specifically trained to portray patients in medical education settings. Each "patient" portrayed a role involving one of two clinical presentations: major depression accompanied by carpal tunnel syndrome or an adjustment disorder accompanied by low back pain. The standardized patients were also trained to request an anti-depressant medication by brand name, or request a general anti-depressant, or not ask for medication.

A total of 298 visits to 152 internists and family physicians in four health care organizations in California and New York took place during the study. The physicians did not know that their appointments were with standardized patients as opposed to real patients, but they did give their permission to be part of the study and were told that the visits were audio recorded and would be examined for content following each interaction.

The researchers studied physician history-taking patterns, examining whether a diagnosis of depression was placed in the medical record, the length of the visit, and whether minimally acceptable initial depression care had been provided. Minimally acceptable depression care is defined as any combination of the following steps -- prescribing an antidepressant prescription, providing a mental health referral, or giving a follow-up visit within two weeks of the initial visit.

Study findings showed that requests for general antidepressant medication were associated with an increase in depression-specific history-taking by physicians. On average, physicians asked 0.80 more questions than if no request was made, while brand-specific requests were only marginally associated with an increase in questions (0.45 more questions).

"It may be that physicians see a request for a general medication as an invitation for further discussion about the diagnosis and treatment options, whereas brand-specific requests may be heard as a consumer demand for medical services in response to emotional persuasion rather than high-quality information," said Feldman.

A greater amount of time spent by the physician in depression history-taking was also directly associated with both the likelihood of a diagnosis of depression being made in the patient's medical record and the provision of minimally acceptable initial depression care.

Findings also showed that physicians obtained more extensive depression-related history from patients who portrayed major depression with carpal tunnel syndrome compared to those who portrayed an adjustment disorder accompanied by low back pain (6.7 questions compared to 5.2 questions).

Patient requests for medication did not appear to distract physician attention from treating the coexisting musculoskeletal conditions presented by patients in the study, and the researchers found no evidence to support the assertion that requests reflecting direct-to-consumer advertising distract the physician from taking a complete medical history. Instead, the research team concludes that a patient request for medication serves to increase the thoroughness of depression history-taking, including inquiries about suicide.

"Patients should be educated advocates for their own quality health care, but if they become over-focused on wanting a particular treatment rather than the most appropriate treatment in general, the result may be missed opportunities and diminished quality of care," Feldman added.