Marsha N. Wittink

Although antidepressants and counseling have been shown to be effective in treating patients with depression, non-treatment or under-treatment for depression is common especially among the elderly and minorities. Previous work on patient preferences has focused on medication versus counseling, but less is known about the value patients place on attributes of medication and counseling. Conjoint analysis has been recognized as a valuable means of assessing patient treatment preferences. We examine how conjoint analysis be used to determine the relative importance of various attributes of depression treatment at the group level as well as to determine the range of individual-level relative preference weights for specific depression treatment attributes. In addition we use conjoint analysis to predict what modifications in treatment characteristics are associated with a change in the stated preferred alternative. 86 adults who participated in an internet-based panel responded to an on-line discrete choice task about depression treatment. Participants chose between medication and counseling based on choice sets presented first for a “mild depression” scenario and then for a “severe depression” scenario. Participants were given 18 choice sets which varied for medication based on type of side effect (nausea, dizziness, and sexual dysfunction) and severity of side effect (mild, moderate, and severe); and for counseling based on frequency of counseling sessions (once per week or every other week) and location of the sessions (mental health professional’s office, primary care doctor’s office or office of a spiritual counselor). Treatment type (counseling vs. medication) appeared to be more important in driving treatment choice than any specific attribute that was studied. Specifically counseling was preferred by most of the respondents. After treatment type, location of treatment and frequency of treatment were important considerations. Preferred attributes were similar in both the mild and severe depression scenarios. Side effect severity appeared to be most important in driving treatment choice as compared with the other attributes studied. Individual-level relative preferences for treatment type revealed a distribution that was roughly bimodal with 27 participants who had a strong preference for counseling and 14 respondents who had a strong preference for medication. Estimating individual-level preferences for treatment type allowed us to see the variability in preferences and determine which participants had a strong affinity for medication or counseling.

Background and Objectives Older African Americans are often under diagnosed and under treated for depression. Given that older African Americans are more likely than whites to identify spirituality as important in depression care, we sought to understand how spirituality may play a role in the way they conceptualize and deal with depression in order to inform possible interventions aimed at improving the acceptability and effectiveness of depression treatment. Design Cross-sectional qualitative interview study of older African American primary care patients. Participants and Setting Forty-seven older African American patients recruited from primary care practices in the Baltimore, MD area, interviewed in their homes. Measurements Semi-structured interviews lasting approximately 60 minutes. Interviews were transcribed and themes related to spirituality in the context of discussing depression were identified using a grounded-theory approach. Main Results Participants in this study held a faith-based explanatory model of depression with a particular emphasis on the cause of depression and what to do about it. Specifically, participants described depression as being due to a “loss of faith” and faith and spiritual/religious activities were thought to be empowering in the way they can work together with medical treatments to provide the strength for healing to occur. Conclusions The older African Americans in this study described an intrinsically spiritual explanatory model of depression. Addressing spirituality in the clinical encounter may lead to improved detection of depression and treatments that are more congruent with patient’s beliefs and values.

Crossing the Quality Chasm¹ called for a vision of the health system that is more responsive to the wishes and preferences of patients. Nowhere is the quality of care more dependent on eliciting patient and family wishes and values than in the arena of end-of-life care. Quality end-of-life care, as outlined by Singer and colleagues,² depends on eliciting the preferences of patients and families regarding the following goals: receiving adequate pain and symptom management, avoiding inappropriate prolongation of dying, achieving a sense of control, relieving the burden on loved ones, and strengthening relationships with loved ones. Nevertheless, various studies revealed that 4 in 10 dying patients had severe pain most of the time,³ almost half of incurably ill patients with advanced dementia and metastatic cancer received nonpalliative treatment,⁴ and bereaved family members believed that communication concerning end-of-life care issues was poor.⁵ Efforts to improve the experience of patients and families at the end of life must incorporate patient perspectives. Advance directives are 1 strategy through which patient preferences can be elicited and recorded, to be invoked at a time when the patient may not be able to make decisions directing care. Since advent of the Patient Self-Determination Act, hospitals, nursing homes, and health care programs have been required to ask patients about advance directives and to incorporate the information into medical records. Physicians are being encouraged to work with patients and families to complete advance directives in the outpatient setting. Despite the emphasis on eliciting and documenting preferences for good quality end-of-life care, to our knowledge, factors related to clinical aspects of eliciting end-of-life preferences, such as stability of choices, have not been extensively studied in community-dwelling older adults.

Past research has suggested that patients might not accept depression treatment in part because of differences between patient and doctor understandings of depression. In this article, we use a cultural models approach to explore how older adults incorporate clinical and experiential knowledge into their model of depression. We conducted semistructured interviews about depression with 19 patients aged 65 years and older who were identified by their physicians as depressed. We found that whereas older adults viewed as helpful the doctor's ability to identify symptoms and “put it all together” into a diagnosis, they felt that this viewpoint omitted important information about the etiology and feeling of depression grounded in embodied experience and social context. Our findings suggest that more emphasis on issues related to the etiology of depression, the effect of depression on social relationships, and emotions emanating from depression might lead to more acceptable depression treatments for older adults.

Background: Recommendation of mammography may be particularly important for older women; nevertheless, physicians are less likely to recommend mammography to older women. Our objective was to examine the characteristics of older patients for whom primary care physicians recommend mammography. Methods: Two hundred sixteen women aged 65 to 80 years were screened for depressive symptoms in primary care offices and invited to participate. They then completed a baseline in-home assessment between 2001 and 2003. At the time of the baseline in-home assessment, mammogram use and psychological status were assessed with commonly used and validated standard questionnaires. At the time of the index visit, physicians were asked to provide assessments of the patients. Results: Patient-reported physician recommendation of mammography was more likely among patients the physicians rated as anxious than among patients the physicians rated as not being anxious (unadjusted odds ratio, 2.08; 95% confidence interval, 1.10–3.94). In multivariate models that controlled for physician ratings of knowledge of the patient, the association between physician rating of anxiety with patient-reported physician recommendation of mammography remained significant. Patient-reported physician recommendation of mammography was not significantly more likely among patients the physicians rated as depressed than among patients the physicians rated as not being depressed (unadjusted odds ratio, 1.57; 95% confidence interval, 0.86–2.85). Conclusions: Identification of anxiety may influence the recommendation of mammography among primary care physicians. An understanding of factors that influence the recommendation of mammography by primary care physicians may have important implications for interventions to improve rates of mammography use among older women.

We wanted to understand concordance and discordance between physicians and patients about depression status by assessing older patient's views of interactions with their physicians. We used an integrated mixed methods design that is both hypothesis testing and hypothesis generating. Patients aged 65 years and older, who identified themselves as being depressed, were recruited from the offices of primary care physicians and interviewed in their homes using a semistructured interview format. We compared patients whose physicians rated them as depressed with those whose physicians who did not according to personal characteristics (hypothesis testing). Themes regarding patient perceptions of their encounters with physicians were then used to generate further hypotheses. Patients whose physician rated them as depressed were younger than those whose physician did not. Standard measures, such as depressive symptoms and functional status, did not differentiate between patients. Four themes emerged in interviews with patients regarding how they interacted with their physicians; namely, "My doctor just picked it up," "I'm a good patient," "They just check out your heart and things," and "They'll just send you to a psychiatrist." All patients who thought the physician would "just pick up" depression and those who thought bringing up emotional content would result in a referral to a psychiatrist were rated as depressed by the physician. Few of the patients who discussed being a "good patient" were rated as depressed by the physician. Physicians may signal to patients, wittingly or unwittingly, how emotional problems will be addressed, influencing how patients perceive their interactions with physicians regarding emotional problems.