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Background: Understanding medical patients' attitudes toward emotional problems and their management is crucial to overcoming obstacles to efficient depression treatment.
Objective: To investigate attitudes toward emotional problems, psychotherapy, antidepressants, alternative treatment approaches, and self-management techniques in depressed and nondepressed medical outpatients.
Design: Cross-sectional interview study, including quantitative and qualitative methods.
Patients: Eighty-seven depressed subjects (mean age, 41.0 years; 66% female) and 91 nondepressed subjects (mean age, 41.4 years; 67% female) from 7 internal medicine outpatient clinics and 12 family practices (participation rate, 91%).
Measurements: Depression diagnoses were established using a structured diagnostic interview, and patient attitudes were investigated with open-ended interview questions regarding treatment preferences, factors improving and impairing emotional well-being, and patients' self-management to improve well-being.
Results: Among the depressed patients, psychotherapy was the most frequently preferred treatment (29%) and the most common factor reported to improve emotional well-being (36%). Twenty-two percent of the depressed patients desired depression treatment within their current medical system, but requested substantially more time to communicate with their physician. Antidepressants were rarely mentioned as a preferred treatment (6%) or factor improving well-being (11%). Thirty-eight percent of the depressed patients attributed their impaired mood to health problems. Compared with the depressed patients, the nondepressed controls preferred significantly less frequent depression-specific therapies.
Conclusions: The vast majority of medical outpatients prefer treatment approaches for emotional problems that go beyond antidepressant medication therapy. Health care providers should consider providing sufficient time to communicate with their patients, the strong preference for psychotherapy, and an appropriate treatment of comorbid physical conditions.
In spite of a series of studies aimed at improving provider detection and treatment of depression over the past 20 years, only 1 out of 5 patients with a major depressive disorder receives adequate treatment.1–5 Nevertheless, 83% of depressed patients desire treatment6 and 84% are at least somewhat interested in receiving help for their emotional distress from their primary care physician.7 In order to bridge the gap between the availability of efficient depression treatment8–11 and the low number of depressed patients actually receiving treatment,1 in-depth investigations of patients' attitudes toward emotional problems are necessary. Existing studies are focused on patient acceptance of psychotherapy or antidepressant medication,6,7,12–16 as opposed to considering alternative treatment approaches and self-management techniques that patients with depression might consider helpful in improving their well-being. To our knowledge, our study is the first to investigate subjective treatment preferences that include alternative approaches and self-management techniques.
Despite our fragmentary knowledge on depressed patients' alternative treatment approaches and self-management techniques, their preferences for traditional treatment approaches are relatively clear: in studies from the United States, Europe, and Australia, most patients prefer counseling or psychotherapy compared to antidepressants.6,7,12–17 A German general population survey suggests that the preference for psychotherapy is based on the idea that this treatment provides an opportunity for personal exchange and problem solving.13 Many patients, who want their physician to help them with emotional problems, do not meet standard criteria for depressive disorders.7,17,18 Nevertheless, patients with major or minor depression are significantly more likely to desire treatment for emotional distress than patients with no depression.7 In addition, because of potential prior experience with depression treatment and the cognitive features of depressive disorders, e.g., diminished interest in activities or negative view of the world,19–21 it is necessary to investigate these questions in depressed and nondepressed patients separately.
Structured interviews or questionnaires are limited in adequately reflecting patients' attitudes, beliefs, and preferences as these methods do not account for reactions beyond the given response format. In order to address these questions in the patients' everyday context, we used a qualitative approach including open-ended questions.22–26 With the long-term goal to better match depression care with patients' beliefs, this study aimed to investigate treatment preferences for emotional problems and factors affecting emotional well-being among depressed and nondepressed medical outpatients.
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Our study findings suggest that traditional psychotherapy and medication are by far not the only treatment approaches that medical outpatients consider for their emotional problems. Altogether, only 35% of the depressed patients reported either psychotherapy or antidepressant medication as their preferred therapy. This low number indicates that, in most cases, the patients' subjective preferences for treatment of emotional problems are not in concordance with what their physicians consider to be effective treatment. In addition, it suggests a lack of confidence in established depression treatment.
A substantial number of depressed patients desired treatment within their current medical system, either as efficacious treatment of their physical disease or as improved medical care. Given that 38% of the depressed medical outpatients thought that their impaired mood was caused by health problems, it is understandable that successful treatment of the physical illness and an enhanced health care system were seen as prerequisites for an improved emotional well-being. The most important demand for an improved health care system was more time with the treating physician, allowing patient–doctor communication beyond the usual pressure of time. Specifically, the patients thought that more information and advice with respect to their physical disease would help them with their emotional problems. Relaxation techniques, alternative medicine, acupuncture, physiotherapy, sports, massage, or weight reduction were also seen as important elements of professional treatment of emotional problems.
A comparable number of depressed patients received psychotherapeutic or psychopharmacological treatment for depression at the time of the study. The finding that depressed patients strongly prefer psychotherapy compared to medication, which was even more accentuated in the subgroup of previously depressed and currently nondepressed patients, is supported by previous studies.6,7,12–17 Our result, that depressed patients frequently attribute improved well-being to psychotherapy, but rarely to antidepressant medication, might partially explain the preference for psychotherapy. Other study results indicate that this preference might go back to the patients' belief that emotional problems are most frequently caused by alterable factors, such as interpersonal problems, work-related problems, and health problems.
The patients' self-management to improve well-being, including exercise, relaxation, active problem solving, activity, and social support, are similar to the key elements of cognitive-behavioral depression therapy.19,21 This indicates that many of the depressed patients are either intuitively familiar with these key elements or that they have experienced benefit from these elements. The fact that the nondepressed patients more frequently indicated that they did not need any treatment for their emotional problems, and that “nothing” impaired their emotional well-being, reflects a realistic estimate of their nondepressed situation.
Our study included predominantly middle-aged Caucasians treated in the German health care system. Compared with most other health care systems, access to psychotherapy is somewhat easier in Germany. Patients may frequent psychotherapists without referral from primary care physicians or psychiatrists, and health insurances pay for 25 or more sessions of individual psychotherapy. It is well known that rates of specialty mental health consultations and pharmacotherapy vary worldwide.40,41 Nevertheless, as assessed by the World Health Organization (WHO) World Mental Health Survey Initiative, overall treatment rates of mental disorders do not vary considerably between the United States and Germany (e.g., moderate cases: U.S., 34.1%; Germany, 30.5%).41 Considering similar treatment preferences among depressed patients from Germany, the United States, the United Kingdom, and Australia,6,7,12–17 we assume that our study findings may also be applicable to other developed health care systems.
The aggregation of patients with major and minor depression into 1 subgroup of patients with depressive disorder might be seen as another limitation of our study. To address this limitation, we analyzed all diagnostic subgroups separately and found that the frequency of response categories did not differ significantly between groups for any response category (all P>.05). Similarly, the responses of depressed patients with and without comorbid panic disorder did not differ significantly (all P>.05).
Medical care for patients with emotional problems could be improved substantially, if primary care physicians were to make more time available to communicate information and advice to patients with emotional problems; in some cases, further treatment might not be required. In the remaining cases, it is suggested to refer depressed patients to psychotherapy or antidepressant medication depending on their decision after detailed information on treatment alternatives has been given. Both psychotherapy and psychopharmacotherapy have proven to be effective for treatment of depression,8–11,19 and treatment with the therapy of preference may improve treatment adherence and outcome.6,42 As the patients' views of emotional problems and their management remarkably differ from both physicians' perspectives and treatment guidelines, future research is necessary to better meet patients' needs for individual depression treatment.