Knowledge and practice of depression management among primary healthcare physicians.

Background: Depression is a mood disease that affects the energy, behavior, and mood of individuals. Depression is associated with an increased risk of chronic disease. Primary healthcare physicians play an important role in the diagnosis and management of depression. We aim to determine the knowledge of primary healthcare physicians on depression.
Methods: This is an observational cross-sectional study that was conducted on primary healthcare physicians using a structured validated questionnaire. Statistical analysis was conducted using SPSS 22nd edition.
Results: This study included 235 primary healthcare physicians, and the mean ± standard deviation of age was 29 ± 3 years. Males were predominant in the study (62%), and the large majority were residents (94.9%). There were 79.5%, 91.5%, and 27.8% who had good knowledge, a positive attitude, and a good practice, respectively. There was no factor found to affect the knowledge and attitude, whereas only the position of participants was significantly associated with the level of practice (P = 0.027).
Conclusion: There were good knowledge and a positive attitude of primary healthcare physicians regarding depression; however, their practice was poor. Copyright:

Introduction

About 20% of adult people attending urban primary healthcare (PHC) clinics have depression,[1] one of the main public health problems all over the world.[2] Depression has been related to a raised risk of chronic diseases,[3] decreased health-related quality of life,[4] poor social role performance,[5] and excess mortality.[6] Although effective depression management strategies occur,[7] most of the depressed individuals do not receive the timely evidence-based, high-quality care they need,[8] causing a higher risk of recurrence and worse results.[9] Moreover, a poor mental health human resource is a significant contributor to the under-use of the best available method.[10] A great solution to these informational and financial barriers in PHC is to reconstruct clinical responsibilities to healthcare individuals with due training and supervision.[11] Thus, a team-driven approach to practice would be necessary to increase working capacity through collaborative care, a primary component for the development of effective integrated behavioral healthcare.[12] In 2013, the World Health Organization (WHO) report on Mental Health Systems in Latin America and the Caribbean expressed the pressing need to increase the training opportunities for undergraduate healthcare students and PHC doctors to learn about mental health.[13]

The importance of depression as a global and significant public health problem and the importance of primary care-based support for most of the people with depression are now well recognized. WHO reports that depression is the main cause of disability and the fourth causing contributor to the worldwide burden of disease. Now, depression is the second cause of disability-adjusted life years in the age between 15 and 44 years for both sexes. However, at present, a large proportion of individuals with depression remain with their condition unrecognized or do not obtain appropriate support or treatment.[14] Primary care support for mental health has been known as the provision of primary preventive and curative mental healthcare at the first contact of entry into the healthcare system.[15] However, Maxwell et al. (2008)[16] reported that general practitioners/family physicians do not treat depression alone. Individuals who are experiencing distress symptoms and misery seek to address these experiences. In this way, they may seek support and help from a doctor but may also access other forms of support, including from within the social community. The treatment of common mental health problems causes a very high burden on primary care; treatment options are confined mainly to medication (which may not be effective as a first-line response for mild to moderate depression and anxiety) and psychotherapeutic and psychosocial treatments.[17]

Martínez et al. (2019)[18] concluded that psychosocial clinicians performed better than biomedical clinicians in the assessed skills. Also, there are a high level of accomplishment in the relationship with the patient, medical anamnesis, health checkup, and lab test requests; heterogeneous performance in-patient management according to screening results, feedback to the patient, and registration in clinical records; and significant deficiencies in the differential diagnosis of bipolar disorder.[19] Odejide et al.[19] (2002) concluded that before training, the health workers had poor knowledge of depression. None of the participants could mention any anti-depressants. There were significant improvements in knowledge post training, with the highest gain in knowledge occurring in drug management of depression. General outcome evaluation 8 showed a significant increase in knowledge and skills for the recognition and management of depression. Barley et al.[20] (2011) conducted a systematic literature search to identify qualitative and quantitative studies published in the United Kingdom since 2000 of general practitioners’ and practice nurses’ attitudes to the management of depression. The study concluded that the studies of managing patients with a primary diagnosis of depression indicated that general practitioners and practice nurses are not sure of the relationship between mood and social problems and of their role in treating it. Among some physicians, ambivalent attitudes to working with depressed people, a poor level of confidence, the use of a limited number of management choices, and a belief that a diagnosis of depression is stigmatizing complicate the management of depression.

Methods

A descriptive cross-sectional study was conducted on clinicians who are working in cluster 1 whose age is between 24 and 60 years.

• Study groups: One group of PHC clinicians.

• Study Tools: A self-administrated questionnaire was distributed to every physician in the primary healthcare of cluster 1 to measure the understanding of the disease and the appropriate way to deal with it.[9]

Ethical consideration:

The study was approved by the Institutional Review Board (IRB) committee at King Saud medical city with number H1R1-03-May21-01 on 11/5/2021.

Statistical analysis

The SPSS program was used for data analysis, with version 22.0. Descriptive statistics was performed. A P value of 0.05 or less will be significant.

Results

The present study included 235 medical personnel; the mean ± standard deviation (SD) of the age of participants was 29 ± 3 years old. There were 145 (62%) males and 89 (38%) females. The large majority of participants were residents 222 (94.9%), whereas specialists were 12 (5.1%) only, Table 1.

Table 1

Demographics

	n	%
Age (mean±SD)	29	3
Gender
Male	145	62.0%
Female	89	38.0%
Position
Resident	222	94.9%
Specialist	12	5.1%

The level of knowledge of participants was investigated through five questions; the questions of knowledge and the answers of participants are shown in Table 2. There were 186 (79.5%) who had high knowledge, whereas 48 (20.5%) had low knowledge [Table 2].

Table 2

Level of knowledge about depression

	n	%
The physician must perform a screening for depression on a 70-year-old patient with suspected depression who attends a routine geriatric check-up
No	7	3.0%
Yes	217	92.7%
I do not know	10	4.3%
Physicians must follow steps to detect and diagnose a moderate depressive episode and sub-clinical hypothyroidism on a 35-year-old female who is referred by another member of the PHC team
No	14	6.0%
Yes	183	78.2%
I do not know	37	15.8%
Are you aware of DSM-5 criteria for depression?
No	1	0.4%
Yes	226	96.6%
I do not know	7	3.0%
The physician must create a treatment plan for a 27-year-old female with a moderate depressive episode with no suicide risk
No	14	6.0%
Yes	203	86.8%
I do not know	17	7.3%
The physician must initiate Selective Serotonin Reuptake Inhibitor (SSRI) to a newly diagnosed depressed patient
No	69	29.5%
Yes	123	52.6%
I do not know	42	17.9%
Knowledge
Low knowledge	48	20.5%
High knowledge	186	79.5%

The attitude of participants was investigated through seven questions; the large majority, 214 (91.5%), had a good attitude, whereas 20 (8.5%) had a poor attitude. The total attitude and the details of the attitude of participants are shown in Table 3.

Table 3

Attitude toward depression

	n	%
I feel confident and comfortable to diagnose and discuss depression with patients
Strongly disagree	11	4.7%
Disagree	15	6.4%
Neutral	31	13.2%
Agree	113	48.3%
Strongly agree	64	27.4%
I feel confident selecting appropriate pharmacotherapy for depression treatment
Strongly disagree	10	4.3%
Disagree	26	11.1%
Neutral	57	24.4%
Agree	84	35.9%
Strongly agree	57	24.4%
It is my responsibility to treat and manage depressed patients
Strongly disagree	4	1.7%
Disagree	9	3.8%
Neutral	44	18.8%
Agree	92	39.3%
Strongly agree	85	36.3%
Depressed patients are better off managed by a mental health specialist than family medicine
Strongly disagree	30	12.8%
Disagree	95	40.6%
Neutral	50	21.4%
Agree	48	20.5%
Strongly agree	11	4.7%
It is difficult to differentiate between a patient presenting with unhappiness and a clinical depressive disorder
Strongly disagree	35	15.0%
Disagree	102	43.6%
Neutral	31	13.2%
Agree	65	27.8%
Strongly agree	1	0.4%
Depression can impact the quality of life for individuals
Strongly disagree	4	1.7%
Disagree	0	0.0%
Neutral	7	3.0%
Agree	42	17.9%
Strongly agree	181	77.4%
There are reliable and easy-to-follow algorithms to guide treatment and follow-up for depression diagnosis
Strongly disagree	7	3.0%
Disagree	17	7.3%
Neutral	75	32.1%
Agree	103	44.0%
Strongly agree	32	13.7%
Attitude
Poor attitude	20	8.5%
Good attitude	214	91.5%

There were four questions to investigate the practice of participants regarding depression. There were 169 (72.2%) who reported poor practice, whereas 65 (27.8%) reported good practice. The details about the practice of participants about depression are shown in Table 4.

Table 4

Practice toward depression

	n	%
Limited clinical time to obtain history regarding patient depression
Rarely	15	6.4%
Sometimes	69	29.5%
Most of the time	98	41.9%
Always	52	22.2%
The patient is reluctant to accept a diagnosis of depression
Rarely	38	16.2%
Sometimes	134	57.3%
Most of the time	56	23.9%
Always	6	2.6%
The patient is reluctant to be referred to mental health services
Rarely	44	18.8%
Sometimes	83	35.5%
Most of the time	80	34.2%
Always	27	11.5%
Lack of access to mental health services available to patients
Rarely	26	11.1%
Sometimes	114	48.7%
Most of the time	70	29.9%
Always	24	10.3%
Practice
Poor practice	169	72.2%
Good practice	65	27.8%

There were no factors found to affect the level of knowledge; the age of participants (P = 0.056), gender (P = 0.055), and their position (0.07) had no significant impact on the knowledge of participants [Table 5].

Table 5

Correlation between knowledge and demographics

	Knowledge				P
	Poor knowledge		Good knowledge
	n	%	n	%
Age (mean±SD)	28	2	29	3	0.056
Gender
Male	24	50.0%	121	65.1%	0.055
Female	24	50.0%	65	34.9%
Position
Resident	48	100.0%	174	93.5%	0.071
Specialist	0	0.0%	12	6.5%

The demographics of participants had no significant impact on their attitude, age (P = 0.72), gender (P = 0.24), and position (P = 0.27), Table 6.

Table 6

Correlation between attitude and demographics

	Attitude				P
	Poor attitude		Good attitude
	n	%	n	%
Age (mean±SD)	29	2	28	2	0.72
Gender
Male	10	50.0%	135	63.1%	0.24
Female	10	50.0%	79	36.9%
Position
Resident	20	100.0%	202	94.4%	0.27
Specialist	0	0.0%	12	5.6%

Regarding the practice of our participants, there was no significant correlation between the level of practice and age (P = 0.075) nor gender (P = 0.059), whereas there was a significant correlation between the position of participants and the level of practice (P = 0.027), Table 7.

Table 7

Correlation between practice and demographics

	Practice				P
	Poor practice		Good practice
	n	%	n	%
Age (mean±SD)	29	3	28	2	0.075
Gender
Male	111	65.7%	34	52.3%	0.059
Female	58	34.3%	31	47.7%
Position
Resident	157	92.9%	65	100.0%	0.027
Specialist	12	7.1%	0	0.0%

Discussion

Depression is a significant global and public problem. PHC physicians play an important role in the diagnosis and management of depression.[21] This study reports the level of knowledge, attitude, and practice of primary healthcare physicians regarding depression. The majority of physicians showed good knowledge about the diagnosis and management of depression. Also, the large majority of physicians (91.5%) showed a positive attitude toward the diagnosis and management of depression. However, there was no factor found to affect the level of knowledge or attitude; the demographics of participants, including age, gender, and position, had no significant impact on the level of knowledge and attitude of physicians. The contrary was found regarding practice, where most physicians reported poor practice and only a few percentages reported good practice regarding diagnosis and management of depression. The position of physicians was the only determinant factor for the level of practice. However, we could find that the poor practice was related to the patients themselves, where the patients tended to be reluctant to accept depression diagnosis and referring to mental health services. Therefore, further factors related to the patients and physicians at the same time should be investigated to understand the reason for the poor practice of physicians regarding the diagnosis and management.

In Abha, Saudi Arabia,[22] PHC physicians had unsatisfactory knowledge about psychiatric diseases, including depression, with several gaps of knowledge. The attitude of the physicians toward the management was mainly positive, which was similar to our study. The knowledge and practice of physicians are required to be improved by attending continuing medical, educational sessions. Similar to our study, it was found that the level of knowledge was not influenced by any of the following factors: age, gender, or position. Also, the attitude and practice of the physicians did not differ according to the personal characteristics of physicians.[22] Another Saudi study by Al-Atram was conducted on physicians in Riyadh; the study revealed that general practitioners and specialists showed a negative attitude toward psychiatric patients, whereas family practitioners showed a positive attitude. The level of knowledge among participants varied regarding depression and anxiety.[23] As far as we know, there was no previous Saudi study conducted on the current subject, so further studies are recommended in order to understand the level of knowledge, attitude, and practice of PHC physicians regarding depression diagnosis and management. These studies enable the researchers to determine the gaps in the knowledge, attitude, and practice and therefore suggest suitable solutions.

A study similar to ours was reported from Cameron[21]; the study was conducted on primary healthcare providers in order to investigate the knowledge, attitude, and practice regarding depression. The study revealed that PHC physicians had limited knowledge and a negative attitude toward depression, which was in contrast to our findings, and this indicates that our physicians had a higher level of knowledge and positive attitude compared to physicians in Cameroon. Moreover, there was inadequate practice regarding the diagnosis and management of depression, which was similar to our study.

A cross-sectional survey that included 72 general practitioners from Nigeria showed that there was limited knowledge about depression among participants and the physicians showed moderately stigmatizing attitudes toward patients with depressions.[24] In Tanzania, a total of 14 PHC physicians were involved. The study demonstrated that the participants had a positive attitude toward the psychological and pharmacological treatment of depression. However, the authors suggested that there was a need to strengthen the training of the physicians about the diagnosis and detection of depression, psychological interventions, and pharmacological treatments.[25] Similarly, in Zambia, it was reported that there was an urgent need to conduct more effective awareness training and educational programs for healthcare providers.[26] In Hong Kong, it was found that two-thirds of the primary care physicians were prepared to look after the depressed individuals, but the experienced doctors in Hong Kong had negative attitudes toward mental health patients compared to younger ones.[27] All these studies reveal limited general knowledge and a poor attitude and practice, which were general and globally. This encourages conducting more studies on such subjects and focuses on depression as there were a few studies on this subject.

Conclusion

This study revealed that there were good knowledge and a positive attitude of primary healthcare physicians regarding depression, but their practice was poor. Therefore, educational and training programs and sessions should be established to increase the practice of physicians by encouraging them and directing them to the correct practice with individuals with depression.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.