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Am Fam Physician. 2009;80(1):91

Background: Depression and other mental disorders are common in older persons and are likely to increase as the population ages. Suicide occurs disproportionately in older persons, and it has been found that of persons at any age who completed suicide, only 9 to 33 percent were using antidepressants. Recommendations for treating depression include at least four office visits, with at least five minutes of counseling per session. Patients should be educated about treatment options and medications. Research on how much time is spent on mental health issues during office visits is limited, as is research on the quality of the interaction involving such discussions. Tai-Seale and colleagues used a quantitative and qualitative approach to evaluate the time spent on mental health in primary care settings and the content and quality of the visit.

The Study: Using a convenience sample of office physicians, they used video to study patient-physician interaction with persons who were 65 years and older. Physicians were not told that the purpose of the study was to evaluate mental health management. Topics and management issues were coded according to a protocol using trained coders. Thirty-six topics were identified, relating to the following areas of content: biomedical, mental health, personal habits, psychosocial, patient-physician relationship, and other. Researchers measured the length of time spent on a topic. Videos addressing mental health topics were quantitatively analyzed. Videotaped patients also completed the 36-item Medical Outcomes Study (SF-36).

Results: Complete interviews with sufficient-quality videotapes were obtained for 385 visits. Of note, there was a higher proportion of black physicians represented in the sample relative to representation nationally (17 versus 6 percent, respectively). Mental health topics were discussed in 84 visits with 74 patients. Median duration of discussion was two minutes, with a range of 14 seconds to 17 minutes, 16 seconds. Discussion of biomedical topics was slightly shorter, by approximately 33 seconds (there was increased patient talk time when discussing mental health issues). Median duration of mental health discussion was significantly shorter in interactions with non-white patients than with white patients, particularly when the patient and physician were black. Mental health problems were common, with 50 percent of patients scoring lower than 42 on the SF-36 and many expressing feelings of sadness and thoughts of death or suicide. Only 25 percent of patients with SF-36 mental health scores lower than 42 (suggestive of major depression) had mental health discussions, whereas 19 percent with scores greater than 42 had mental health discussions. A qualitative analysis of these conversations revealed that physicians often did not address mental health cues or concerns adequately.

Conclusion: Even when physicians spent time with patients discussing mental health topics, they often did not adequately address the patient's problem. Monitoring adherence to guidelines may be difficult when the content of patient-physician discussions is unknown. Black patients were more likely to have a shorter mental health discussion. The authors suggest that physicians need more support in addressing and treating mental health problems in older patients.

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