Recognition of Depression by Non-psychiatric
Physicians—A Systematic Literature Review and Meta-analysis
Monica Cepoiu, MD, MSc
1,2
, Jane McCusker, MD, DrPH
1,3
, Martin G. Cole, MD, FRCP(C)
4,5
,
Maida Sewitch, PhD
1,6
, Eric Belzile, MSc
1
, and Antonio Ciampi, PhD
1,3
1
Department of Clinical Epidemiology and Community Studies, St. Mary’s Hospital, Montreal, QC, Canada;
2
Department of Community
Health Studies, University of Calgary, Calgary, AB, Canada;
3
Department of Epidemiology and Biostatistics, McGill University, Montreal, QC,
Canada;
4
Department of Psychiatry, St. Mary’s Hospital, Montreal, Canada;
5
Department of Psychiatry, McGill University, Montreal, Canada;
6
Department of Medicine, McGill University, Montreal, QC, Canada.
BACKGROUND: Depression, with up to 11.9% prevalence
in the general population, is a common disorder strongly
associated with increased morbidity. The accuracy of non-
psychiatric physicians in recognizing depression may
influence the outcome of the illness, as unrecognized
patients are not offered treatment for depression.
OBJECTIVES: To describe and quantitatively summarize
the existing data on recognition of depression by non-
psychiatric physicians.
METHODS: We searched the following databases: MED-
LINE (1966–2005), Psych INFO (1967–2005) and
CINAHL (1982–2005). To summarize data presented in
the papers reviewed, we calculated the Summary receiv-
er operating characteristic (ROC) and the summary
sensitivity, specificity and odds ratios (ORs) of recogni-
tion, and their 95% confidence intervals using the
random effects model.
MEASUREMENTS AND MAIN RESULTS: The summary
sensitivity, specificity, and OR of recognition using the
random effects model were: 36.4% (95% CI: 27.9–44.8),
83.7% (95% CI: 77.5–90.0), and 4.0 (95% CI: 3.2–4.9),
respectively. We also calculated the Summary ROC. We
performed a metaregression analysis, which showed
that the method of documentation of recognition, the
age of the sample, and the date of study publication
have significant effect on the summary sensitivity and
the odds of recognition, in the univariate model. Only
the method of documentation had a significant effect on
summary sensitivity, when the age of the sample and
the date of publication were added to the model.
CONCLUSION: The accuracy of depression recognition
by non-psychiatrist physicians is low. Further research
should focus on developing standardized methods of
documenting non-psychiatric physicians’ recognition of
depression.
KEY WORDS: recognition; depression; meta-analysis.
J Gen Intern Med 23(1):25–36
DOI: 10.1007/s11606-007-0428-5
© Society of General Internal Medicine 2007
BACKGROUND
Depression, with up to 11.9% prevalence in the general popula-
tion,
1,2
is a common disorder strongly associated with increased
morbidity.
3
It has been estimated that in 2020 depression will
become the second leading cause of disability,
4
which empha-
sizes the importance of its early detection and treatment. The
accuracyof non-psychiatric physicians in recognizing depression
may influence the outcome of the illness, as unrecognized
patients are not offered treatment for depression. Currently, less
than half of patients with depression are recognized by their
primary care physicians, even after 5 years of follow-up.
5
Moreover, studies show that among recognized depressed
patients only a few receive appropriate care, which may further
lead to poor outcome of depression and increased health service
use and mortality rates in these patients.
6,7
There are many potential reasons for the underrecognition
and undertreatment of depression; patient, provider, and
system barriers have been identified. Patients reduce the
likelihood of being diagnosed by presenting with somatic
rather than emotional complaints
8–10
and may resist a diag-
nosis of depression or anxiety by attributing their symptoms to
physical causes.
11,12
Provider barriers include concerns about
potential patient stigma,
13,14
time pressures,
14
a belief that
such diagnoses are burdensome,
15
inadequate knowledge
about diagnostic criteria or treatment options,
6
lack of a
psychosocial orientation,
16–18
and inadequate insight into differ-
ent cultural presentations of mental disorders.
19
System bar-
riers include productivity pressures, limitations of third-party
mental health coverage, restrictions on specialist, drug, and
psychotherapeutic care,
13,14
lack of a systematic method for
detecting and managing such patients,
20
and inadequate conti-
nuity of care.
13
The accuracy of recognition of depression by attending
physicians can be assessed using measures such as sensitiv-
ity, specificity, and odds ratio, when the clinical diagnosis
made by the physician is compared to a gold standard
diagnosis of depression. The estimates of these measures
reported in the literature vary according to the method used
Received April 3, 2007
Revised September 29, 2007
Accepted October 4, 2007
Published online October 26, 2007
25