Geriatric depression assessment by rural primary care physicians

Introduction: Depression is the fourth leading cause of the global disease burden, and approximately one in four elderly people may suffer from depression or depressive symptoms. Depression in later life is generally regarded as highly treatable, but undertreatment is still common in this population, especially among those in rural areas where access to healthcare is often an issue. In this study rural primary care physicians’ practices, attitudes, barriers and perceived needs in the diagnosis and treatment of geriatric depression were described, and trends in care delivery examined. Methods: A survey was sent to 162 rural Illinois family physicians and general internists. The survey focused on current practices, attitudes and perceptions regarding geriatric depression, barriers to and needs for improvement in depression care and physician and practice characteristics. Results: Seventy-six physicians (47%) responded. The rural physicians indicated that over one-third of their patients aged 60 years and older were depressed. All reported routine screening for depression, with 24% using the Beck Depression Inventory. Overall, physicians expressed positive attitudes about their involvement in treating older depressed patients. However, 45% indicated a ‘gap’ between ideal and available care in their rural practices. Physicians with higher proportions of elderly patients in their panels were more likely to feel that more training in residency in geriatric care would be helpful in improving care, and that better availability of psychologists and counselors would be important for improvement of care for older, depressed patients.


Introduction
Depression is the fourth leading cause of the global disease burden 1 .By 2020, depression will be second only to heart disease in its contribution to the global burden of disease in relation to disability-adjusted life years 2 .Several studies have shown that up to 23% of elderly patients suffer from depression or depressive symptoms 3,4 .Although major depression is relatively rare in the population of older adults, minor depressive symptoms are particularly common in later life.Importantly, the consequences of these minor depressive disorders for the well-being and functioning of older adults seem to be similar when compared with major depressive disorders, contributing to adverse effects on quality of life 5,6 .
Depression in later life is generally regarded to be highly treatable, but under-treatment is still common in this population [7][8][9][10][11][12][13] .Up to 20% of people attending primary healthcare providers in developing countries suffer from the often-linked disorders of anxiety and depression, but symptoms of these conditions often go unrecognized, with under-reporting of depression being a major problem worldwide 1 .Additionally, past research has shown that only 35% of those with depression receive treatment 14 .Based on a convenience sample of 482 primary care visits by patients 65 years and older, Adelman and colleagues found that depression was discussed in only 7% of medical visits 15 .The researchers note that this low figure could be related to the cross-sectional design of their study; nonetheless, they express surprise at the low rate of depression discussion in a population where depression is prevalent.Given that the majority of depressed elderly people are treated in the primary care sector 8,[16][17][18][19] , and that depressed older patients are more than twice as likely as non-elderly patients to visit their primary care physician at least once a month, even after controlling for co-morbidities 20 , it is critical to better understand how primary care physicians approach and treat depression in their older adult patients 21 .
The treatment of depression in older adults by primary care physicians may be especially important in rural regions, where ready access to healthcare providers is an issue.For instance, in the USA, while more than 20% of the population lives in places defined as rural, only 9% of all physicians practice in these communities 22,23 .However, the greatest need may be in rural America, where patients have rates of suicide and major depression equal to or slightly higher than their urban counterparts [24][25][26] .The disparity in mental health services between rural and urban areas is a major concern 27,28 .To improve mental health care in rural areas, it is important to examine and understand the barriers and needs that primary care physicians experience in their care of depressed elderly people.

Study population
The present study focused on rural Illinois primary care physicians: family physicians and general internists.Surveys were sent to a convenience sample of 68 primary care physicians affiliated with 6 different hospitals in rural Illinois, and to all 94 graduates and preceptors of the Rural Medical Education (RMED) Program of the University of Illinois College of Medicine at Rockford.This represents a sample of approximately 25% of rural family and general practice physicians in Illinois.

Instrument
The data collection instrument consisted of a four-page survey composed of 5 parts, based on an earlier survey of primary care physicians 29

Data collection
All physicians in the study sample were initially contacted by mail, which included the survey instrument, a personalized cover letter stating the purpose of the study, a pre-addressed, stamped return envelope and a postcard.The physicians were requested to either fill out the written survey or were given the option to complete the survey online at a designated website location, as an option to the written questionnaire.A second wave of surveys, accompanied by a reminder letter, was sent after 3 weeks.Additionally, 1 week after the second mailing, randomly selected non-respondents received an email or telephone call to request the physician to complete the survey.

Analysis
Data were analyzed using SPSS statistical software (SPSS; Chicago, IL, USA; www.spps.com).Univariate analysis described physicians' current practices, attitudes toward geriatric depression, experienced barriers and needs to improve the diagnosis and treatment of depression in the geriatric population.Chi-square tests, independent t-tests and F-tests, as appropriate, were used to assess possible differences in physicians' responses related to the demographic variables of age and sex, and the practice characteristic of proportion of elderly patients in the physicians' patient panels.

Results
A total of 76 rural primary care physicians (47%) responded to the survey.Demographic and practice characteristics of the responding physicians are presented (Table 1).More than 90% of responding physicians were family doctors.Most were male (59.2%) and the mean age was 40 years (SD = 10.2).
Thirty percent of the doctors reported practices where over 50% of their patients were older adults (over the age of 60).
In response to the question 'About what percent of your patients do you estimate to be depressed?'most physicians (47.4%) estimated the percentage of depressed patients in their practices as 25% or less, but over one-quarter reported greater than 25% depressed patients.The figure increased to approximately one-third for depressed patients over the age of 60.There was a strong correlation between overall estimate of depressed patients in the physicians' practices and percentage of older adults with depression (r = .80;p <.001).
Nearly 45% of the physicians indicated having attended continuing medical education programs relating to older adult healthcare within the past year.And almost three-fifths of the physicians were involved in teaching medical students and/or residents.In terms of building mental health capacity within their own practices, five physicians (6.6%) indicated that psychologists or counselors were on-site in their clinics, and four physicians (5.3%) were certified in geriatric medicine.
Physician practices in depression screening and treatment: All responding physicians indicated they routinely screened for depression in their older patients.
Information is presented on the symptoms these rural primary care physicians used in conducting screenings, as well as tests or interviews in the diagnosis of depression in older adults (Table 2).Six symptoms were identified by 90-100% of the physicians as used in screening for depression in their patients: sad mood; loss of interest/pleasure; decreased energy; anxiety/irritability; sleep disturbance; and multiple worries/distress.The symptom least often mentioned in relation to depression screening was pain (45%).On average, the physicians indicated approximately 9 symptoms considered in the screening and diagnosis of depression in older patients.
Sixty-one percent of the primary care physicians reported that they did not use a standard test or screening instrument for depression diagnosis.When a depression assessment instrument was used, most often mentioned was the Beck Depression Inventory (24%), followed by the Geriatric Depression Scale.The Mini-Mental State Exam (29%) was also commonly used to evaluate geriatric patients.
In establishing a new diagnosis of depression in elderly patients, laboratory tests most often used to screen for causes other than depression were for thyroid stimulating hormone (84%), a complete blood count (75%) and a comprehensive metabolic profile (41%).Specific medications most often mentioned in the treatment of depression were escitalopram (47%) and sertraline (30%).Besides medications, counseling was reported by the majority of physicians (80%) as another treatment modality.Exercise (12%), social activities (7%) and psychotherapy (7%) were mentioned considerably less frequently.
When asked 'Do you use clinical guidelines for diagnosis and treatment of geriatric depression?' 10 of the primary care physicians (13%) responded yes.Forty percent of the doctors indicated that they routinely gave patient education materials to those suspected of being depressed or diagnosed with depression.When asked about a gap between the treatment physicians preferred and availability of that treatment, 45% somewhat or strongly agreed that a gap existed.To some extent this view was related to the age of the patient panel, where primary care physicians with higher proportions of patients aged 60 years and older were more likely to agree that there were gaps between available and preferred treatment of depression in older adults (42.3% vs 35.1% of patients >60; p = .081).

Physician attitudes towards depression diagnosis and management:
As presented (Table 3), all of the rural physicians agreed that helping depressed patients was important to them.Further, nearly all the physicians (99%) agreed that they felt confident in accurately diagnosing depression in the elderly.This confidence carried over into diagnosis and treatment of depression and prescription of antidepressants in the elderly, with 97% and 89% of physicians, respectively, reporting confidence in their abilities in these areas.Consistent with these perceptions, all the physicians agreed that diagnosis and treatment of depression in elderly patients was their responsibility as primary care doctors.Additionally, 92% of the physicians agreed that treating depressed patients is an aspect of practicing medicine that is rewarding, and no physician agreed with the statement that there is nothing that can be done for older patients with depression.In this regard, 96% of the physicians agreed with the view that elderly patients expect primary care physicians to deal with depression in their patients.Eighty-six percent of the rural physicians disagreed that they were too pressured for time to routinely investigate depression in their older patients, including 32% who strongly disagreed.Similarly, 76% disagreed that elderly patients have so many problems that the physician does not always have time to consider depression.For the most part, the primary care physicians disagreed that depressed, older patients frustrated them (84%).Ninety percent of the physicians disagreed that it is preferable not to use the term depression because it potentially labels or stigmatizes the patient.Finally, only 3% of physicians agreed that they would send elderly patients for a psychiatric consult, rather than diagnose and treat depression themselves.
In relation to attitudes toward treatment modality as well as involvement of family members, 93% of the physicians felt that psychotherapy can help depressed elderly patients.The physicians also tended to disagree (77%) that psychotherapy is less efficacious for older, compared with younger, patients.The majority of the physicians (94%) felt comfortable dealing with family members of depressed patients, with 99% indicating that family member information was useful in the diagnosis of depression in older adults.Consequently, 88% of the rural doctors agreed that family members should be included in decisions and plans about the treatment and management of depression in their elderly patients.
Overall, related to physicians' attitudes and perceptions, there was a mixed reaction to caring for older patients with depression currently, compared with 5 years in the future.Over half (54%) disagreed that in 5 years, caring for elderly patients with depression would be more important than at present.
In my experience, family member information is useful in diagnosing depression in older patients.Future needs and directions in the care of older, depressed patients were assessed by physician responses to a list of 15 items that could be helpful in improving their ability to care for depressed, geriatric patients.All but three of the responding physicians agreed that it would be helpful or very helpful to have a better availability in rural areas of psychologists and counselors for improving care for older patients with depression (Table 5).This was followed most closely by increased time to spend with patients, improved patient compliance with treatment and increased reimbursement for counseling services.Also highly evaluated in terms of helpfulness for patients was location of mental health services in primary care offices.At the level of physician education, evaluated as potentially helpful were: greater emphasis in training on the link between mental and physical health; greater emphasis in residency training on geriatric mental health; and availability of continuing medical education conferences on geriatric depression.
Better relationships with referral colleagues was interesting in terms of distribution of responses -50% of the physicians, respectively, reported that better referral relationships would be not at all/possibly helpful versus helpful/very helpful.
Viewed as least helpful in patient care was the availability of telephone hotline or consulting services.
These needs and directions (Table 5), were examined in relation to the earlier question of primary care physicians' views of a possible gap between available care in the rural setting and preferred treatment practices by the physicians.Physicians who responded that they agreed there was a gap between available and preferred treatments were also more likely to indicate: there should be better availability of psychologists and counselors (p = .003);there should be greater emphasis during training on the link between physical and mental health (p = .021);and there should be increased reimbursement for counseling (p = .057).

Attitudes and reports of behavior by physician age, gender and proportion of patient panel 60 years and older:
Also examined were physicians' reported practices and perceptions and attitudes by age (physicians less than or equal to 49 years vs greater than 50 years), sex and patient panel age (5-35% less than 60 vs 40-85% greater than or equal to 60).Younger physicians reported higher estimates of patients in their panel who were depressed: 24.4% vs 15.6% (p = .002).They were also somewhat more likely than older physicians to indicate that they could be too pressured for time to routinely investigate for depression in older adults (p = .043).However, older physicians were more likely to state that: family members are included in decisions and plans on the treatment and management of older adult depression (p = .034);inadequate insurance coverage can be a barrier to mental health care in rural areas (p = .019);and there is a need for increased time to spend with patients to improve care for older adults with depression (p = .008).

Attitudes and reports of behavior by physician age, gender and proportion of patient panel 60 years and older:
Also examined were physicians' reported practices and perceptions and attitudes by age (physicians less than or equal to 49 years vs greater than 50 years), sex and patient panel age (5-35% less than 60 vs 40-85% greater than or equal to 60).Younger physicians reported higher estimates of patients in their panel who were depressed: 24.4% vs 15.6% (p = .002).They were also somewhat more likely than older physicians to indicate that they could be too pressured for time to routinely investigate for depression in older adults (p = .043).However, older physicians were more likely to state that: family members are included in decisions and plans on the treatment and management of older adult depression (p = .034);inadequate insurance coverage can be a barrier to mental health care in rural areas (p = .019);and there is a need for increased time to spend with patients to improve care for older adults with depression (p = .008).
In relation to gender, female physicians, compared with males, reported higher rates of depressed patients in their practices: overall, 31% compared with 16.1% (p <.001) and with respect to geriatric depressed patients, 33.2% compared with 19.9% (p < .001).While males were more likely to report patient rejection of psychotherapy as a barrier to care (p = .016),females were more likely to view patient reluctance to discuss emotional problems as a barrier (p = .014).Finally, males were more likely to indicate that a better availability of psychologists or counselors was a need in improving care in rural areas (p = .047).
Possible variations in reports of attitudes and care delivery were, additionally, examined in relation to proportion of elderly patients in the physicians' practices.Those rural physicians with proportionately more older patients in their practices, on average, checked more needs and directions for improving their ability to care for older adult patients, 10.3 vs 8.8 (p = .056).These physicians were also more likely to: feel that more training/attention in residency to geriatric care would be helpful in improvement of care (p<.001); indicate the need for greater emphasis in and training on the link between physical and mental health (p = .041);and mention that better availability of psychologists and counselors would be important for the improvement of care for older, depressed patients (p = .020).2.12 (.85) †Not at all helpful = 1; possibly helpful = 2; helpful = 3; very helpful = 4.

Discussion
This study contributes to the recent call by the American Geriatrics Society to understand how primary care physicians diagnose and treat depression in older adults, with a specific focus on rural primary care physicians 21 .
Responding primary care doctors in Illinois reported higher averages of their older patient panels suffering from depression than is indicated in the existing literature: 33% compared with 23% 3,4 .By sheer numbers alone, the need is reinforced for better understanding the diagnosis and treatment of older, depressed adults.
There are many positive outcomes in this study of rural primary care physicians.All responding physicians indicated routine screening for depression in their older patients.
While the majority of physicians did not indicate the use of specific instruments or inventories for depression assessment, they reported a range of symptoms addressed in depression diagnosis (average = 8.8), and two-fifths provided patients with educational materials related to depression.Approximately one-quarter of the physicians used the Beck Depression Inventory in their geriatric assessments.
Interestingly, just 13% of the rural physicians responded that they used clinical guidelines in diagnosis and management of depression.At first glance, this seems low.However, this finding is consistent with the depression clinical guidelines research of Feldman and colleagues who found that while 90.5% of primary care physicians treated depression, only 13.1% reported having a copy of depression guidelines 30 .Perhaps more importantly, nearly 45% of the physicians had attended continuing medical education programs focused on the health needs of older adults.Related to Feldman et al.'s analysis, the rural physicians in our study appeared to have the 'content knowledge' important for geriatric depression diagnosis and care.
Our study does indicate areas for future attention.First, while being willing to take on depression in the elderly in rural primary care (all physicians agreed that diagnosis and treatment of depression in older patients was their responsibility as primary care doctors), the physicians themselves provided ample indications that there are ongoing needs to be addressed in this area of primary care.
In comparing available versus ideal treatment, nearly half the rural physicians reported a gap between their preferred treatment and the availability of treatment for their older patients.It will be important to identify what rural primary care physicians specifically refer to as gaps in care.
Second, the physicians identified a number of needs or directions in depression care, diagnosis and treatment.Most important was better availability of psychologists and counselors for attending to the needs of older depressed rural people.This was particularly emphasized by male physicians and those with higher proportions of older patients in their practice.Perhaps not surprisingly, more time to spend with patients was also mentioned as a major need in depressionrelated care.These are system-level factors that, if addressed, could potentially improve the mental healthcare of the rural elderly.
The challenges of time could potentially be addressed through interprofessional interventions and taking a team approach to the treatment and management of depression in older adults.Certainly, this may be more difficult in rural areas where access to healthcare professionals remains a concern.But models of care might include those similar to the primary care or patient-centered medical home, in which physicians work in a team environment to address the diverse healthcare needs of their patients 31 An important message to the health education community provided by the primary care physicians in this study was the potential role of teaching in preparing physicians to address geriatric depression, as well as other mental health issues.In addition to other recommendations related to access and availability factors in geriatric mental health, the responding physicians indicated there could be greater emphasis in their training on the link between mental and physical health.One aspect of this could be more training or attention in residency on geriatric mental healthcare awareness and practices.
A possible limitation of the study is that while it had a respectable response rate for a physician survey, still less than 50% of physicians in the sampling frame responded to the study questions.It is possible that a more positive picture of physician attitudes and experiences was obtained if physicians less positive in attitude and less sure of their care opted to not respond to the survey.The responses also reflect reports of attitudes and experiences, rather than observations or chart reviews.However, our response rate is consistent with past research on physician attitudes and practices 32 , and we are able to provide information on an often underexamined group of physicians in the realm of mental healthcare delivery 33 .With respect to the latter, the study is responsive to the conclusion of a recent Lancet editorial stating 'Mental health must be one of the key priorities in any country's clinical and public health agenda' 34 .Overall, the study has identified the types of barriers primary care physicians experience in their diagnosis and treatment of geriatric depression, and has demonstrated a need for more attention to be directed to this important topic in rural healthcare delivery.("l"=strongly disagree, "2"=somewhat disagree, "3"=somewhat agree, "4"=strongly agree) Strongly Disagree Strongly Agree 1.
Helping depressed patients is important to me.Treating depressed patients is an aspect of practicing medicine that I find rewarding.Patients are concerned about medication side effects 1 2 4 Which one of the above choices do you consider the most significant barrier?(Please choose a number 1-9): ____ What other barriers do you experience?(please list): _______________________________________________ Needs and Directions: Please indicate whether each of the following would be helpful for improving your ability to care for geriatric patients with depression by circling 1-4.
Increased time to spend with each patient 1 2 3 2.
More support staff in office 1 2 3 4.
Improved patient compliance with treatment 1 2 3

Part 1 :Part 2 :Part 3 :Part 4 :Part 5 :
and updated to reflect the recent literature on the treatment of depression, especially that related to older adults (Appendix I).Current practices: Data collected on current practices was in regard to recognizing and managing depression in older adults, including questions about routine screening methods, use of screening tests and guidelines, laboratory examinations, gaps between preference of treatment and the availability of that treatment and the use of patient education materials.Information on attitudes and perceptions: Data on attitudes and perceptions included responses to statements on the diagnosis and treatment of geriatric depression in primary care, where physicians were asked to specify the extent of agreement or disagreement using a 5 point Likert scale.Identification of barriers: Barriers to adequate diagnosis and treatment of geriatric depression were identified, including the stigma of psychiatric treatment, access to mental healthcare in the community, inadequate insurance coverage for mental health care and not enough time for discussion.Physicians' reports of needs and directions: Physicians' reports of needs and directions to improve care for depressed geriatric patients was collected by asking the respondents to rate 15 items, including increased time with each patient, better availability of psychologists, increased reimbursement for counseling and mental health services located in primary care practice.Background and demographics: Background and demographics data included physicians' sex, age, specialty, percentage of depressed patients in practice, percentage of depressed elderly patients and involvement in teaching medical students and residents.The survey was a self-report, self-administered instrument, taking approximately 10-15 min to complete.It was tested and piloted in relation to content and completion time.The survey instrument and study methods were approved by the university Institutional Review Board.
disagree = 1; D, disagree = 2; A, agree = 3; SA, strongly agree = 4.Physician reports on barriers to care and views on improving ability to care for depressed, geriatric patients: Physicians were asked to respond to a list of 9 possible barriers to the diagnosis and treatment of geriatric depression by indicating the extent to which each was perceived as a barrier.Results of the physicians' assessments are presented (Table4).Most likely to be viewed as barriers to diagnosis and treatment of geriatric depression were inadequate insurance coverage for mental healthcare and lack of access to mental healthcare in the community (both with a mean score >3 on a 4 point scale).These two most often reported factors reflect access or system-level obstacles to care.On the individual side, approximately 62% of the physicians agreed barriers to diagnosis and treatment of geriatric depression could be patients' rejection of psychotherapy and perceptions of the stigma associated with psychiatric treatment in general.Least likely to be viewed as barriers in depression diagnosis and care were: low confidence by the patient in treatment involving counseling, and the patient's reluctance to discuss emotional problems (with mean scores of 2 and 1.5, respectively).
Attitudes and Perceptions: Please indicate whether you agree or disagree with the following statements by circling a number 1-4.
that I can accurately diagnose depression in elderly patients.

Table 1 : Demographic and practice characteristics of responding rural primary care physicians
CME, Continuing medical education.

Table 2 : Rural physicians' reported practices in the screening and diagnosis of depression in older adults Screening and diagnosis practice Physicians n (%) Symptom †
† Mean symptoms listed = 8.8 (SD = 2.1).

Table 5 : Rural physicians' views of items potentially helpful in improving ability to care for geriatric patients with depression Helpfulness rating † n (%) Item Not at all helpful Possibly helpful Helpful Very helpful Mean (SD)
Which one of the above choices would be the most helpful to your current practice?(Please choose a number 1-15): ____ Other suggestions for improving care (please list): ________________________________________________ About what percent of the patients in your practice are over age 60? ____________________% 7. Approximately what percentage of your patients reside in extended care facilities?________% 8.About what percent of your patients do you estimate to be depressed?___________________% 9.About what percent of your geriatric patients do you estimate to be depressed?___________ % 10.Have you attended conferences/CME activities which specifically focus on the health needs of older adults?___ Yes ___ No 11.Do you hold a certification in geriatrics?___ Yes ___ No 12. Are you involved in teaching medical students or residents?___ Yes ___ No Please briefly describe these activities, if any: ______________________________________________ ___________________________________________________________________________________