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Psychosomatics 41:39-52, February 2000
© 2000 The Academy of Psychosomatic Medicine

Review

Interventions to Improve Provider Diagnosis and Treatment of Mental Disorders in Primary Care

A Critical Review of the Literature

Kurt Kroenke, M.D., Anne Taylor-Vaisey, M.L.S., Allen J. Dietrich, M.D., and Thomas E. Oxman, M.D.

Received March 2, 1999; revised May 20, 1999; accepted August 24, 1999. From the Department of Medicine, Indiana University School of Medicine and Regenstrief Institute for Health Care, Indianapolis, Indiana; Office of Continuing Education, University of Toronto, Toronto, Ontario, Canada; and Departments of Community and Family Medicine and Psychiatry, Dartmouth Medical School, Hanover, New Hampshire. Address reprint requests to Dr. Kroenke, Regenstrief Institute for Health Care, RG-6, 1001 West 10th Street, Indianapolis, IN 46202; e-mail: kroenke_k{at}regenstrief.iupui.edu


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 FUTURE CONSIDERATIONS
 REFERENCES
 
The authors conducted a critical review of the literature on interventions to improve provider recognition and management of mental disorders in primary care, searching the MEDLINE database for relevant articles published from 1966 through May 1998 and finding 48 usable controlled studies (27 randomized controlled trials and 21 quasi-experimental studies). Improved diagnosis of mental disorders was reported in 18 of 23 (78%) of the studies examining this outcome and improved treatment in 14 of 20 studies (70%); clinical improvement in psychiatric symptoms or functional status was documented in 4 of 11 and 4 of 8 (36% and 50%, respectively). Considerable study heterogeneity precluded subjecting the literature synthesis to a formal meta-analysis of pooled results; the authors were therefore unable to demonstrate an association between efficacy of an intervention and any specific variables. A variety of interventions and further research may be effective in improving the recognition and management of mental disorders in primary care.

Key Words: Treatment • Mental Disorders • Primary Care

  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 FUTURE CONSIDERATIONS
 REFERENCES
 
Diagnosis and treatment of mental disorders is a key area for quality improvement in primary care. Despite their prevalence, associated disability, costs, and treatability, mental disorders are adequately treated in less than one-third of primary care patients.1–3 This fact has stimulated over the past 20 years a series of studies aimed at improving provider detection and management of common mental disorders.4,5 The science of modifying provider behavior has been derived from health-services research and other areas of continuing medical education (CME).6–8 CME principles allow classification of particular studies in terms of specific types of interventions as well as evaluation measures used to assess outcome. Our objective was to apply these principles in critically examining the literature on the efficacy of interventions focusing on mental disorders in primary care. We considered evidence from all controlled trials—both randomized and quasi-experimental—in order to provide the most comprehensive view.9

Our primary question was whether interventions aimed at providers can improve the diagnosis, treatment, and clinical outcomes of depression and other mental disorders in primary care. Secondarily, we explored the effects of the number and types of interventions, provider training status and specialty, type of psychiatric disorder, and study design.


  METHODS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 FUTURE CONSIDERATIONS
 REFERENCES
 
Literature Search
We searched the MEDLINE database from 1966 through May 1998 to identify articles with the medical subject headings Mental Disorders or Depression Disorders or Depression or Anxiety and Physicians, Family or Primary Health Care, or Family Practice. Articles were also identified from bibliographies of review articles and retrieved articles. Two investigators independently evaluated titles and abstracts and reached consensus on which articles to retrieve. When data from one study were published in multiple papers, they were still analyzed as a single study.

Studies were eligible for inclusion if they met the following criteria: 1) the design was either a randomized clinical trial (RCT) or quasi-experimental (pre–post or nonrandomized, controlled trials); 2) the primary focus was on improving the recognition and/or management of one or more mental disorders in the primary care setting; 3) outcome assessment included at least one of the following: provider knowledge, attitudes or skills; process of care (e.g., diagnostic rates or treatment actions); and clinical outcomes (e.g., symptom severity, functional status, health care costs, satisfaction with care).

Data Abstraction and Analysis
Type of intervention and outcome evaluation were abstracted from each paper. The three major categories of interventions were "predisposing," "enabling," and "reinforcing."10 Details of this classification system are described in more detail elsewhere.7,8,11 Briefly, predisposing interventions focus on simple educational strategies, such as lectures, workshops, courses, self-study materials, and single academic detailing visits. Enabling interventions are those aimed at improving provider behavior at the time of the visit, such as giving feedback of psychiatric screening results to clinicians; providing tools for clinicians to use, such as screeners or memory aids for diagnosis and treatment; allowing for longer clinic visits or extra follow-up appointments; improving access to mental health specialists (often in an on-site or collaborative fashion); and supervision of real patients. Reinforcing interventions include providing feedback on a provider's actual performance (e.g., chart audit or review of videotaped encounters) as well as academic detailing that involves both initial and follow-up visits.

Secondary variables abstracted from each paper included the specific type of primary care setting, the number of providers and patients, provider specialty and training status, the type of mental disorder, and the country in which the study was conducted. Two authors (AD, TO) independently reviewed each paper, and areas of disagreement were reviewed by a third (KK). Final classification was decided by consensus of all four authors.

Our primary analysis focused on the impact of the intervention in each study on three outcomes: diagnosis of mental disorders, treatment actions, and clinical outcome. Studies were classified as positive for an outcome if the intervention resulted in statistically significant (P<0.05) improvement. We also report the magnitude of a positive effect. Pooling of study results (i.e., formal meta-analysis) was not possible because of the heterogeneity of study designs, interventions, and outcome assessment. Potential relationships between selected secondary variables and study outcomes were examined with Fisher's exact test. Such univariate results, however, should be interpreted cautiously because of multiple subgroup comparisons.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 FUTURE CONSIDERATIONS
 REFERENCES
 
A total of 48 studies met our inclusion criteria: 27 RCTs, 11 focusing on depression12–24 and 16 on other mental disorders25–40 (see Table 1); and 21 quasi-experimental studies, 8 focusing on depression41–51 and 13 on other mental disorders52–66 (see Table 2). Of the 29 studies focusing on other mental disorders, 12 focused on general psychological distress as measured by the General Health Questionnaire (GHQ), 3 on multiple psychiatric diagnoses, 3 on somatoform disorders, 1 on anxiety disorders, and 1 on alcohol disorders. Nine of the 29 did not involve actual patients, but measured provider knowledge, attitudes, or skills. Most findings summarized below are derived from the tables, which contain source citations. For findings not provided in the tables, citations are provided in the text.


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TABLE 1. Randomized clinical trials to improve Provider recognition and/or management of depression and other mental disorders in primary care




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TABLE 2. Quasi-experimental interventions to improve Provider recognition and/or management of depression and other mental disorders in primary care



The majority of studies (n=33) were conducted in the United States; 10 originated in the United Kingdom;25,37,38,47,50,51,56,58,62,65 and 1 each from Canada,55 Australia,46 India,59,60 Sweden,41–44 and Saudi Arabia.39

Interventions
Predisposing interventions were used in 34 studies, including reading materials (n=2); didactic training sessions lasting 1–4 hours (n=9), 5–12 hours (n=9), or 3 days–2 weeks (n=8); an extended series of conferences or seminars (n=4); one-to-one tutorials (n=1); and academic detailing or continuous quality improvement initiatives (n=1). One or more enabling interventions were used in 24 studies, including feedback of psychiatric symptom scores or diagnoses (n=17), mental health professional consultation (n=6), patient educational materials (n=4), longer or extra clinic appointments (n=2), screening tools for clinician use (n=3), and academic detailing (n=2). The two most commonly studied measures for providing feedback were the GHQ (n=6) and the Zung Self-Rating Depression Scale (n=5); three studies provided feedback on actual psychiatric diagnoses, and one study each used the SCL-90, SCL-20, and the Hamilton Rating Scale for Depression. One or more reinforcing interventions were used in 17 studies, including review of videotaped patient encounters (n=6), monitoring of patient treatment and/or response with feedback to the primary care provider (n=6), supervised training rotations lasting 1 month or longer (n=6), and Balint groups (n=2); and follow-up academic detailing or continuous quality improvement endeavors (n=1).

Process of Care: Diagnosis and Treatment Rates
Improvements in diagnostic rates were reported in 18 of 23 (78%) of the studies examining this outcome, and improvements in treatment in 14 of 20 studies (70%). Clinical improvement as measured by psychiatric symptoms was noted in 4 of 11 studies (36%) and improved functional status in 4 of 8 studies (50%). Lower health care costs, reduced utilization, and improved satisfaction with care were noted in 3 of 4, 3 of 3, and 2 of 4 studies, respectively. Provider knowledge, attitude, and skills were most often measured in quasi-experimental studies; when assessed, knowledge improved in 14 of 14 studies (100%), attitudes in 7 of 9 (78%), and skills in 4 of 4 (100%). Finally, when asked if a particular intervention had been useful, providers responded affirmatively in five of six studies.46,48,61,62,64,65

Clinical Outcomes
Since clinical outcomes are more important than intermediate process of care measures, the 16 studies evaluating clinical outcomes were examined in more detail. All except one study41 were randomized clinical trials. Psychiatric symptom severity was measured in nine studies, functional status in four studies, and both outcomes in three additional studies. Depression was the disorder targeted in seven studies (three were positive and four negative); general psychological distress in five studies (two positive and three negative); somatization in three studies (two positive and one negative); and anxiety in one negative study. The three studies that assessed both symptom severity and functional status were concordant for these outcomes (i.e., neither symptom severity nor functional status improved).

The eight studies reporting a favorable effect on clinical outcomes included a multifaceted collaborative care intervention for depressed patients in two studies22,23 and a psychiatric consultation letter providing management suggestions for somatizing patients in two studies.34,35 For both interventions, the same investigators had reported an earlier negative study (see below). Interventions to reduce psychological distress had a positive impact in three clinical trials, including a feedback and counseling protocol,31 an 8-hour interviewing skills training course,36 and simple feedback on patients' GHQ scores in a study that involved only a single provider.25 Finally, an educational program improved depression outcomes in a pre–post study conducted on a Swedish island.41–44

The eight studies that did not improve clinical outcomes included three multifaceted interventions: one study involving collaborative care management of patients who were not only depressed but also high utilizers of health care;19 a second study that focused on depressed geriatric patients, many of whom had substantial medical comorbidity and low socioeconomic resources;21 and a third study involving three arms that compared intensive continuous quality improvement programs or academic detailing with usual care.24 The other negative studies included simple feedback of depression,18 anxiety,33 or psychological distress scores;38 a psychiatric consultation letter regarding somatizing patients;28 and an intensive 1-month rotation to improve residents' interviewing skills.40

Exploration of Secondary Variables
The relationship between selected secondary variables and improved diagnostic rates and treatment is shown in Table 3. Except for provider type, none of the relationships achieved statistical significance. Because clinical outcomes (i.e., psychiatric symptom severity or functional status) were measured in fewer studies, subgroup analyses of these patient outcomes are reported for only a few variables.


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TABLE 3. Characteristics of intervention and improvements in diagnostic rates and treatment



Intervention Characteristics.
There was considerable variability in types and intensity of predisposing, enabling, and reinforcing interventions used across the different trials. When comparing studies that used only one of these types of interventions to those that used two or all three types, the multiple-intervention studies showed a statistically insignificant trend toward greater efficacy.

The predominant intervention in the 30 studies that assessed diagnosis and/or treatment changes could be classified into one of four categories: 1) providing feedback to providers of the results of psychiatric screening (n=13 studies);12–15,17,27,29–33,38,66 2) brief provider training (n=7);26,36,37,41,45,46,49 3) more intense provider training (n=4);39,53,54,56 and 4) multifaceted interventions (n=6).19,20,22–24,47 Of note, none of these 30 studies used simple lectures or other traditional continuing medical education formats. Rather, even brief provider training ranged, on the low end, from 8 hours of interviewer training or videotape review of actual patient encounters to as much as five 6-hour training days. Although simple feedback of screening results seemed somewhat less efficacious than either provider training or multifaceted interventions, the differences were not statistically significant.

Study Design.
Randomized clinical trials appeared somewhat less likely than quasi-experimental studies to find an intervention efficacious, particularly in improving treatment (Table 3). Within RCTs, studies that randomized patients were somewhat less likely to show improvements in diagnosis or treatment than studies that randomized providers. None of these relationships, however, achieved statistical significance.

The mechanism used to ascertain mental disorder diagnoses was weakly related to the likelihood of demonstrating diagnostic improvement. Improved diagnostic rates after intervention were shown in 11 of 12 studies relying on chart review, compared with 7 of 11 based on post-visit provider questionnaires (92% vs. 64%; P=0.14).

Provider Characteristics.
Providers included physicians in 42 studies (family practice in 9, internal medicine in 10, both family practice and internal medicine in 8, general practice in 14, not specified in 1), nurses in 3 studies, medical students in 1, and multiple health professionals in 1. Interventions targeting exclusively internists were somewhat less likely to show improvements in diagnostic rates (P=0.04) and, possibly, treatment (P=0.11).

Training status of physician-providers was unrelated to intervention efficacy. Since all resident-directed interventions were conducted in academic settings, and all practitioner-targeted interventions except one17,18 were situated in community settings, we were not able to distinguish the effects of practice setting from those of trainee-practitioner status.


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
FUTURE CONSIDERATIONS
 REFERENCES
 
Where outcomes were examined, interventions improved the primary care provider's diagnosis and treatment of mental disorders in three-fourths of studies. Although assessed in fewer studies, patient outcomes improved with 36%–50% of the interventions evaluated. These findings suggest that, either alone or in combination, predisposing, enabling, and/or reinforcing interventions can improve the process of care for mental disorders, and potentially clinical outcomes. Considerable differences in type of interventions, outcome assessment, providers, and clinical setting make each study essentially unique and preclude identifying any particular intervention as superior. The remaining question is not "Can we improve the quality of primary care for mental disorders?" but rather "Which ways are most effective?"

Two of the most common interventions studied have been provider education and feedback of psychiatric screening results. Although traditional CME programs, such as simple lectures, are often ineffective in changing provider behavior, the educational interventions we reviewed typically involved more extensive provider training efforts. Screening as a single intervention seemed somewhat less likely than provider training to improve diagnostic or treatment process of care measures, but differences were not statistically significant.

Does the number of interventions matter? In a systematic review of CME, Davis67 found that as the number of interventions increased from one to two to three, efficacy increased from 60% to 64% to >80%. A similar trend was suggested in our review but was statistically inconclusive because of a smaller number of studies. However, the intensity–efficacy relationship is not a straightforward one. For example, only two of five studies using the most intensive multifaceted interventions improved clinical outcomes of depressed patients,19,20,22–24 whereas two of three studies using a simple letter of advice to primary care physicians caring for somatizing patients also reported improved clinical outcomes.28,34,35 Certainly, important differences in disorders and outcome measures among these studies makes direct comparisons problematic.

How do provider characteristics influence an intervention's efficacy? Although fewer of the studies targeted solely at internists reported successful interventions, this finding should be interpreted cautiously because of its borderline statistical significance, number of confounding variables, and multiple hypothesis-testing. However, others have noted a difference among several types of providers in attitudes toward psychosocial problems, with internists' attitudes being intermediate between the more favorable attitudes of family practitioners and the less favorable attitudes of surgical specialists.68,69 Although not as well studied, characteristics of the individual provider are probably even more important than provider specialty. For example, if knowledge deficits are important, a program to increase specific knowledge might have a greater effect on providers with lower baseline knowledge (i.e., less previous training in mental disorders). Efforts to tailor interventions to particular provider needs warrant greater attention.

Do residents respond differently than practitioners to interventions aimed at modifying their behavior? Some have speculated that physicians-in-training may be less autonomous and more susceptible to interventions, whereas others believe they may be less responsive because of preoccupation with physician identity and procedures as well as limited experience with the magnitude of psychosocial issues in primary care. Although neither hypothesis is supported by our literature review, no specific intervention was tested in both academic and community settings. Further empirical data are needed before we dismiss the generalizability of intervention studies involving residents and potentially discourage primary care research in academic settings.

Do interventions administered for a fixed period of time have a lasting effect? Few of the studies reviewed examined the durability of an intervention. Although several quasi-experimental studies revealed conflicting results,43,61 the follow-up report by Lin et al.70 of a successful randomized clinical trial by Katon and colleagues22 demonstrated that benefits of even a multifaceted collaborative-care intervention decayed soon after being discontinued and that, within 6 months, providers' practices had reverted to usual care. Consistent with other studies on modifying provider behavior,6 this finding suggests that interventions might need to be sustained or at least periodically reinforced. Alternatively, it may be that focusing on provider behavior alone is insufficient in the absence of other systems changes or additional assistance.

Miscoding of mental health problems is common in primary care because of concerns about reimbursement, stigmatization, and other factors.71 For this reason, chart documentation may underestimate provider recognition of mental disorders. However, studies that relied on chart review to assess diagnostic performance were just as likely to show improvement as those that used post-visit provider questionnaires. This could be due to similar accuracy of the two methods, a Hawthorne effect (i.e., documentation was better than usual because providers knew they were being monitored), or the fact that relative differences between study and control groups was the outcome of interest rather than absolute levels of diagnostic performance. Until the most valid method of ascertaining provider recognition of mental disorders is determined, investigators might consider using several ways of assessing diagnostic performance.

Our review has several important limitations. First, the considerable variability in research design, patient selection, interventions, outcome measures, and clinical setting made each study essentially unique. This made our primary analysis descriptive and all subgroup analyses exploratory. Second, this study's heterogeneity precluded quantitative pooling of study results and only allowed a vote-counting approach (i.e., a study was simply classified as positive or negative regarding a particular outcome). Third, many of the studies assessed only process-of-care measures rather than actual clinical outcomes. Fourth, the approach to mental disorders in primary care may be a rapidly evolving area. Newer antidepressants, brief diagnostic instruments, and organizational changes in health care delivery may augment the effectiveness of interventions that were tested prior to these recent advances. At the same time, cost-containment measures intrinsic to capitated reimbursement could have opposite effects.


  FUTURE CONSIDERATIONS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 FUTURE CONSIDERATIONS
REFERENCES
 
In summary, the evidence is strongest that interventions can improve the process of care for mental disorders in primary care in terms of diagnostic rates and initiation of treatment. Fewer studies have assessed the impact of interventions on actual patient outcomes, and even fewer have replicated successful interventions. There are at least several important considerations for the future suggested by our current review as well as emerging research:

  1. Multifaceted interventions may be more effective than single interventions, a preliminary finding that requires more extensive validation. Besides targeting the primary care provider, the added importance of system changes such as longer appointments and on-site mental health specialists suggested by Katon and colleagues in their collaborative care model22,23 warrants replication in other settings. Clinical trials of other promising collaborative-care models (brief telephone follow-up of depressed patients by nurses, stepped-care interventions, etc.) are nearing completion and will extend our understanding of multifaceted interventions.
  2. Tailored interventions might be more effective than generic (i.e., "one size fits all") interventions, whether aimed at the "macro" level (internal medicine vs. family practice) or "micro" level (individual clinics or providers). In this regard, academic detailing or other individualized interventions deserve additional study.72–74
  3. Durability needs particular attention. Which element or types of interventions are long-lasting and which must be ongoing or episodically repeated to maintain efficacy?
  4. What is the impact of managed care? Its population-based approach as well as its potential to influence larger groups of providers could be salutary to mental health interventions, whereas the pressure to see more patients and contain costs could be deleterious. Most interventions reviewed were not conducted in a capitated system.
  5. Competing demands inherent in the primary care setting need to be addressed.75–77 Limited time, frequent medical comorbidity, and the somatization and stigmatization of mental disorders are major barriers to assessment and management of mental disorders in the busy outpatient setting. Failure to recognize these constraints may sabotage interventions.

An array of newer psychotropic agents, validated self-administered questionnaires, and increasing public awareness of depression and other mental disorders offer the promise of substantially enhancing the mental health of primary care populations. For this potential to be realized, interventions found effective in previous studies will need to be refined with further research and adapted to a changing health care system.


  ACKNOWLEDGMENTS

 
This work was supported by funding from the John D. and Catherine T. MacArthur Foundation Initiative on Depression and Primary Care.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 FUTURE CONSIDERATIONS
 REFERENCES
 

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