Multiple determinants of depression treatment decisions: From the DEED Project

Depression is a highly prevalent, disabling public health condition in the US and throughout the world. Treating this critical condition has not been successful for sustained good outcomes. Evidence-based depression guidelines assume symptoms of depression (regardless of clinician/patient interaction or practice context) are the main factor in determining treatment approaches. However, our NIH funded project (DEED) found that, in a real-world practice environment, multi-level contexts infuse complexity into depression treatment decisions. Using mixed methods, including in-depth individual interviews and quantitative surveys (depression treatment decision-making and provider attitude toward psychosocial care), obtained from fifty-three ethnically and gender diverse primary care clinicians (21 general internists, 20 family physicians, and 12 nurse practitioners) in 38 primary care offices, we identified multiple real-world factors: patient's preference, perceived causes of depression, familiarity with patient, familiarity with a given antidepressant, comfort with depression care, time and competing demands of the encounter, sources of recognition of depression (patient- or clinician-initiated), availability and relationships with mental health specialists, and patient's ability to pay. While the three most used methods of depression treatments were medication, counseling, and referral, their decisions on which ones to use for a particular patient were highly dependent on interplay of these factors. Our findings suggest that successful treatment of this critical public health condition will require targeting multi-level and multi-sectorial approaches, such as increasing public understanding of depression, creating organizational and financial structures to facilitate continuity of care and collaboration among general and specialty clinicians, and tailored training for provider's comfort with depression care.