Research report
Do GPs' medical records demonstrate a good recognition of depression? A new perspective on case extraction

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Abstract

Background

Previous estimates of depression recognition in primary care are low and inconsistent. This may be due to registration artifacts and limited extraction efforts. This study investigated a) whether GPs' medical records demonstrate an accurate recognition of depression and b) which combinations of indications within the record most accurately reflect a diagnosis of depression.

Methods

GPs' registrations were compared with a reference standard, the Composite International Diagnostic Interview (CIDI), according to DSM-IV criteria.

Six definitions of GPs' recognition of depression were tested using diagnostic codes, medication data, referral data and free text in the medical records. The Youden-index was used to select the optimal definition of recognition. Data were derived from the Netherlands Study of Depression and Anxiety. 816 primary care patients from 33 general practitioners were included in the vicinities of Amsterdam and Leiden, The Netherlands.

Results

Registration of antidepressant prescriptions was the best single indicator of GPs' recognition of CIDI depression with a recognition rate of 0.43. The best combination of indicators increased the recognition rate to 0.69. All indications except the specific diagnostic codes for ‘depressive disorder’ and ‘depressive feelings’ were included in this definition.

Limitations

Potential bias due to the selection of participating GPs might have influenced our recognition rates.

Conclusion

GPs are aware of mental health problems in most depressed patients, but labeling with specific diagnostic codes is weak. Researchers should consider that diagnostic coding alone is not an accurate measure of the diagnostic ability of depression and strongly underestimates the accuracy of the GP.

Introduction

Most care for depressed patients is delivered in general practice (Tiemens et al., 1996, Bijl and Ravelli, 2000, Wittchen et al., 2001, Kessler et al., 2005, Harman et al., 2006). Research shows that General Practitioners (GPs) fail to diagnose a large number of cases of mental illness. Recognition rates vary greatly between individual studies, but overall GPs correctly identified depression in less than 50% (Hirschfeld et al., 1997, Klinkman et al., 1998, Rost et al., 1998, Schmaling and Hernandez, 2005, Jackson et al., 2007, Cepoiu et al., 2008, Mitchell et al., 2009). If these estimates are correct, a considerable proportion of depressed patients are overlooked, particularly in the short term (Wittchen and Pittrow, 2002, ten Have et al., 2004).

However, the low recognition and registration rates of GPs reported in previous studies are perhaps underestimates. Studies examining medical records mostly based their estimates on a registration code as evidence of the GPs' diagnosis (Nuyen et al., 2005, Smolders et al., 2009). These estimates may not reflect the actual diagnostic process in primary care. Depressed patients might be labeled by their GP as having other psychiatric problems, or the registration code could have been limited to a symptom code (‘feeling depressed’), to psychosocial problems or to a prescription of an antidepressant (Tiemens et al., 1999, Volkers et al., 2005). Other previous studies have used a simple questionnaire or form to assess whether GPs are able to diagnose depression (Ormel et al., 1990, Tiemens et al., 1999, Balestrieri et al., 2007, Menchetti et al., 2009). Diagnostic sensitivity in these studies was slightly greater than in the medical-record studies (Mitchell et al., 2009), but recognition rates could have artificially been raised through cueing. Furthermore, these results may not reflect ‘real’ clinical diagnoses, as the registration sheets were completed for research purposes.

It is unclear to what extent the recognition by GPs is better reflected when all available medical record data are taken into account. The aim of this study was to answer the following research questions: 1) How accurately do GPs' records of indications of depression or mental health problems reflect diagnoses of depression? and 2) Which combinations of indications within the medical record most accurately reflect a diagnosis of depression?

Section snippets

Study design, procedures and participants

This study compared diagnoses of depression by GPs during routine care contacts with a reference standard to diagnose depressive disorders. GPs, patients and interviewers were blinded to the diagnosis by the reference standard.

Data were derived from the baseline measurements of the Netherlands Study of Depression and Anxiety (NESDA), a large longitudinal cohort study among 2981 participants aged 18 to 65 years. NESDA has been described in detail elsewhere (Penninx et al., 2008). The study

Characteristics of the study sample and GPs

The 816 participants were recruited by 33 GPs from 12 general practices in the vicinities of Amsterdam and Leiden, The Netherlands. The mean age of the participants was 46.17 years (SD 12.3, range 18–65) and 68.0% were female (68.0%). Their educational level differed between basic (6.6%), intermediate (55.9%) and higher education (37.5%). Participants were less likely to have attended higher education (X2 = 9.89, df 2, p = 0.007) and had less often experienced lifetime depression (not current)

Summary of main findings

One aim of this study was to report how accurately GPs' records of indications of depression reflect the diagnosis of depression and to evaluate which combinations of indications were the most accurate. According to the most optimal definition of recognition, 69.3% of the depressed patients were identified by the GPs, while they could accurately exclude 81.1% of the non-depressed patients. Recognition even increased to 80% for the (very) severely depressed cases. The most accurate definition

Role of funding source

The infrastructure for the NESDA study (www.nesda.nl) is funded through the Geestkracht program of the Netherlands Organization for Health Research and Development (ZON-MW, Grant Number 10-000-1002) and is supported by participating universities and mental health care organizations [VU University Medical Centre, GGZ inGeest, Arkin, Leiden University Medical Centre, GGZ Rivierduinen, University Medical Centre Groningen, Lentis, GGZ Friesland, GGZ Drenthe, Scientific Institute for Quality of

Conflict of interest

The authors declare that they have no conflicts of interest.

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