Elsevier

Asian Journal of Psychiatry

Volume 36, August 2018, Pages 54-59
Asian Journal of Psychiatry

Primary care physicians’ perceived barriers on the management of depression in China primary care settings

https://doi.org/10.1016/j.ajp.2018.06.019Get rights and content

Highlights

  • Social stigma is one of the biggest barriers to mental health care, with more than 34.6% of the primary care physicians (PCPs) in our study have reported that the patients with depression or their families were reluctant toward diagnosis of depression; nearly 80% of patients were hesitant in consulting a mental health specialist.

  • PCPs felt comfortable on discussing psychological issues with patients, and majority of them believed the time spent on depression management was well spent.

  • Our findings suggested that PCPs required more training on mental health care.

Abstract

Background

Chinese patients with depression have limited access to mental health specialty care because of myriad barriers at different levels. Recently, there has been increased interest in targeting primary care settings for managing depression, because most depressed individuals visit their primary care physicians (PCPs) during the course of their depressive episodes. The present study examined PCPs’ perceived barriers on the management of depression.

Methods

A total of 295 PCPs completed a 36-item survey by mail. The survey questions included demographics, years in primary care, mental health training experience, and perceived barriers regarding the management of depression in their clinical and current practices. Chi-square and t-test analyses were used to compare the difference of demographic variables between the two districts. For the correlates of PCPs’ clinical practices and their perceived barriers, logistic regression models were used.

Results

At the practice level, lack of access to mental health specialists (37.8%) was the most commonly reported barrier and at patients’ level, reluctance toward diagnosis of depression (34.6%) was the high barrier. Results have indicated that most PCPs (69.2%) felt comfortable discussing psychological issues with patients. Mental health training is significantly related to PCPs’ clinical practice. When PCPs perceived moderate to high-level practice level barriers, prescription and referral were mostly preferred.

Conclusion

PCPs in China perceived some barriers in the management of depression, but they were open to modifications and enhancement of their skills related to managing depression.

Introduction

Depression is projected to have the greatest negative impact and highest disease burden among all illness by 2020 worldwide (Kessler et al., 2017; Lopez and Murray, 1998; Whiteford et al., 2015). Among community-dwelling older adults, the effects of depression are already evident. For older adults aged 75 years or older, a meta-analysis revealed a pooled prevalence of 7.2% (range 4.6%–9.3%) for major depression and 17.1% (4.5%–37.4%) for other depressive disorders (Luppa et al., 2012), making it the most common mental health disorder in elderly population. Late-life depression is associated with physical limitations, greater difficulty with daily tasks, increased utilization and cost of healthcare, and increased suicide and mortality (Alexopoulos and Kelly, 2009; Blazer, 2003). Late-life depression also represents a major public health issue in China. In Beijing, the 1-year prevalence of geriatric depression is 4.3% (Ma et al., 2008), whereas among patients in general hospitals in Shenyang, the rate is 11% (Qin et al., 2008). Rates of depression are even higher, approaching 33%, among patients with chronic diseases such as uncontrolled hypertension (Xue et al., 2017). In 2002, the total estimated cost of depression in China was US$ 6.3 billion (Hu et al., 2007).

In China, patients with depression have limited access to mental health specialty care. Barriers to care include shortage of mental health professionals, limited mental healthcare access in the community (most mental health professionals in China work on inpatient units), and stigma related to seeking mental health care. The community mental health systems in several large cities such as Shanghai, Hangzhou, and Beijing primarily focus on treatment and management of psychosis, mental retardation, and seizure disorders, with much less emphasis on the treatment of depression (Xiao et al., 2004).

Currently, there is increased interest in targeting primary care settings for the treatment of depression, because most depressed individuals visit their PCPs during the course of their depressive episode (Coyne et al., 1994; Kutcher et al., 2016; Wun et al., 2011). Combinations of pharmacological and psychosocial interventions, currently available to PCPs, have been found to be effective in treating patients with depression in primary care (Gensichen et al., 2006; Gilbody et al., 2006). In western countries, >50% of all depression patients are treated in primary care clinics (PCCs) (Oxman et al., 2002). The proliferation of available antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), has made it safer and easier for PCPs to treat depression (Olfson et al., 2002). Given the low rates of older adults seeking specialty mental health services (Hays and Gilreath, 2017; Klap et al., 2003; Rice et al., 2017), it is crucial that PCPs recognize and treat older patients with depression on priority.

With the new health policies by the Central Government of China, the development of community health services will include: primary care as the central component of new strategy for health education and promotion; outpatient evaluation; and case management of chronic disease and physical rehabilitation as the major responsibilities of the primary care (Wang et al., 2007). And, mental disorders are considered as chronic diseases in these community health service policies. Depression is considered as chronic disease due to its frequently relapsing and recurring course.

In China, mental healthcare delivery offers various advantages to PCCs. First, they are convenient: in most of the urban areas, residents can conveniently find a PCC within half a mile. Second, government health insurance covers a greater proportion of care when delivered through the primary care system (90–100%) as compared to care in hospitals (70–100%). Third, PCC professionals are trained and have expertise in the treatment and management of chronic diseases. Fourth, PCCs are associated with less stigma and fewer barriers. Epidemiological studies have shown that elderly Chinese have lower rates of depression as compared to western population (Parker et al., 2001). However, older adults are at greatest risk for suicide, with rates as high as 200 per 100,000 (>65 years), over four times greater than the general Chinese population (Li et al., 2009); and depression is a major risk factor for suicide among older adults (Conwell et al., 1996; Dong et al., 2015). In elderly Chinese, Chinese culture, stigma, and the tendency to express depression somatically make them reluctant in seeking care from mental health specialists (Kleinman, 2004; Parker et al., 2001). In PCC, individuals are more likely to seek the treatment for mental health problems (Dwightjohnson et al., 2000), as less stigma is associated with primary care treatment as compared to mental health care clinics in China (Roeloffs et al., 2003).

Despite the potential role of primary care in the management of depression, low levels of detection and treatment of depression have been highlighted in primary care settings (Sirey et al., 2017; Tylee and Gandhi, 2005). Many barriers such as lack of awareness and reluctant behavior among healthcare professionals and patients respectively, and also some practice level barriers significantly contribute to the unsatisfactory recognition and management of depression in primary care settings (Coventry et al., 2011; Sirey et al., 2017). At the PCPs’ level, they may portray late-life depression as a normative condition; or project their personal experiences with depression onto the patient, or fail to use screening tools on a routine basis (Main et al., 1993).

Attitude of PCPs’ towards patients with depression play an important role in communication, engagement, and treatment decisions. Recognition, understanding, and support of the condition and treatment are considered to be the most important characteristics of communication between healthcare providers and their patients (Cooper et al., 2000; Wun et al., 2011). A provider’s negative attitude toward depression adds to patient’s experience of social stigma and discrimination (Hugo, 2001). Several studies among PCPs have shown that knowledge and attitude toward mental illness are associated with recognition of depression (Goldberg et al., 1982; Kutcher et al., 2016; Parchman, 1992; Robbins et al., 1994). PCPs considering depression as a chronic disease recommend antidepressants than psychotherapy, and are significantly more likely to prescribe medications. However, those who reported greater professional unease in managing depressed patients, taking late-life depression as an inevitable, natural outcome of aging, were less likely to treat their depressed patients (Dowrick et al., 2000; Kerr et al., 1995; Ross et al., 1999).

PCPs’ attitude toward patients significantly affects the confidence and ability to effectively diagnose and manage depression (Richards et al., 2004). Botega et al. (1992) (Botega et al., 1992) reported that PCPs experienced a more comfortable and rewarding work environment when they were trained to distinguish between depression and unhappiness in patients. In order for PCPs to help patients with depression, they first need to accept the responsibility of recognizing the problem. Primary care pediatricians recognizing maternal depression were more likely to assess cases more completely and intervene in those cases, and were also more willing to consider implementing change in their practice (Olson et al., 2002). Dowrick et al. (2000) reported significant association between PCPs’ observed diagnostic ability and attitude toward depression, preference for psychotherapy, ease in managing depression, and belief in successful treatment (Dowrick et al., 2000). A western healthcare study demonstrated that mental health professional training in primary care setting significantly improved PCPs’ attitude toward depression, and PCPs who had more practice in treating depressed patients are more likely to have a positive attitude, better confidence, and knowledge in managing depression and identifying barriers to care (Pincus et al., 2001).

To our knowledge, no such research has been conducted in China. Our objective was to investigate the significant barriers in the effective assessment and management of depression in Chinese PCPs.

Section snippets

Procedure and participants

Two of the total eight urban districts of Hangzhou City, China, were randomly selected based on the random numbers generated by a computer program. The population size and social economic status of these two selected districts were similar, with 208 and 199 PCPs serving their residents respectively. All these 407 PCPs were sent a package including an anonymous questionnaire; a self-addressed stamped envelope; statement outlining the purpose of the research; and a written informed consent form.

Participants’ characteristics

Of the all 407 participants, 295 PCPs completed the survey (responding rate = 73%). Research team did the telephone review for the 112 PCPs (27%) to ask the reasons of rejection. Most of them reported lack of time and 30% of the respondents said lack of experience in mental health and did not want to answer the survey. Among the 295 participants, 56% (n = 167) were female. The age in this group ranged from 24 to 63 years with the mean of 35 years. Only 24.4% (n = 72) of the PCPs had mental

Main findings

Primary care physicians have the opportunity to detect depressive symptoms early and provide adequate care or a timely referral to their patients. However, many barriers prevent the appropriate depression management in primary care settings in China (Katz et al., 1998). These barriers may impact the healthcare decisions of individuals with depression. Our results provided a deeper understanding of these barriers as perceived by PCPs. The growing awareness among PCPs is essential in addressing

Conclusion

Results from the study reported that PCPs were open to modifications and enhancement of their skills and practices related to managing depression. In addition, most PCPs felt comfortable on discussing psychological issues with patients, and majority of them believed the time spent on depression management was well spent. Our findings suggested that PCPs required more training on mental health care. Certain educational interventions have shown promising results in the past; however, results from

Conflict of interest

None.

Acknowledgments

The project was supported by Fogarty International Center, the National Institutes of Health of United States of American grant R01TW008699. This work was also supported by the Program for New Century Excellent Talents in University from the Ministry of Education China.

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