Recognition of Depression in Medical Patients With Heart FailureHarold G. Koenig, M.D.
From the Duke University Medical Center and GRECC VA Medical Center. Send correspondence and reprint requests to Dr. Koenig, Box 3400, Duke University Medical Center, Durham, NC 27710.
From the Duke University Medical Center and GRECC VA Medical Center. Send correspondence and reprint requests to Dr. Koenig, Box 3400, Duke University Medical Center, Durham, NC 27710.
The author examined physician and patient factors related to recognition of depression in depressed medical patients. Medical inpatients over age 50 were systematically identified with depressive disorder (N=1,000). Medical physicians (N=422) treating these patients were asked whether they believed patients had depression warranting specific treatment. Frequency of seeing and treating older depressed patients and attitudes toward treatment effectiveness were key factors related to physicians’ recognition of depression. Patient factors were younger age, white race, female gender, and persistence of depression after discharge. Although physicians’ intuition about depression course was often correct, persistent depression was not recognized in nearly 40% of patients.
For patients with congestive heart failure (CHF), depression accounts for nearly $5 billion of the $20 billion total treatment costs, and severely depressed CHF patients show a fourfold increase in mortality. Approximately 14 to 20 million Americans have chronic pulmonary disease (CPD), which is the fourth leading cause of death in the United States, and death rates are likewise increased by over threefold among depressed patients. Studies using structured psychiatric interviews have reported that depressive disorder is present in 36%–59% of medical inpatients with CHF (16%–22% with minor and 20%–37% with major depression). Depression rates in patients with CPD are also high (7%–57%). This is particularly true for hospitalized CPD patients, where the rate of depressive disorder is close to 60% (unpublished data). Thus, a significant proportion of hospitalized patients with CHF/CPD (CHF and/or CPD) have depressive disorders that interfere with functioning, quality of life, and medical outcomes. Underrecognition of depression is widespread among older medical patients in general and CHF/CPD patients in particular (over 90% in one study).
When told that their patient met criteria for a depressive disorder, only two-thirds of physicians agreed with the diagnosis and need for treatment. Although physicians were often quite accurate in assessment (based on remission of depression after hospitalization), nearly 40% of the time they were wrong, and these patients continued to suffer from depression for months after discharge (most without treatment). For physicians managing patients in the hospital, there are patient characteristics (age, gender, race) and physicians’ attitudes toward treatment that influence whether or not they believe that patients have depressive disorder warranting treatment, and these factors are independent of the type of depressive disorder, severity of depression, or the course of depression after discharge. This may be partially the result of bias or stereotyping. Medical training programs should emphasize the recognition and treatment of depression in older patients with CHF/CPD and the necessity for referral if patients are not responding to treatment.
Psychosomatics 48:338-347, August 2007
No comments:
Post a Comment