An Exploratory Analysis of the Attitudes of Family Physicians towards Depression in Primary Care:

An Application of Dual Scaling

Kathryn L Parker

A Thesis submated in conformity with the requirements for the Degree o f Master of Arts

Deparment ofcurriouhun, Teachg and Learnhg Ontario Institute for Studies in Education of the

University of Toronto

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Canada

Kathryn Parker AN EXPLORATORY ANALYSE3 OF ATTITUDES OF FAMILY PHYSICIANS TOWARDS DEPRESSION IN PRDlARY CARE: AN APPLICATION OF DUAL SCALING Graduate Department of Education, University of Toronto Master of Arts, 1999

Abstract

An anaiysis of attitudes of family physicians towards depression was conducted using qualitative

methods and dual soaling. Data fiom a focus group, a literature review and fàce-to-&ce interviews

aided m the development of an attitude m y . The 35 item survey was admmistered to 400

Ontario fàmiiy physicians. Dual scaling was conducted usmg the data f?om the m e y and

generated attitude profiles of survey respondents. Dual scahg was also helpfùi in determinhg the

association of gender, work environment and length of practice with swey items. Attitude

profiles support the iqlementation of a shared care mode1 m which both the famify physician and

the psychkttrist play vitd roles m the treatment of depression m primary care. Accesshg

psychtnsts for consultations is one of the barriers to shared care identified by these fa-

physicians. Work enviromnent and length ofpractice are associated with attitude items.

Acknowledgements

1 wodd sincerely iike to thank Dr. han Sihrer, Dr. Ross Traub and Dr. Shinihiko N i i t o for

their guidance, supervision and support throughout the presentation of the present thesis.

A note of gratitude is expressed to Dt. Jay Moss, Mr. Michael Floro and Dr. Dave Davis for their

support and kind efforts.

Dedication

Dedicated to my beloved parents7 Raymond and Beverley Parker, and to my dearest sister, Laura

h o s e constant support, love and guidance is uncondirionaL

Table 3.1 Table 4.1

Table 4.2

Table 4.3

Table 4.4

Table 4.5

Table 4,6 Table 4.7 Table 4.8 Table 4.9

Table 4.10

Table 4.11 Table 4.12 Table 4.13

Table 4,14

Table 4.15 Table 4.16 Table 4,17

Table 4.18

Table 4.19

Table 4.20

Table 4.21

Table 4.22

List of Tables

Focus group questions Pge 16 S w e y items reflecting attitudes towards psyc hia trists

S w e y items reflecting attitudes towards depressed patients

S w e y items reflecting attitudes towards treatment of depression

S w e y items refïecting attitudes towards depnssion as an iünas Gender, years since graduation hom medical school and current work environment of the reapondenb, n=lS2

Response fkequencies for physicians attitude survey, 11452 Solution statistics for attitude profile #1 Item correlations for attitude profie #1 Survey items describhg attitude profde #l with a correlation of .450 or greater Dominant reaponse options and corresponding option weights for attitude profiie #l items Solution statistics for attitude profiie #Z Item correlations for attitude prof* #2 Survey items dacribing attitude profde #2 with a correlation of .450 or greater Dominant response options and corresponding option weights for attitude profde #Z items

Solution statistics for the shared care attitude profde Item correlatio.n~ for the shared care attitude profde Survey items deaeribing the shared care attitude profde with a correlation of .450 or greater Dominant reaponse option, and corresponding option weighta for the shared care attitude profie items Survey items correlated with criterion item "work environment*

Weights for criterion item ÿvork environmentH and nsponse option weights for correiated items Survcy i tem correlated with criterion item "years since graduation* Weights for criterion item ÿ e a r s since graduation* and raponde option weighb for correiated items

Table of Contents

Abstract

Acknowledgements

Dedicatiou

List of Tables

1, IMRODUCIION 2. LJTERATURE REVIEW

2.1 What is depression? 2.2 Epidemiology and prwalence of depression m Cimada 2.3 The burden of depression 2.4 The problem of depression m primary care 2.4 Attitudes of fhdy physicians towards depression - A lack of &dence

m Canadian fiudy physicians

3, ME:TEIOD 3.1 Focus group 3.2 Face-to-&ce interviews 3.3 Survey construction 3.4 Dual scaüng

4, RESULTS 4.1 Focus group and mterviews 4.2 Smey - construction 4.3 Survey - prelimmpry re&s 4.4 Dual scaling re&s

5. CONCLUSIONS AND RECOMMENDATIONS

References

Chapter One

LNTRODUCTION

In Canada, depression is a cornmon ühiess in primary care patients. Family physiciaus, m

parti&, have noted a . bcrease m the prevalence of depression m their practice over the lad

decade. Lt has been widety documented that depressed patients pose a signincant chical

problem for fémüy physicians (Ankmsson & Zich, 1990). Issues such as diagnostic problems

and under-treatment are listed as some of the perceived b&s to optimal c m . Furthemore,

ahhough fàmiiy physicians have reported an increase m confidence m diagnoshg depression in

their practice (Banazak, 1996), barriers to effective treatment is stül a topic of concem. In

order to address the problems associated with the treatment of depression m niriiS, practice,

educatoa have bem active m design& W t i v e s that aim at soiving the problems of

recogniPng and treatmg depression.

It has been suggested by maay educaton that effective educational initiatives for physicians

should result m a change m the sküls, knowledge set and/or attitudes of the physiciaa Various

continuhg medicd education mterventions have attempted to measure change (Davis et al.,

1993). Commcm methods used to measure change mchide instruments aimed at measuring

physician knowledge (pre and post event), physician satisfaction and, more unusunY,,

evaluating prescription pattern up to six months post-educationd intervention. They say very

linle, however, about change m physician attitudes. (3ne of the possible barriers to optimal

treatment of depression h primary care may be the attitude of the fàmiiy physician towards

various aspects of treating these patients Before aiming to change physician attitudes,

examination of m e n t attitude profiles of Canadian family physicians t o w d s treathg

depression m their practice is required While physician attitudes towards mental illness and

depression have been the focus of a few mtemational studies, the investigation and

meawement of various attitudes of Canadian fhdy physicians towards depression is lacking

. Furthemore, it is not known if demographic variables such as a physician's gender, work

environment or length of practice f i e n c e s their attitudes towards depression m theg

practice.

Combmmg both qualitative and quantitative methodologieq this papa is an exploratory

andysis of the attitudes of Canadian h d y physicians towards mental illness and depression m

their practice. This papa also explores the efFects of gender, work environment and number

of years pra*ismg fbdy medicine on these attitudes of nimüy physicians.

A review of erasiing literature on attitudes towards depression in fàmiîy practice ühistrated the

need to investigote the role of attitudes as possiile baniers to optimal care. A mini-focus

group offarirhr physicians and &c,ceto-face m t e ~ e w s were then conducted to coîiect

qiislitative daîa on prevailing attitudes of fhdy physicisns towards depression m th&

practice. Data acquired fiom the focus group and interviews dong with the iiterature review

aided in the construction of a survey which was distrr'buted to fhmily physicians,

The data obtained fiom the m e y were subjected to a principal component -sis (PCA)

for categorical datacalled dual scaling. The r?se of dual scaling enabled this researcher to

answer two imp oamt research questions:

1) Are there part ich categories (or 'profiles'') of anitudes held by fàmily physicians towards

treating depression?

2) Are variables such as gender, work environment and/or nurnber of years praçcismg fanllly

mediorne correlated with attitude "profiies" of faniüy physicians towards treating depression?

Answering these questions may lead to a better understandhg of the attmides held by fàmily

physicians towards the treatment of depression m primary care. A better understendhg of

physician attitudes may benefit educaton who take interest m teachhg these physicians about

optimal treatment strategies. Knowledge of attitude profiles may aid m the assessrnent of

leaming needs and the development of education programs.

Chapter Two

LITERATURE REVIEW

WHAT IS DEPRESSION?

Depression is a chronic h e s s characterized by the presence of one or more depressive

episodes (DSMIV). A depressive episode Iasts at Ieast 2 weeks, during which the mdIvidual

eqexiences depressed mood or loss of interest or pleasure in d d y actMties as well as a

composite of the foilowing symptoms; weight loss or a decrease in appaite, hsomnia or

hypersomnis, psychomotor agitation or retardation observable by others, fhtigue, feelings of

worthlessness or excessive guih, Ammiiled ability to thmk or concentrate, or recurzent

thoughts ofdeath. One of the most miportant aspects of the diagnosis of depression is the

presence of mnrked disaess or mipairment m social or occupational hctionmg. A decrease in

quality of life is also a consequence of depression.

EPIDEMIOLOGY AND PREVALENCE OF DEPRESSION IN CANADA

Depression is a Secious ihess affecthg over 2 million Canadians muaîiy. It has been

reported that 1 m 5 North A d c a n s wiil expe0ence a depressive episode at some pomt m

th& Wetime (Joffe and Levin, 1996). Revalaice rates for depression varies across provinces.

One-year prevdence estimates for depression in the province of Ontario have been reported to

be 4.2% in urban areas and 3.2% m m a l cornmiinities (Parikh et al., 1996). In Edmonton,

sixmonth prevalence for a depressive episode is 3.2% (Bland et ai., 1988). rii the province of

Quebec, Kovess et ai. (1990) found that roughly 3.1% of the province's population d e r

fiom a depressive disorder at any one time.

A depressive episode can occur at any age. The prevalence rates are highest between 15 and

24 years for women and between the ages of 25 and 44 for men (mord et a l , 1996). Women

are more iikely to report a depressive episode. However, due to under-report@, Ét is

estimated that depressive episodes may o c a u as fiequently m men as in women. The mortality

of patients with mood disorders is 42-50% higher than in the general population. Furthemore,

the W h e suicide rate for depression is 2.5% (Blainvest, 1997). Reports mdicate that 40-

50% of ail suicides involve individuais with undiagnosed or under-treated depressive disorders

(lonsson & Rosenbaum, 1993).

THE BURDEN OF DEPRESSION

Several studies have mdicated that depression is strongiy associated with occupationai

disabiiay (Broadhead et al, 1990; Fredman et al., 1988; Wells et ai., 1989). In the province of

Ontario. Parikh Bt aL (1997) reported that 32.8% of those with a mood disorder reported 1 or

more days with total worldactivity disab* in a one month pe!riod, aimost 3 times the

percentage reported by those with no mood disorder cikgnosis.

The economic burden of depression is strüring. Studies m the U.S. (Greenberg et al., 1993)

conclude that the annual costs of depression is approximately $43.7 billion with 28%

attributed to direct costs such as mpatient and outpatient care, 17% atüibuted to mortaiity

cos&, and 55% due to morbidity costs nich as reduction m productive capacity and days lost

at work

THE PROBLEM OF DEPRESSION IN PRIMARY CARE

Depression poses a sexious problem for the famüy physician (Miranda et d, 1994). Eigh

prevalence of depression m primary care, low detection rates, and suboptimal treatments have

led many educators to target fhmiiy physicians as a population in need of educatioxtal

initiatives designed to address these deficits (Craven et ai., 1997). It has been estanated that

the prevalence of depression m a primary care setthg ranges âom 5925% h the United States

(Klinkmaa et aL, 1997, Zung a al., 1993). Furthemore, almost 40% of hdividuals

diagnosed with an afkctive disorder employ ody their fàmily physician for diagnosis and

treatment of the disorder (Parikh et ai., 1997). Family physicians in Ontario who responded to

a m e y , conducted at the Clarke Institute of Psychiatry, mdicated that, on average, 26.4% of

their practice is comprised ofpatients who d e r sole@ fiom mental ilInes with the mejority

ofthese patients SUffering fkom a depressive disorder.

Diagnmis

There are several b&s to diaposing depression by fm physicians. B a n k s found by

Docherty (1997) mclude both patient-related and physician- related factors. Patient Lctors

mciude the foliowhg. Firstiy, depressive symptomatology often occurs conmently with

symptoms of a medical iihess, thus, makmg a diaposis of major depression more difEcuit. A

diagnosis of depression is more Iütely to ocnrr if the patient is aware of it's symptomatology

and is able to articulate the particuiar symptoms of depression to their hdly physician.

Conversely, feelings ofhelplesmess or hopelessness, mdicative of depression, can often leave

the patient feeling unworthy of seekhg help. Thus, they are less likely to c o d c a t e these

symptoms to the fitrdy physiciae Phytician-related barriers hciude certain beliefk and attitude

barriea as weli as knowledge and ddl deficits. An mcreased likelihood ofdiagnosing

depression is associated with the physicians' belief that they c m effective@ treat the iüness as

wen as a confidence m the effectiveness of treatments for depression. Furthemore, tiimüy

physicians are more orientai towards the diagnoses ofmedical illnesses, or the assesment of

physical symptoms wbich lead to a diagnosis of an organic &es. It is common for f h d y

physicians to overlook ailments which have a significant psychological component (ShuDbmg

et al., 1986). In order to fàoilitate an accurate diagnosis of depression, it has been

recommended that physinaiis exnploy a screening tooL (Magruda-Habib et ai., 1990).

However, a recent shidy whioh examined treatment of depressed elderly patients by primiry

Gare phpicians concluded that only 25% ofphy9cians routineiy use a screening tool to detect

depression m th& practice (Banan& 1996).

Treatment

F a d y physicians have diiiiniity providmg adequate treatment for depression. In a recent

study by Matthews et al. (1993), 26% ofthe physicians surveyed indicated an mabüity to

make an Wormed decigon about antidepressant treatment. Simon et al (1995) foimd that

primary care patients 6equentty receive less than adequate doses of antidepressants and are

o h discontinued nom the medications before the optimal dose cm be realized. M e r studies

(Web et al, 1994, Matthews et al., 1993, EkchfeId et ai., 1997) have drawn similar

conchuions. The reasons for the under-treatment of depression in primary care may mchde

madequate teachmg in medical school, residency training and contÎnUing education. The

National Depressive and Manic-Depressive Association's co11sex1sus statement on the under

treatment of depression (1997) listed clinician factors which contribute to the under treatment

of depression. These inchde not oniy hadequate trainmg m detectmg depression but also

m d c i e n t education m mterpersonal skills, faihire to consider p sychotherap eutic treatments,

stigma and madequate thne to assess and treat depression.

Patienb

Depression in primnry care is often more dîfEcuh to treat due to various beliefk held by

patients with depression, Not surprismgiy, b&s to optimal treatment are oten buüt fiom

the reiuctame of the patient to disctose the problem. Initial presentatîon of depressive

symptomatology to the primary care physician may be hidden by the patient for several

reasons Firstly, the patient m y believe that they have a better chance of being seen by the

fbdy physician ifthey avoid disc1osing my psychologicil symptoms (Katon, 1982).

Furthemore, the patient may be concemed about dimimmation m the workpiace or

stigmatization by peers ifdiagnosed with major depression. It has been reported that barriers

to treatment also inchde patient doubts about treatment beneas (Callahan et al, 1996). M e r

beiiefi held by patients mchue perceived lack of support from f h d y and fiiends and a lack of

understandmg of the *ess Tbis is commoniy echoed by patieats as the beiief that they are

"ma# and should be able to ' h a p out ofit".

ATTITUDES OF FAMILY PHYSICIANS TOWARDS DEPRESSION - A LACK OF EVIDENCE IN CANADIAN FAMlLY PHYSICWS

Attitudes of famüy physicians towards various aspects of mentai h e s s such as depression

have been examhed in countries such as Scotland (Lawrie et aL, 1996) the United States

(Dusynski d al, 1995), England (Monktey-Poole, 1995), Spain (Garcia-Campayo et al,,

1998, Markez, 1994, Nunez del Arco et al., 1992) end Venezuela (Baptista et al, 1993).

Accordmg to these studies, attitudes held by fhdy physicians towards mental iiJness reflect

concems about treatment issues. Physicians are confident m their ability to prescribe

antidepressants and they are confident that antidepressants yield satisfàctory resuhs m the

treatment of depression @odegr et ai., 1992, Kerr et ai., 1995, Shao et ai,, 1997). Attitudes

towards psychotherapy as a viable treatment for depression are llso positive yet the use of.

medications is more fàvourably endorseci. It is not known ifcmâian fiiroihr physicians &are

these attitudes.

~ v e n though phYsicians are confident m proviâing phumncologicai treatments rnd they view

treatmg depression as a responsiility m their practice (Banazak, 1996), phyticians prefer to

refer depressed patients to psychiatrists than treat depression themsebes. When compared

with psychiatrists physicians were found to be less cornfortable treatmg depression m their

practice and to view the work harder and less rewardhg than treating patients with a medical

ihess (Kerr et al., 1995). This may be due to thea perceived mabiüty to provide optimal care.

The relationship between abiiity to manage depression and codon level is a complex one. It

is likeiy that the physicians' attitude towards depression management would be more

Eivourable iftheir perceived ability to provide optimal care iniproved. Furthemore, positive

anmides towards managing patients with depression in primary care have been direct& W e d

to the expenence of successfiiy. treating depression (Danieh et al., 1986, Main et al, 1993,

vonK&& Myers, 1987).

The fàmüy physician's attitudes towards their patient may also be perceived as a barrier to

op- treatment. For example, their attitudes towards patients may invohre assigning blame

to the patient for magniSing the severity of th& symptoms and perpetuating the mess. In a

recent study, over 40% offamily physicians believe that patients cause the illness and that

patients are prone to exaggerating their symptoms (Shao et aLJ997). Physicians who endorse

these beliefs make fewet psychosocial assessments and often misdiagnose mental ihess

(Robbms et al., 1994). It is not known if Canadian f b d y physicians possess these attitudes.

ûne of the more hteresting attitudes held by famüy physich t o w d s the treatment of

mental illaes m primary Gare is the endorsement of a shared care modeL In shared care, the

treatment, and hence the long-tenn management, of these patients should mcorporate the

expertise of both the h d y physician and the psychiatrist. Garcia-Campayo (199%) M d that

famüy physicians viewed theruselves as a filter to specialised care by a psycbtrist for patients

with somatofonn disorders, whüe fady physicians focused on patients with cbronic physical

symptoms. Lake's schkophrenia study (1996) found that f k d y physicians are not wilüng to

have schizophrenic patients m th& practice and are likeb ta refer patients to a psychiatrist for

treatment. However, the fUmüy physician would be willing to treat schizophrenic patients for a

medical condition. While these studies do not reflect attitudes about the shared care model in

the treatment of depression specincally, these studies do provide a foundation for Mer

investigation mto this modeL

Canadian family physicians have reported Smilar attitudes towards a shared care modeL This

model is hi* aidorsed by famüv physicians y& unreaiized due to a perceived gap b w e - è n

the desired and the aotual role of the physician and the psychiatrist m the

treatmentlmanagement ofmental ilhiess. Accordhg to Craven's qutifitative research study

(1997), physicians view themsebes as monitors of pharmacologicai treatments and the

psychiatrists as the inidators. Fmhermore, fhdy pphysicians do not see themsehres as

practitioners of cognitive behaviour therapy as practised by psycbiatrists. Famüy physichs

primdly view themselves as practitioners ofwhat Craven c a b "supportive counse11nig9'

techniqyes. The actual cliaical picture, however, is quite Mixent. It is exceedmgly dZIicuit to

refer patients to a psychiatrkt for continuing care for reasons such as patient redance (Kates

et a l , 1992, and the low number ofpsychiatrists who are able to take on new patients. The

12

relationship between fàmily physicians and psychiatrkts also appears to be less than desirable.

There are a number of studies that Hidicate a lack of collegiality between these two disciplines

(Craven et aL, 1997, Cummins et al, 1980, Williams & Wallace, 1974). Famüy physicians

b e k e that their chical judgement is ofken undervahied by psychiaûkts. Furthemore, famüy

physicians have mdicated that comrmmicating with a psychiatxbt is o%en diflicuh. It has o f h

been cited by fhdy physicians that their treatment and management skilis would be enhanced

ifthe accessiibility to psychiatrists were improved (Craven et ai., 1997). A shared care mode1

wiE not be re-d mtil this gap, perceiived by f h d y physicians, between desired and actuai

roles in the treatment of this ihess is addressed.

In su-, depression is a seriouq debilitating ihess which has formidable consequemes for

the patient, the family and society. The number of fhdy physicians providmg treatment to

depressed patients is sisnificant and is moreas@. Furthemore, proMchg optimal treatment

for depression is a problem for fkdy physicians. Barriers to diagnosing and treating

depression m primaiy care has mchded both patient and physician factors. Various attitudes

towards depression may be barriers to optimd treatment. Attitudes towards treating

depression in Canada is splrse and deserves investigation. Hence, this p a p a hoped to

answer some of these previously unexplored questions about the attitudes of C m h fhdy

physicinas towards th& depressed patients.

Chapter Three

METHODS

This project seeks to explore and rneasure attitudmal baniers to changing the management of

depression by fhdy physicians by synthesPng qilalitative and qyantitative research

techniques. The advantage of using this composite of methodological paradigrns is the ab*

for the strengths of each method to compensate for the wealmesses of the other. Furthemore,

as suggested by Steckler (1992), m order to fiiY. understand the complexity of heahh

education systerns the application of both methodologies is warranted. This chapter details

three steps used in the exploration of the attitudes towards depression and mental ilhess of

Canadian famüyphysicbns, FÙ*, a focus group yielded quPlitatke data on barrias to

change that aided in the decision to explore attitudes about mental h e m . The focus group

data, d e n coupled with e-g üterature, provided the mgredients for the construction of an

attitude survey. The survey was distn'buted to a p u p of- physichns and dual scaling

analysis was then nui on the data to extract attitudinal profiles of these f h d y physicians.

3.1 The Focua Group

In order to help decide &ch of the many barriers to change should be examined fiirther, a

focus group was conducted wiih a d group of fbdy phygicians. Admtages to the

utilizaticm ofthis method when exploring the various baniers to change in mdIvidUZLJS are

numerous. In order to fidyunderstand some ofthe b&s to change m the treatment of

14

mental heahh patients, it was cruciai that the f b d y physiciaas felt at ease with exploring

various attitudes that may pos9bly be udkvorable towards various aspects of mental h e u

The focus group interview is often seen as a social arena for mdividuals that provides an

atmosphere of contentment and ease. This atmosphere o f t a promotes and suppoas the

sharia.g of ideas and attitudes that may not be extracted through other methods of data

colIection (surveys, questionnaires, and fàce-to-face interviews). The second advantage to

employhg this method of data collection is the ability of the researcher to scruthim. This

feature is not present m structwed methods of data colIection such as mail-out s u ~ ~ e y s .

Another important feature of focus group is their high face vaiidity; focus group data are oftan

presented m lay terminology congsting of quotations fiom group participants. Most

iniportantly, the focus group augmmted the idormation already obtained by the litmature

rewiew, thus sening as a second source for item constmction.

Focus group participants were chosen ushg a convenience samplmg procedure. Recruithg

numüy physiciaris for such a ta& cm be arduous; therefore, a kt of 8 fàmily physicisas was

provided by a CO-worker at the Sunnybrook Health Science Centre. This psychiatrkt

prewiously practiced Eimily medicine and was active in the trainmg of fàmiiy physicians prior

to spechking m psychîatry. These fbdy physicians were contacted hith& by phone to

describe the procedure of the shidy and of the focus group. M'ter initîd consent was obtpined

over the phone, each participant was sent a f o d Inter, detaümg the study, tirne and

location, and a consent fom, hdicatmg that th& identity wodd be known oniy to myseif and

my reseaich assistant and that theic names and any identifying characteristics would not be

1s

published without their consent. They were also @en the oppominity to ask for a copy of the

shidy's initial findings w i m avaüable. The participants were provided a dinner prior to the

start of the focus group and were provided a d honorarium for their participation. [fthey

were unable to attend the focus group, they were bvited to participate m a face-to-face

m t e ~ e w at a thne or location that was more agreeable for them.

The focus group was scheduled for the spring of 1997 at Sunnybrook Heahh Science Centre

for approrcîmateiy 2 hours. As the lead investigator, 1 was present to moderate the group and

take notes of the proceedhgs. A research assistant was employed as a . assistant moderator to

take detailed notes of the content and to document any relevant happenings during the group

(e.g. specXc changes m facial expressions). The session was also audio taped

Focus group questions were generated beforehand, and given to a f à d y physickn for review.

The famiIy physician was bstnicted to review each question for cl* and relevant

ternmiology. The revised questions were used with the group. The session began with each

member inaoducing her/himselfand giving the group a brief description of M e r m e n t

practice. Two mtroductory questions were then asked as a means of definhg the theme of the

session. Questions were then asked regardhg barriers to change. The list ofintroductory,

transition and key pestions asked during the group are provided m the foiiowing table.

Table 3.1 Focus group questions

1 Question Type

1. ûpeming Question

I 3. Transition Question

Question

Please mtroduce yourself and give a brief description of your curtent practice

1. Lfyou have a question about a depressed patient m your care, what source do your use most ofken to answer the question?

2. Teii me about your expaience with primary care patients wiîh depression?

1. Many educators are currently mterested in educating f h d y physicians about depression in primary care through formai evmts, such as conferences, semimus, workshops etc. Teil me about your experiences with such initiathes.

1. What fiictors encourage or promote change m your behaMour aiter such an event? Mer reading a jounxal article? M e r askmg a colleague? After accesrisig the Internet?

2. What factors do you thmL are necessary for educators to understand ifthey are to design events that wiii resuit in change in physician practice patterns?

3. Give me an ewmple ofa learning experience where you did change your behaviour as a result. This leamhg exp-ce could be a f o d event, reading a j o d article, askmg a colleagw, eqIoring the h t m e t etc.

4. GNe me an example of a leamhg experience where you did aot change your behaviour as a resuh.

The results of the focus group were then analyzed Immediateiy foilowing the session, the

audiotape was iistened to in order to review the material and complete any missing data. A

back-up copy of the audiotape was then produced The content of the focus group was then

transcnied. Extra copies of the transcript were made. A copy of the transcript was sent to

each participant for review. Participants were instnicted to comment of the content and cl*

ofthe transrript. Coding of the trBILsciipt was conducted by both myselfand my research

assistant. In order to eliminate possible biaq we coded our copies of the transaipt

independent@ Codhg procedures consisted of identifying possible barriers to change by

circling the comment on the amscript which refiected that barrier. Each barrier was named

and the number of times that each barrier was mentioned was noted. Mer codmg was

complete, we discussed the various baniers that we had identified. The b&s identified by

both of us were retained. A summary of those b8mers m tabuiar form is provided in the

resuhs chapter of this paper. We then coiiectiveiy reexaaiined the data that were not mchded

m the sunmuy and considered any revisions.

Ifphysicians were not able to participate m the focus grop, they were asked to engage m a

niceto-hce mteruiew. The mterview was conducted by me and my nsearch risistant. Out

research roles were similar to tbat of the focus group: my research assistant was responsible

for takhg notes and 1 conducted the h t d e w . Each i n t d e w was audio tape& The

qgestions'asked m the mterview were the sime questions that wae asked m the focus group,

18

with the exception.of the introductory question. Anaiysis of the interview data was smiüar to

analysis ofthe focus group data as descriied in the precedmg section.

3.3 Survey Construction

Focus group data were anaiyzed for baniers to change. Each banier to change to be hcluded

in the sutvey was determined using the following de r in : firstty, the banier had to be one that

figured prohentiy m the focus group and h t e ~ e w data. Secondly, the barrier had to be one

that has bem largely ignored m the Merature on Canadian b d y physicians. Fmalh,, the

barxie~ had to be intereshg to both this mvestigator and the conmninity of educators mvohred

in irnptoving the care of depressed patients m primary care as stated in the litmature. These

criteria were iniplemented for the purpose of selecting one or two b h s to focus on where

potentiany there could be numerous baniers identifie& The qualitative data on the barrier,

coupled with existing Liierature, provided the mformatioa c r u d to the dwelopment of each

item m the survey. Items for the survey were constructed by myselfand my research assistant.

The w e y incbided 35 items and asked participants to hdicate th& level of agreement with

each statement. Response options mchded strongiy disagree, disagree, mon& agree, agree

and no opinion. Demographic questions regarding gender, years since graduation âom

medical school and work environment was also inciuded m the m e y . Once the &st drsft of

the survey had bem constructeci, the instniment was givm to 3 fàmiiy physicians for feedback

on itemtetminology and cinnty. The instniment was then revised and presented again to a

group ofeducators for m e r suggestions. Suggestions Ïnade by the group ofedwtors were

implemented and the ha1 draft of the survey was constnrcted

The kalized survey was administered to a sample of Ontario family physicians at a local

educational event. The went, titled 'Saturday at the UaiVerw', is mounted annuaUy at the

University of Toronto and provides the f b d y physicians with an update on major medicai

ilInesses. These physicians worked m various environments such as hosptals, CO&

heahh centers and in private practice clinics. The participants were handed the nwey upon

regjstration and were esked to retum the completed survey to the regkation de& at the

conchision of the event.

The m e y collects data in the form of predetermined categones. Che of the methods of

an-g categorical data is dual scaling. Accordmg to practitioners of dual scaling, it is

defmed as principal component ady& for categorical data ( N i i t o , 1994). A more explkit

definition by N i i t o is as foiîows:

'M ~alÎng is a technique used to explore the hidden structure of categorical data through compIex mathematical manipulations" ( N i h t o , 1994)

Dual scaling anaiysis is appropriate for the analysis of attitudes for several reasons. Firdy,

attitudes are produas ofdiffaent individuai expiences. Dud scaling takes into a c c m t

individual response patterns rather t h overaging out responsea Secondty, we were able to

examine attitude "categoriesYy that may not have been expected. Furthemore, dual scaling

allows us to judge the importance of these "categories" m the data. The s p e d c purpose of

employing dud scalhg anasis is to answer the two research questions below.

1) Are there p a r t i a h categories (or 'profiles") of attitudes held by fàdy physicians towards

treateig depression?

2) Are variables such as gender, work environment andfor number of years practising f b d y

medicine associated with attitude 'profles" of family physicians towards treating depression?

There are two principles parti& to dual scaling which answer these questions. Fi.*, duaf

scaling explores the hidden structure ofcategorical data through the assignment of optimal

scores (assigned to subjects) and weights (assigned to response options) m order to optimize

Guttman's principle of mternal consistency, which is defhed as follows:

"Mgn as smiilar scores as possible to those subjects who chose the same option of a question, and these scores should be as diffaent as possible fiom the scores of those who chose otha options; assign as smiilnr weights as possible to those options which were chosen by one subject, and these option weights should be as Merent as possible f?om the weights of options which were not chosen by tbis subjeot" (NirshisPto, 1994)

The opthkation of Guttman's prmciple generates rmixbnaRy reîiable scores for subjects and

weights for response options. These sets of scores and weights provide an optimil composite

(or "sohrtiony') of seiationships inherent in the data. Furthemore, when the optirml solution

2 1

does not explain the data m an extensive way, a second set of scores and weights is generated

m order to explain the Hiformation in the data that was unexplamed by the nrst sohition. Then,

if the ha two solutions do not capture enough mformation Siherrnt in the data, a third set of

scores and weights is generated to explain the infoxmation unexplahed by the fist two

sohtions. This process is contmued mtil the desiied amount of information is explamed. Thiç

process is called muhidimensional decomposition of data. When interpretmg the resuhs of

rrmlfxdimensional decomposition, 3 statistics are important to examine; a measure of how

good the sohition is compared to the ideal (correlation = 1) solution (Percentage

Homogeneity), the degree of consistency beh~een subject scores and option weights

(ReIiabiüty Coefficient Alpha) and the correlation between each item and the survey.

Percentage Homogeneity (Duo1 Scaling for multiple choice &ta) and Delta statistic

Percentage homogeneity is an mdicator of how good the solution is compared to the condition

of al l inter-item correlations equahg 1 (the ideal case). N i i t o (1984) defines this statistic

as a measure of%e degree to which the derived sohition codorms to the case of perfect

mtertlal coILSiStencf'. Percentage homogeneity is a normed vahe fkom O to 100 and is

calnilated by Iinihipiying the sqwed correlation ratio for thit sohition by 100. Dual scaling '

also gaierates a statistic &ch Bidicates the totd mount of mformation m the data set that is

eqlained by that sohtioa This is caiîed the delta partial staiistic. The delta partiPl statistic

wiiî not be reported in the r e d s of thiP papa for one important reason: the influence ofthe

number of options m the data set. As the number of options increase, the total v h c e to be

explamed'hcxeases. For muhiple choice data, the totd amount of Wonnation is equd to the

22

average number of options minus 1. Thus, if ail items have 5 options each, then the total

amount of mformation to be explaiued is 4. Smce the correlation ratio camot exceed one, the

delta partiai statistic cannot explain more than 25% of the information in the data set, thus, the

statistic tends to be low.

Reliabifity Coeflcient A @ha

This statistic is a derivative of Kuder-Richardson reliability and measures the interna1

con&ency of subject scores on the solution. This statistic mdicates the extent of agreement

between subject scores and option weights.

This is possibty the moa important statistic to consider when mterpreting solutions m duai

scaliag. This value mdicates the strength of the correlation baween each item and the

solution. In other words, R@) is a measure of the amount of information that the item

conmbutes to the sohition. Detemination of the nitoff value of this s t a w c is ofken arbitrary

in dual scaling. Obvioudy, the higher the vaiue criteria, the more infiormation accounted for by

that item For the purpose ofthis adysis, however, al1 items with an R@) vahe of .45 or

higher were considered m the mterpretation. The rationale for choosing thh vahie is provided

m the resuhs chapter,

Forced Clarszfiation

In order to examine the rehtionship betwei the demographic variables and the attitude

23

survey, a technique' m dual scaling called forced classification was used. As Wkhïsato defines

the procedure as "discriminant anaiy sis for dtiplechoice data" ( l994), forced classification

is a usefiil technique to examine the association of items and item options wah a particutar

criterion item Forced classification allows us to examine ifgaider, work environment and

years since graduation are associated with one or more of the attitude items by foilowing the

pn'nciples of interna1 comistency (PIC, mentioned above) and equivalent partitionhg (PEP).

The PEP (Nishisato, 1984), in conjunction with the PIC, dows the repetition of data in order

to maicimize the correlation between each survey item and each category of each variable

(work environment, gender and years since graduation). Once this conehtion has been

mxhked, option weights for each response of noncriterion items as weil as weights for each

category are generated. Using these option weights, forced chssification assigus discriminant

scores to subjects which "classify each subject into subgroups associated wah the criterion

item" ( N i i t o , 1994). Associations betweai the aiterion and noncriterion items are then

interpreted by examining the weights for each category of the onterion item and the response

option weights for items hi& correiated with the der ion item

Each of the variablediems (gender, work environment and number ofyears practismg

medicine) was adysed separately to determine its correlation wiîh the 0 t h attitude items m

the m e y .

Data fiom the survey wae hiiidy adyzed ushg the SPSS StaWcal Software Program

Responsë means and ftepencies were generated. Durl scaling anaiysis was then conduaed

24

ushg the DUAW software program Data were entered u d g the folIowing vahies: Strongly

Disagree = 1, Disagree = 2, Agree = 3, Strongly Agree = 4, No Opinion = 5, Missing Vahies

= O. Solutions (chisters of mformation) m the data were then generated Forced classification

anaiysis was then conducted in order to examine the relationship between the survey tems and

each demographic variable.

Chapter Four

RESULTS

This section detaüs the resuits of the exploratory anaiysis of the various attitudes of fnmilv

physicians towards depression in their practice. The section is presented m two parts. Firstly,

resuhs fkom the focus group and fàceto-fice mteMews detail the specific barriers to

iniproving the care of depressed patients mentioned by fsrahr physicians. nie second part of

this section det& the results of the survey given to a group of fkdy physicians m Toronto.

4.1 Focus Group and Face-to-face interviews

Introdirction

A focus group and &ce-to-&ce interviews were conducted to explore various baniers to the

iolprovement of care of depression in primary care. The data fiom both sources detaiis the

spedic barriers to miproving the care of depressed patients mentioned by fàmily physlcians.

These r e d s aided in the decigon about which barriet to investigite in the mey.

F m w Group and Face-teface Interview Remffs

The focus group took place in Novemba 1997 and was 2 hours m duration. Both myselfand

my research assistant were present to take notes and the session was audio taped A

26

transcript-based analysis ofthe data was then conducted. The interviews were conducted

without the aid of my research assistant between December 1997 and March of 1998. Each

interview was audio taped and traiimied. A transcript-based anaiysis was performed on the

m t e ~ e w data. When combiued, the focus group and the mterviews yielded over 50 pages of

transcriied data. The results presented below are comprised of both focus group and

interview data. The sources of the data are indicated in the report ordy when relevant to the

nadmgs.

ParfiarficipanIs

Eight fiimihr physicians were mvited to attend the focus group. Three f h d y physicians

attended and three agreed to provide mterviews at a time that was more convenient for them

The three fhdy physicians who attended the focus group were female physicians fiom the

Toronto area and ranged m age from 36 to 43 years. Two of the three physicians worked m a

private practice setting, the third was employed m a community h e a centre. Two of the

three participants were afnliated with a local hospkd n i e number of years praciising fhdy

medicine ranged fiom 3 to 16 and each physician reported that they were then treathg at least

25% of th& patients for a mental heahh problem.

The fhdy physicians who agreed to provide interviews were three male physicians, two fiom

the Toronto area and one fiom Haimihon. Demographic information for these physicians were

q d e s h h r to those fkom the foous gronp, The age range ofthese fiimiiy phyScians was 35

to 48 yeak and the n d e r of years practîsing famüy medicine ranged fiom 9 to 20. Two of

the three worked m a private practice h g m the community and one worked m a private

practice located in a Toronto hospital. Ali three of these physîciaiis reported treatmg at least

30% of their patients for a mentai health problem.

Barriers to Imprming the Treamient of Deprasion

la A ththtudes of fmily physiciianr tmm& depressed patients in fheir pructice

According to the fàmiiy physicians m the focus group and the interviews, depressed patients

are more problematic to treat than other patients. Family physicians m the focus group voiced

a fhstration with the rehictance on the part of the patient, and often the fh@, m accepthg

the diagnosis of depression. Furthermore, patient compliance to accept treatment for

depression is poor. Patients are not only rehictant to take medications, such as Rozac, but are

also reiuctant to accept ongoing treatment fiom a mental heahh professionai. Physichm

suggest that hcreasiag the avaiiabiiay ofpatient idormation may help to sobe this problem.

FUtthennore7 it was expressed by these physioians that patimts with depression should be

more informed about their ilhaess, not soieiy for the purpose of hproving compliance but also

to enable the patient to help decide which treatment is best for them S m a the patient oflai

refiises medication for depression, the physicians feel that the best that they oan do to m a t

these patients is provide "supportive coimselling': These physicians hdicate, howeveq that

they counsel these patients more thm they would îike to.

Ib. Attitudes towarrdr treatmenrs of depression

Family physicians did express a confidence in the effectiveness o f medications h the treatment

of depression. They were, however, somewhat ambivalent about the effeectiveness of o h

methods of treatment, such as electro-convulsive therapy (ECT).

Ic. Attitudes towmdr the relatiomhip between fmniiy physiciam mid psychiatrisb

A serious problem, accordmg to all participants, is the poor relationship between themsehres

and psychiatrists. These fàmiJy physicipns feel that psychiatrists should be more available to

them for consuhations about treatment-resistant depressed patients, and inquines into dmg

treatment recommendations. The physicians aise feel that psycbtris&s should be more

understanding of the ciinical needs of fhdy physicians when treating this patient population.

Furthemore, fiimity physicians mdicated that there are depressed patients in their practice

who require specialwd care and feel that there are not enough psychiatrists avaiiable to care

for these patients. F e physicians m the focus group indicated that psychiatrists iack

confidence m the ab* of the h d y physician to diagnose depression.

Physicians in both the focus group and m the mte~ews expressed the belief that depression is

quite extensive in the general population and is due primarüy to stress. There is also a belief

that the s&erity of depression is dir* linlred to the quaüty oftesources (education,

finand, etc.) available to ind~duals.

2. Perceived Ability Defcit

Physicians are fiustrated when treating depression due to the fact that they have not been

trained to deal with mental ittness. Physicians indicate that they are ignorant about the

treatment of mental illness and depression. Consequentiy, they feel that they are not qualified

to treat these disorders.

3. Physician con$dence

This b a n k is sumewhat reiated to the preceding b8mer regarding a disabüay to treat

depressed patients. These physicians hdicate that they ofien question th& diagnosis of

particular illnesses. They also question their abüay to disemguish between the different types

of depression (major depression, dysthymia, minor depression, double depression) indicating

that they wae likeiy to make a g e n d diagnosis of depression and not consider the particular

type. Furthemore, physicians mdicated a iack of CO& with psraicular treatmmts for mental

mess. They are cornfortable prescnbmg certain antidepressants but feel unquaMecl to suggest

or prescribed treatmmts such as ECT for tzeatment-resistant depression. The group also

mdicated that they are often uncertain of subsequent strategies to employ when the first

treatment fâiis.

4. TIme comtrainks

EducatBig the patient and their nimüies about depression and it's treatment, such as Romc, is

too the consuhg according to these physicians. They also feel that they do not have the

time to pro* adequate coimselling to the patients. Physicians are p r b d y concerned with

treating Unesses that respond to inmiediate treatmmt (eg. physical ailments) and indicate that

' providhg contirnous therapy to patients with mental illness is too tirne consuming.

5. Availabili~/~ccesribi~i~ of informatiodresources

Another b h e r to providing optimal treatment to depressed patients is lack ofavailable and

accessible information or resources. Not only are few psychiatrists available for consultation

(as stated above), but accordhg to the respondents, there is a lack of educational material for

k d y physioians on the treatment of depression. What to do ifthe nrst treatment fails? How

long should the patient be on medication before an ahernative treatment is attempted? Should

1 try another medication or augment the m e n t medication? These questions often require

immediate attention, but resources to answer these questions are not available.

6. Abil~/Opportunity to reinforce learned behaviov

The mabiüty or lack ofoppommity to iiiiplement new treatment strategies and diagnostic

skills is also a problemfor these physicians. FoUowing an educational eqerience, the

physicians are eaga to PPiplement new treatment strategies with depressed patients but ofien

encounter redance fkorn the patient. Another barrier to improved treatment is the shortage

of patients at a time when new treatment skiils shodd be practised. Physicians say that by the

tune that they see a new patient suffiring nom a partxcular disorder, they have forgotten the

skiüs thPtthey were previody tau&

4.2 S w e y - Construction

At the conchision of the qualitative data anal@, a decision was made regardmg which

barriers to explore ikrher. Mer an examination of the qualitative data and a review of the

literature, it was decided that attitudes towards psychiatrists, depressed patimts and the ükiess

of depression were to be considered in m e r research. Many of the items were actually

direct quotes fiom both the focus group and the interviews. ûther items were generated fiom

a review of the literature. The final drafk of the swey consiszed of 35 items and instnicted the

respondent to mdicate on a iikert sale fÎom 1 to 5, the extent to which they agree or disagree

with each of the above statements (l=Stron& disagree, 2=Disagree, î=N&er agree or

disagree, 4=Agree, 5=Strongty agree). The nnal draft ofthe w e y is provided m AppendVr

A The attitude barriers to be Hichided m the swey and the rationale for their inciusion is

detailed below.

1) Attihrdes towarcls the relationsrhp between family physicianr midpsychiafrists

Attitudes towards the reiationshp, between f h d y physicians and psychiatrists were chosen for

several reasons, Fistly, f h d y physician attitudes towards psychiatrists was a dominant theme

m the qualitative data. Seconcüy, whüe some literature does e>8st regarding the midequate

relationship between nimüy physicians and psychiatrists, thete is îittie idormation on the

correhtion between these attitudes and demographic variables. FmPlly, the concept ofa

shared cale mode1 oftreatment is ganiing mterest in the he&h care c o m m i ~ ~ In order to

develop a s h e d care mode1 effectively, fùrher exploration mto the perspectives of fhüy

physicians (and psychiatxists) regardhg the role of each party as heahh care providers is

warranted Items generated to reflect this bamer are mcluded m the table below.

Table 4.1 Survey items reflecting attihides towards psychiatrists

ITEM

Famüy physicians should speak to mental health profession& for th& opinions about treatment.

1 13. 1 1 am saWied with the professional relationship that I have with psychiatrists* 1 1 16. 1 Psychiatrie consultations for medical or surgical patients are not helpfuL 1

. - -- - - - - - - - p. -

Psychiatrist's should have more confidence m the abiüty o f a f b d y doctor to diagnose depression.

-

17.

28.

3 1.

32.

1 34. 1 1 amnot satisfied with the contact bat 1 have with psychiatrists.

- - ---

Tt should be easier to refer depressed patients to psychiatrhs for continuhg care. 1

It should be easier to find psychiatrists thPt wiii do consultations.

I like to consuh with psychiatrists about deprewd patients.

Psychiatrists should be more accessible for consuitations.

- -- - -

1 would iike to con& with psychiattists about depressed patients more ofien than 1 have been.

1 10. 1 Depressed patients should receive treatment by i psychiatrist. 1

I Patients with depression shouid see a psychiatrist as a concurrent method of treatment.

2) Attitudes of f&i& piphysicim towards depressed patient in their practice

Attitudes of physicians towards depressed patients in theu practice was also a domkant

theme in both the focus group and the mte~ews. Craven et ai. (1997) exarnined these

attitudes m a ment Caaadiaa study. It would be ofmterest to both validate the hdings of

Craven's study and to determine ifthese two aninide b d e r s contribute to an attitude

'profile" of fimiiy phyticians in the treatment of depression. The content of the items m this

group reflect two attaudes towards depressed patients; one is towards treating them, the other

reflects t h perceived respomiôility of the patient m the treatment of depression. Items

generated to refled this attitude are mciuded m the table below.

Table 4.2 Slnvey items reflecthg attaudes towards depressed patients

ITEM

- -- -- .- . -. - . -.

- [patients with depression should be more infonned about th& &es. 1 - -

2.

1 4. 1 Depressed patients should be less rehrctant to treatment fiom a psychiatrist. 1

- - - - - - -

Patients with depression should appreciate the t r e a h t 1 am provihg.

3.

1 Depresseci patients are more ~~ to treat than other patients. 1

1

Patients with depression are more problematic thon 0 t h patients.

1 6. 1 Fami& members should play an important role in the treatment of depressed patients. 1

I

1 Depressed patients should heip decide which treatment is best for them 1 1 11. 1 Depressed patients should c o q & with drug treatment recommendations. 1 1 18. 1 Patients should be l e s refuctant to try psychotropic medications as treatment. 1

People who d e r fiom depression are more cornplirint with medication than those who are psychotic*

1 30. 1 Treathg my d q x e d patients is rewuding. 1 1 27. 1 Patients d o sufk fiom depression should be able to heip themselves. 1 1 29. 1 Depressed patients should be more wiiling to take psychotropic medicatiom. 1 1 20. 1 I counsel my patients with depression more t h I wou~d Iüre t a I

3) Attirudes fowar& treaments of depression

Che ofthe bamers towsrds optimil treatmait of depression may be the lack of confidence m

the effectiveness of various treatments for depression. This was noted m the focus group and

m the mterviews and was, thedore, mchded m the mey* Fdermore, iiterature focushg

on this topic is sparse. Items geaerated to reflect this attitude are mchided m the table below.

Table 4.3 Survey Items refiect a t h d e s towards treatment of depression

In Canada at present, too much psychotropic medication is used for depressed I

- . -. - - .. .

7.

1 26. 1 There is no place for ECT in the treatment of depression. 1

-

Psychotropic medications are an effective way t O treat dep ressed patients.

One of the barriers to optimal treatment of depression mny surround the famüy physicians'

belief of depression as an invalid iihess. Researchers have concluded that some physicians

believe that depression is not a cîinicd ihess in it' s own nght ; that depressive

symptomatology is simply a resuh of an underiyhg medicai illness. Furthermore, qualitative

data fiom stage one of this paper sugged that phyticians believe bat depression is due

primady to stress. The m a t i v e data also mdicate that physicians believe that depression

and it's severity is direct@ linked to the quality of tesources (education, h m d ) available to

mdividuals* Items reflecting these attitudes are mchided m the m e y and are detailed below.

Table 4.4 S w e y Items refiect attitudes towards depression as an ilhiess

1 ITEM 1

1 19. h generaj, the fewer the resources (education, financial), the higher the incidence of 1 1 21. Depression is often just caused by stress 1 22. A lot of people wodd meet deria for depression ifyou asked enough questions.

24. Psychiatry is imprecise.

4.3 S w e y - Relimhary Rewlta

The survey was distributed to a group of b d y physicians attendmg an educational event at

the University of Toronto. Four hundred m e y s were disEri'buted and 152 completed surveys

were renimed for a response rate of 38%. Six ofthe respondents submated the completed

m y with over 40% of the questions unanswered and were, therefore, not mchided in

mer anaiyses. The data were initiilly anaiysed using the SPSS statistical software package,

version 4.1. Dmiographic mfomtion on survey respondents is presented below in Table 4.5 .

Table 4.5 Gender, years since graduation fiom medical school and m e n t work environment of the respondents to the physician attitude survey, n= 15 2 (percentages provided)

1 VARIABLE 1 DESCRIPTOR 1 PERCENTAGES

Male

Femaie

Hospital 3.4

56.2

39.7

Misgng

Rivate Practice (Chic etc.) 1 58.2

4.1

C o d Heahh Centre 11.0

Hospital + Rivate Ra&e 10.3

Hospital + C o d H& 8.2 Centre

YEARs SINCE GRADUATION FROM MEDICAL SCHOOL

Hospital, Private Ractice + .7 Community Heaith Cemre

Other I .7

Physician Attitudes - Prelirnimty Impressions

Response percentages were generated and are presented in Table 4.6 below. A Sgnificant

number of physicians indicate that treathg depressed patients is a rewardmg expenaice

(80.1% of respondents either agree or strongly agree). However, hast ail physicians mdicate

that patients with depression should be more Hifomed about their ihess (97.3 %

agreelstrongly agree). Furthexmore, when treating depression, most physicians agree that

depressed patients shouid help decide which treatment is best for them (74.7%) and feel that

Ezmüy members play an miportant role m the treatment of depressed patients (85%).

When treating depression, most fkdy physicians endorse p sychotropic medication as an

effective method of treatment (85.6%). The majority of faniüy physicians Mcate, however,

that patients shouid be less rehctant to try psychoaopic medications (52.7% agreefstrongly

agree) and shouid compiy with drug treatment recommendations (72.6% agree/sttongly

agree). Most physicians (68%) also mdicate that there are parcicutar cases of depression which

may warrant the use of eleotroconvulgve therapy (ECT).

Most fnmhl physicians take pleasure m sharing the Gare of depressed patients with

psychiatrists; 67% ofrespondents indicate that they enjoy consuhing with psychiabrists and

63.1% mdicated that they would like to consult with psychiatrists about depressed patients

more ofken. Howevet, whboration with psychiatrists is oftm düEcuh for the fbdy

physician: A mat majonty of fàndy physicians agree thot it should be easier to refèr

39

depressed patients to psychiaorists for continuhg care (80.1%) and that psychiatrkts should be

more accessible for consultations (86.3%).

Table 4.6 Response fiequemies for physician attitude swey (n=152)

Disagree Agree I Saont&

No Opinion Strongly Disagree

1.Patimts wÎîh depression should be more informed about their iihess.

2.Patient s with depression should appreciate the treatment I am providing.

3. Patients with depression are more problematic than other patients.

4. Depressed patients should be less rebctant to treatment fiom a psychiatrist.

7. Psychotropic medications are an effective way to treat depressed patients.

5. Depressed patients are more difficuit to treat than other patients.

6. Fami@ &ers should play an important role in the treatmeet of depressed patients.

8. Depressed patients should heip decide which treatment is best for them.

3

O

9. Family physîcians shouid speak to mental health profesioiuls for th& opinions about treatment.

10. Depressed patients should receive treatment by a psychiatrist.

11. Depressed patients should comply with dmg treatment recommendations.

13.1 am satisfied with the professional relationship that 1 have with psychiatrists.

I 14. Psychiahrists overanaiyse human behaviour. . 1 15. In Canada at present, psychotropic medication is used for depressed patients.

-1 -- -

16. Psychiatrie consultations for 7 medical or surgical patients are not helpfiil

--

17. It shodd be easier to refer O depressed patients to psychiatrists for continuhg care.

18. Patients should be less rehctant to try psychotropic medications as treatment.

19. In generd, the fewa the resources (education, financial), the higher the incidence of depression.

20.1 counse1 my patients wiih depression more than I wouid U e to.

21. Depression is ofienjust cawd by 1 m.. 22. A lot ofpeople wouid meet 4 criteria for depression if you asked enough questions.

23. People who d e r fiom depression are more coqliant with medication than those Who are psychotic.

25. Patients with depression should see a psycbiatrkt as a concment method of treatment.

26. There is no place for ECT m the treatment of depression.

27, Patients who &er fiom depression should be able to hefp themselves.

28. It should be easier to find pqchiatrists that will du consultations.

29. Depressed patients shouid be more wüling to take p sychotropic rnedications.

30. Treating my depressed patients is rewarding.

3 1. I Iüre to consult with psychiatrists about depressed patients.

32. Psychiatrists shodd be more accesd'ble for condations.

33. PsychiBtrist's shouid have more confidence m the abüity of a fbdy doctor to diagnose depression.

34.1 am not s a M d with the contact that I have with psychiatrists.

3% 1 would E e to consuit with psychiatrists about depressed patients more ofken than 1 have been.

4.4 Dual Scaling Resulb

Part One

Are there partÎcuIar cafegories (or groups) of attiiudes held by fmily physician?

The m e r to this question is yes. The total number of possible of solutions is equal to the

number of items x number of options per item - number of items. Thus, the number of possible

solutions for this data set is (35 x 5 ) - 35 = 140. Exaimnmg a l l p o d l e solutions would be

very clifbit. However, the first two optimal sohitions yield some mteresting hterpretations.

Statistics descnibing these soiutions (referred to m this paper as "anihide profiles') are listed

beIow.

Percentage homogeneity, the degree of consistency between subject scores and option weights

(Reliabiiity Coefficient Alpha) and the correlation between each item and the survey, are

provided for solution #1 in the Tables below.

Table 4.7 Solution statistics for attitude profile #1

I Statistic I Value I

The percentage homogeneity is the quality of this solution compared to a case of perfect

intemal coniistency. Considering that there are a total of 140 possible sohitions m this data

set, a percentage homogeneity vaine of 20% is substantial. The reliabiiay coefficient of 0.89

mdkates that the correlation betwem subject scores and option weights is high. In order to

d e t d e which items are descriptors of this profle, the next step is to examine the

comeiations between each item and the profile. The codation (RQt)) of each item to attitude

profile # 1 is provided m the table below.

PERCENTAGE HOMOGENEITY (%)

RELIABILI'IY COEFFICIENT ALPHA

19.5

O, 89

Table 4.8 Item correlations for attitude profile #1

Each of the above correlations hdicates the strength of the relationship betweea each item and

Item

1

attitude profile #1. For the puposes of this study, items with correlations of .45 Serve as

descriptors ofthis attitude profite. 'ïhere is no known prescribed procedure to indicate what

Rüt) .18

the cut-off R@) vahie shouid be. hterpretabiiity oten guides the reseucher m decidmg

Item

19

R(it)

.5 1

which vahe to use.

Table 4.9 Swey Items describing attitude profile #1 with a correlation of .45 or greater

Smey Item

1 5. Depressed patients are more difEcuit to treat thaa other patients.

1 3 1. 1 iike to cons& with psychiatrists about depressed patients.

1 30. Treathg my depressed patients is rewarding.

25. Patients with depression shodd see a psychiatrist as a concurrent method of treatment.

28. It should be easîer to h d psychiatrists that will do consultations.

3. Patients with depression are more problematic than other patients.

-55

.55

22. A lot ofpeople wouid meet criteria for depression ifyou asked enough questions.

34. 1 am not satisfied with the contact that I have with psychiatrists.

18. Patients shouid be l e s rehrctant to try psychotropic medications as treatment.

.53

.53

-53

19. In gaierai, the fwer the resources (education, hancial), the higher the incidence of depressio11.

10. Depressed patients shodd receive treatment by a psychiatrist.

15. In Canada at present, too much psychotropic medication is used for depressed patients.

6. Famüy members should piay an important role m the treatment of depressed patients.

- -- - - - - - - - - -- - -

29. Depressed patients should be more winmg to take psychotropic medications,

.5 1

.5 1

.50

.45

-- - -

26. There is no piace for ECT in the treatment of depression

14. Psychiatrists overinaiyse human behaviour.

3 5.1 would Iüre to con& wÎîh psychistrists about depressed patients more ofien than 1 have been.

.46

.49

Ofthe 35 survey items, 17 were retained due to the fidfiîment of the correlation der ion of

-45. Mer having identified each item that represents this profile, the next step was to

associate the response option (strongly disagree, disagree, agree, strongly agree) for each item

endorsed by respondents m this profle. Each domhant response option and the correspondhg

weight for each of the above items is provided below. The vahe of dominant response option

weight d e n compared to other response options for that item is twofold: FirsUy, the higher

the weight, the more mformation conaibuted by that response option. However, following the

rule that the sum of ai l response options products (the response option weight X the number

of respondents) must equal zero (see Gutûmn), however, the higher the weight, the fewer the

number of respondents endorshg that response optioa. Furthmore, the direction of the

weights (+ or -) provides mfonnation regardhg the number ofrespondents for each response

option. This consideration is cmcial when mterpretmg these resuhs. When two opposhg

response options (agree and disagree) show large weights, the next procedure wouid mvobe

examination of the fkequency ofeach response option This is accomplished by obtahhg une

average weight for both agree and disagree by collapshg both &on& agree with sgree and

stronpiy disagree mth disagree, thus, yielding one weight for agree and one for disagree. The

fomnila for this produre is provided below.

F (1) X W(1) + F(2) X W (211 / [FI+ F2] = Average option weight

Where F(l) is the fie~uency ofresponse option 1, W(1) is the weight of response option 1, F(2) is the fiequency ofresponse option 2 and W(2) is the weight ofresponse option 2. Each domiitresponse option (and weight) is provided below for each ofthe profile #1 items.

Table 4.10 Doxnhant Response options and correspondmg option weights for attitude profile #1 items

1 Survey Item 1 Response Option and 1 Option Weight

.. .

1 25. Patients with depression should see a psychiatrist as a conment 1 Strongly Agree (3.26) 1

5. Depressed patients are more difEcult to treat thm other patients.

3 1. I Iüre to consu& with psychiatrists about depressed patients.

1 method of treatment. 1 1

StxongLy Agree (2.63)

Strongly Agree (3.85)

30. Treatmg my depressed patients is rewarding.

3. Patients with depression are more problematic than 0 t h patients.

22. A lot of people would meet criteria for depression ifyou asked enough questions.

--

19. In general, the fewer the resources (education, hmciml), the higher the Sicidence of depression.

Strongly Disagree (3.02)

Strongiy Agree (2.45)

AGREE (-.024)**

. - - . . . . - - -- . -. .

34. 1 am not satisned with the contact that 1 have with psychiatrists.

18. Patients shouid be less rehictant to txy psychotropic medications as treatment.

l -- -

AGREE (0.179)**

- - - .- . -- - . . - - - .

Strongly Agree (1.3 9)

Strongiy Disagree (6.10)

.. . . . . . . . - ... -.

10. Depressed patients should receive treatment by psychiatrists.

15. In Canada at present, too much psychotropic medication is used for depressed patients.

- - - -. - - - - - . -. -

Strongly Agree (2.78)

AGREE (.6224)**

6. F a d y members should play an important role m the treatment of depressed patients.

Strongly Agree (.7 162)

26. There is no place for ECT m the treatment of depression. Strongly Agree (3.32)

14. Psychiatrists overmaiyse human bebaviour.

1 35.1 wodd E e to consuh with psychiatrists about depressed patients 1 Strongly Agree (1.39) 1

Strongîy Agree (3 -99)

29. Depressed patients shodd be more willing to take psychotropic medicatiofl~~

1 more o f t a thin 1 have beea 1 1

Strongiy Disagree (3 -92)

l

**These items reported 2 opposing d o h a n t response options (Strongly disagree and stron& agree). The direction for these items was then determined by obtaining one average weight for both agree and disagree. See above for procedure formula.

The attitudes of physicians who fit this profile inchde feelings towards treathg depression m

their practice, sharing care of these patients with psychiatrists and beliefk about the Unes

itselE Physicians who nt this pronle ("profile 1 physicians'') do not find treating their

depressed patients rewarding. This is a noticeable contrast fiom the preliminary results

reported earliec Over 80% of physicians reported tbat treating depression in th& practice is a

rewardmg expience. Accordhg to profile "1" physicians, depressed patients are more

difficult; to treat and more problematic than other patients. in regards to treating depression,

these physicians do acknowledge that medications play a role m the treatment of depression

but they agree that, m Canada, too much medication is currentiy used for depressed patients.

Furthemore, these physicians endorse that psychiatrists should aid m the treatment of these

patients. This may be interpreted as a belief that providhg optmial treatmait to those sufféxing

îkom depression mvohres the expertise ofboth farnihr physicians and psychiatrists.

Furthmore, these physicians report enjoying the coliaborative process with psychiatrists.

However, they are currentiy dissatisfied with the contact that they have with psychiaarists. An

mteresting hdkg with this group is item #28. This group reports that hding psychiatrists

that do consubations is not a problem. This may be mterpreted as physicians hiowing

psychiatrists who will do consuitations, but trymg to access them m y be a problem Profle

"1" physicians view depression as a conmion problern correiated with socioeconomic fictoxs.

Physicians agree that many people would mea criteria ifyou asked mough questions ami,

49

fcurtheirmore, physicians agree that depression is comekted with educational and hancial

disadvantages.

Physicians close@ associated with this profile Vary in length of practice, gender and work

environment. f i e r 7 1% of physicians with .50 or highet normed score for this profile are

male. Physicians associated wah this profile are not new graduates. Approxhately haif of

physicians associated with this profile graduated medical school between 2 1 and 3 0 years ago.

Ninety-two percent of the physicians graduated over 10 years ago. The work environment of

these physioians highly refiects the profle of physicians who responded to this survey. ûver

50% of the physicians afFliated with this profiîe work m private practice.

Percentage homogeneity, the degree of consistency between subject scores and option weights

(Relisbiiity Coefficient Alpha) and the correlation between each item and the survey are

provided for sohition #2 in the Tables below.

Table 4.11 Sohaion statistics for attitude profile #2

Statistic

PERCENTAGE HOMûûENEirrY (%)

RELIABILITY COEFFICIENT ALPEEA

Vafue I

15.71

-86

50

The percentage homogeneity is the quality of this soiution compared to a case of perfect

mtemal consistency. Coidering that there are a total of 140 possible sohxtions m this data

set, a percentage homogeneity vahie of 20% is substantiaL The reliability coefficient of 0.855

mdicates that the correIation between subject scores and option weights is hi& In order to

detemine which items are descriptors of this profile, the next step is to examine the

correlations between each item and the profiie. The correlation (R@)) of each item to attitude

profile #2 is provided m the table below.

Table 4.12 Item co~elations for attitude profile #2

Items with a correlation vaiue o f -45 or greater were retahed for fiutha examination. The list

ofthese items is provided below.

Table 4.13 Survey Items descriiing attitude profile #2 with a correlation of .45 or great er

1 3 1. 1 Iüre to consuit with psychiasists about depressed patients.

- --

S w e y Item

30. Treating my depressed patients is rewarding.

I 18. Patients should be reiuctmt to try psychotropic medications as treatment.

- -- - --

Ri31 -64

1 24. Psychiatry is iniprecise.

-

1 3. Patients with depression are more problematic that other patients.

22. A lot of people would meet criteria for depression if you asked enough questions.

.

1 19. In general, the fewer the resources (education, hancial), the 1 higher the incidence of depression. 1 1 26. There is no place for ECT m the treatment of depression. 1 *49

I 15. In Canada at present, too much psychotropic medication is used for depressed patients.

Ofthe 35 survey items, I l wae retained due to their fMment of the correlation criterion of

.45. Mer having identified each item that represents this profile, the next step is to associate

the response option (strongiy disagree, disagree, agree, strongiy agree) for each item which

wiü provide a clearer picture of the attitudes endorsed m this profile. Each dominant response

option and the correspondmg weight fot each ofthe above items is provided below. As a

reminder, the vahe of dominant response option weight when compared to other response

options for that itemis twofolk Fw, the higher the weight, the more idonnation

28. It should be easier to h d psychiatrists that will do c o ~ a t i o n s . -47

53

contnbuted by that response option. However, fouowing the d e that the sum of all response

options products (the response option weight X the number of respondents) must equal zero

(see Guttman), the higher the weight, the fewer the number of respondents endorshg that

response option. For Item 15, M e c examination of response option fiequemies and weights

was required due to the significance of both options "strongly disagree" and "strongly agree"

to attitude profie #2.

Table 4.14 Domhant response option and correspondmg option weights for attitude profile #2 kems

S w e y Item

1 30. Treathg my depressed patients is rewarding.

3 1. 1 like to consult with psychiatrists about depressed patients.

29. Depressed patients should be more willing to take psychotropic medications.

18. Patients should be l e s reiuctant to ûy psychotropic medications as treatment.

1 3. Patients with depression are more problematic that other patients.

22. A lot ofpeople wodd meet onteria for depression ifyou asked enough pestions.

19. Iii generd, the fewer the resoutces (educatioq financial), the higher the incidence of depression.

( 26. There is no place for ECT in the treatment of depression. - - --

15. In Canada at present, too mch psychotropic medication is used for depressed patients.

Response Option and Option Weight

Agree (-3.59) 1 Strongly Disagree

(5.07)

Strongly Disagree (6.90)

Strongly Agree (2.5 8) 1

Strongly Agree (-2.10) 1

Strongly Disagree (2.73) I Strongly Agree (3.93) 1 DISAGREE (O. 1 146)**

28. It should be easier to h d psychiatrists that wili do consultations. 1 StrongIy Disagree (-5.33) 1 **These items reported 2 opposing dominant response options (Strongiy disagree and strongky agree). The direction for these items was then detemined by obt&g one average weight for both agree and disagree.

Attitude profle #2 is simüar to the results found in #I with respect to views on treating

depression m their practice, sharing care with psychiatrists and the validity of the iIlness.

Physicians feel that treating depressed patients is not rewarding* Furthemore, patients with

depression are more problematic than other patients. Attitudes towards various treatments of

depression are mixed m this profile. The response option weight for item #l8 may be

interpreted as an endorsement for patients to be somewhat rehictant when trying psychotropic

medications as a method of treatment. Furthermore, this profile does not support the use of

ElectroconvulSve Therapy (ECT) as a treatment for depression. Howwer, attitudes towards

the amount of medication used for the treatment of depression m Canada is mixed: option

weights are substantial for both "strongiy disagree" and ccstr~ngiy agree" response options.

However, after averaghg response option weights, there is a tendency towards a

disagreement that too much psychotropic medications are currentiy used to treat depression.

PhyScians Who fit this amitude profiie enjoy consuithg with psychiatrists about depressed

patients, however, they do fée1 that psychiatrists tend to overanaiyse human behaviour*

Phyticians support depression as an ihess with specific criteria but feel that psychiatry as a

discipime is imprecise.

Phpicians close& associated with this profüe are somewhst simüit to those a t e d with

profile #le Approh te ly 51% of physicians with .50 or higher normed score for this profile

55

are male compared to 7 1% in profile # 1. This is more of an equitable representation âom both

genders. S i . to pronle #1, phyticians associated with this profile are not new graduates.

Forty-tbtee percent of physicians associated with this profile graduated medical school

between 21 and 30 years ago. Nmety-two percent ofthe physicians graduated over 10 years

ago. Smiüar to profile #1, over 50% of the physicians afnlüited with this profile works in a

private practice. Howwer, there is greater representation fiom the diffèrent work

environments associated with this profile compared to profile #l.

In order to examine the attitudes of fkdy physicians towards mental h e a profession& and

then role in the treatment of primary care depressed patients, a dual sciling anaiysis was

performed with the questionnaire items which focus solely on mental heaith profession&

(Item #s 9, 13, 14, 16, 17, 28,3 1-35). The sohition (named "shnred me") that provides the

greatest amount of infomation contained m this data set is proviâed below.

Percmtage homogmeity, the degree ofconsistency between subject scores and option weights

(Reliabiiity Coe5cient Alpha) and the correlation between each item and the Questionnaire

are provided for the "shared care" sohition m the Tables below.

1 RELIABILITY COEFFICIENT ALPHA 1 .8 1 1

Table 4-15 Soiution statistics for the "shared care" profile

The percentage homogeneity is the quality of this sohmon compared to a case of perfect

intenial consistency. Howevex, the percentage homogeneity of 28% is high considering that

the number ofpossible soiutions to explain the variance m the data is 44 soiutions (11 items x

5 options per item - 11 items = 44 possiile sohitions). The reliabiiity coefficient of 0.8 1

hdicates that the co~eiation betweai subject scores and option weights is higb. In orda to

d e t d e which items are descriptors of this profile, the next step is to exsrnine the

correlations between each item and the pronle. The correlation (R(jt)) of each item to attitude

profile #2 is provided m the table below.

Statistic

Table 4.16 Item correlations for the "shued care" attitude pronle

Vahie

Items wiîh a correhtion vahie of.45 or greater were retained for fùrther examination. The list

of these items is provided below.

Table 4.17 Survey items descnibmg the "shared careY7 attitude profle with a correlation of .45 or greater

11.1 would h?re to con& with psychtrists about depressed patients more often than I have been.

Survey Item L I .

10.1 am not satidied with the contact that I have wiui psychiatrists

1 8. Psychiatrists should be more aocemile for consuhtions. 1 -72 1

R(ii)

.8 1

1 6. It should be casier to fhd psychiatrists that wül do consuhations. 1 .70 1 5. It shodd be easier to refer patients to psychiatrists for contmumg 1 Cam.

2.1 am satisfied with the professional relationship that 1 have mth psychiatrists.

ûfthe 11 survey items focusing on attitudes towards psycbiatrists, 6 were retained due to

their fidfihent of the correiation derion of.45. respectable correlation with this soiution.

Mer ha* identified each item that represents this profile, the next step is to associate the

response option (strongiy disagree, disagree, agree, strongly agree) for each item which will

provide a clearer picture of the attitudes endorsed in this profle. Each dominant response

option and the correspondmg weight for erch of the above tems is provided below.

Table 4.18 Domniant response option and correspondhg option weights for "shared care" attitude profiie items

Swey Item

10. I amnot satisned with the contact that 1 have with psychiatnsts

Response Option and Option Weight

Strongiy Agree ( 1.95)

11. I would Iike to consuh with psychiatrists about depressed patients more oeen t h 1 have been.

Strongiy Agree (1.74)

8. Psycbtrists should be more accesgble for consuhations.

6. It shouid be easier to find psychiatrists that will do consultations.

Strongly Agree (1 .O 1)

Strongiy Disagree (3.9 1)

5. It should be easier to refer patients to psychiatrists for conthhg 1 C a m .

The shared care profile ilhistrates the discrepancy between desired and perceived contact with

psychiatrists m the treatment of depression m primary care. Physicians are not satMed with

the contact that they cuxrentiy have with psychhtrists (thip is strongly evident m the option

weights of items #10 and #2). Physicians mdicate that they wouid iike to con& with

psychiatrists more ofken than they have beea Siinüor to profde #1, h d y physicians have

kuowledge of psychiatrists who provide consultations, but the problem lies m accessing them

Furthemore, it is not onîy di&& to access psychiatrists for condtations but it is ciif&& to

refer dificult patients to psychiatrists for continuhg care.

Strongiy Agree (0.95)

2. I am satisfied with the professional rehtionship that 1 have with p sychiatrists.

Physicisns closeîy associated wah the shared ocire pronle differ on a number of demogtaphic

Strongly Disagree (1.73)

59

variables fkom those physicians afnliated with both previous profiles. Approximately 5 1% of

physicians with -50 or higher normed score for this profile are female. Both profiles 1 and 2

repoaed the major@ of their physicians as male. Physicians associated with this profiie are

equdy distriiuted across aJl 'Years Snce graduation" groups (0-10 years, 11-20.21-30, and

3 1-40 years). Simüar to both profiies I and 2, the majority of the physicians affitiated with this

profile work m a p d e practice (45%). Howwer, there is representation fiom di work

environments associated with this profiie compared to both prwious profles.

Is gemkr, work environment a d o r munber of years pructising family medicine related to

the affi'iudes of famiiy physcianr?

A procedure m dual scahg called forced classification (Nishisito, 1984), was used to answer

this question. Forced ciassincation aides in the examination of a particular item (cded the

cccritenon" item) and the extent to which each survey item correiates with the onterion item.

For the purposes of this project, work environment, years since graduation and gender were

each designrted as mitexion items. R e d s mdicate that work environment and years Snce

graduation are correlated with par t idu attitude items. However, gender is not signincantiy

correlated with eny ofthe attitude items. The r e d s that are cn~ciaî to the understanding of

the correlation between both work environment and years since graduation with each attitude

item are provided below.

Work Emironment

Respondents were mstnicted to mdicate which of the fo i Iodg environments they currentiy

worked m; hospital, private practice, CO& centre or other. Responses to this question

were entered as item #38 both in SPSS and m the DUAU Rogrnm There are 7 possible

environments tahg hto accouat that a physician may work in more than one environment.

Work environment was then correlated mrh each attitude item For the purposes of this study,

items with a correlation of .30 or greater with the criterion item 'kork environmentY'were

mchided in the interpretation of this forced clasgfication procedure. There is no lmown

prescnbed technique to hdicate what the correlation vahie should be, therefore, .300 was

chosen for mterpretabüay.

Swey Item

1 32. Psychiatrists should be more accessie for consuhations. 1 .67 1 1 28. It should be easier to fmd psychiatrists that wül do consuhations. 1 -52 1 1 34.1 am not satisfïed with the contact that 1 have with psychiatrists. 1 .32 1

19. In generai, the fewer the resources (fiamciai, education), the higher the incidence of depression.

35.1 would iike to con& with psychiatrists about depressed patients more ofken than 1 have been,

Resuhs hdicate a relation&@ between attitudes about sharins of the Gare of these patients

and work environmentt. h order to futher e x d e this relationship, response option and

criterion item weights rmist be mvestigateb Both response option weights for the derion

item and correlating items are presented below.

Table 4.20 Weights for criterion item ' h r k environment" and response option weights for correiat ed items

Work Environment Groups and Weights

Private Ractice (Chic etc.) (4.31)

CommUnay Health Centre 1 (0.341

Hospital + Rivate Ractice 1 (OJ41

Hospital + Corn- He& Centre (0.30)

Private Ractice + CommUnay Health Centre (0.09)

Hospitai, Rivate Ractice + Comnninity He* Centre (6.38)

-0.22 1 -0.08 1 No Opinion

The procedure used to mterpret the above table mvolves the exmination of the weights for

the d e r i a item and their pro* to the response option weights for the correlating items.

As mdicated above, physicbs employed in a hospial sethg have a tendency to agree that

psychiatrists should be more accessib1e foi consuitations (item 32) and that they would like to

consuh with psychiatrists more often thm they have been (item 35). The ability to fmd

psychiatikts that will do coflsuffations is a major concem for aiî h d y physicians. This

62

perceived inability to find psyctiiatrists does Vary dependhg upon the work environment of the

family physician. Physicians employed m a hospital sethg have a tendenoy to agree that it

shouid be easier to find psychiatrists that will do consuhations. However, phyScians m private

practice strongly disagree that is should be easier to find psychiatrists that wiii do consdts.

This may be due to ikdy physihs working in private practice havmg better knowledge of

psychiatrists that wiil do consultations than hospitai physicians. Physicians worhg in both

settmgs tend to be satkfied with the contact that they have with psychiatrists @em 34),

suggesting that the more diverse the work environment, the greater the level of satisfhction

with the contact to psychiatrists. Furthermore, those physiciens who work m a i l 3 listed

environments (hospital, private practice, and comnmity he& centre) tend to diugree that

psychiatrists s h d d be more accemile for consuitations. This lads support for the assertion

that the more diverse the work environment, the greater the access%iiity to psychiatrists.

Yems since Gr&att'unfrom Medical School

Respondents were instnacted to provide the date of their graduation nom meâicd schooL The

number of yeam since graduation was caicutated and entered as item #37 m both SPSS and m

the DUAU Program Number of years since graduation was then correiated with each

attitude item Item correiations wiîh a vahie of.30 or higher are provided below.

Table 4.21 Survey items correleted with derion item 'years since graduation"

survey Item -

3 1. I iike to consult with psychiatrists about depressed patients. -

13.1 am satkfied with the professional reiationship that 1 have with p sychiatxists.

4. Depressed patients should be less rehictant to treatment fiom a psycbiatrist.

Results indicate a relation@ between attitudes about the relationship with psychiatrists, the

reluctmce of patients to treatment fiom a pycbtrists and rider of years &ce graduation.

In order to fiuther examine this relationship, response option and Miterion item weights must

be mvestigated Both response option weights for the criteaion item and correhting items are

presented below.

19. In general, the fewer the njources (finand, education), the higher the incidence of depression.

Table 4.22 Weights for criterion item ' l e m since graduation" and response option weights for correiated items

.30

Years &ce Graduation and Item 3 1 Item 13 Item 4 Item 19 1 Weights 1 1 1 1 Response Options

Strongly Disagree

Disagree

Agree

Strongly Agree

Recent graduates tend to strongly disagree that patients should be less rehictant to treatment

fiom a psychiabist (item M). This may be mterpreted in two ways. Firstly, this may reflect a

beliefthat patients should be rehctant to obtain treatment fiom a psychiatd. This may be

interpteted as a confidence in newer graduates in their abiiity to provide care to these patients

themsehres. This may also reflect the type of depressed patient seen by newer graduates*

Patients seen by recent graduates may not be reluctant m accepting treatment fiom

p sychiatrist S.

Physicians who graduated over 30 years ago tend to enjoy consuhmg with psychiatrists about

depressed patients (item #3 1). This may be due to their lack offormal education about

depression in medical sohool It is iintikely that these physicians were formaUy educated m

medicai school about the recognition and optimal treatment of depression. Therefore,

consuithg with psychiatrists about the treatment of depressed patients is an mvahiable

activity. Recent graduates f?om medicai school do have eqosure to mental healîh problems in

medical schoot Thus, there may be a greata confidence m the ability to mdependentiy care

for depressed patients m younger graduates compared to older graduates.

C hapter Five

CONCLUSIONS AND RECOMMENDATIONS

The purpose of this paper was to explore the various attitudes of family physicians towards

treating depression in their practice. This was accomplished by combinhg both qualitative and

quantitative research techniques; the focus group provided a general understandmg of some of

the barriers to changing their behaviour and dual scaüag provided a method for hther

exploration hto various attitudes held by h d y physicians that m y be perceived as barriers

to change.

F m Gr-

The focus group and the mterviews rweaied some interestmg barriers to optimal treatment

that have been previoudy mentioned in the lirerature such as time comtraints, p h y s i h

confidence and a perceived mability to manage these patients. Som of the other hlÏngs fiom

the focus group and interviews indicated a problem of accessiibiîity, not on& to psychititristq

but also to mataiels which 8flswer specific qpestions about clinical concans such as what to

do d e n the &st treatment fiiils and the Iength of time that patients shouid be on a pareicuiar

medication. Analysis ofthe qualitative data also indicate a iack of oppommiîy to remforce

Ieamed behavior. Thus, ualess the infio~mation meets an immediate leaming need, there is a

danger of losing the newfy acquired infomation ifthe physician is unable to mip1ement it in

66

th& practice. Furthex mvestigation hto these particulaf bankrs to optimal treatment would

provide an oppominay for medical educators to develop produas &ch address these needs.

Attiîuàè proflies

Sweral attitude profiles were identifid m the fhdy physicians who participated m this shidy.

The first profite W a t e s that physicians are faced with diflbiCUIf problems treatmg depression

m their practice. This perceived clinical problem coexists with a lack of fiMment m treathg

these patients. To remedy this problem, profile "1" physicians desire a coihborative

relationship with psychiaükts m treatmg these patients. This rehtionship does not currently

exist. This discrepancy between the a d relmtionship and the desired relationship between

these two heahh professions may prove to be a barder to providing optimal txeatment for

depressed patients.

The second attitude profile is comprised of 9müpr concerns. Treating depressed patients is not

rewarding and physicians Who fit this profile olso desire the aid of psychiaarists in the long-

t e m managemant of these patients Attitudes towards the various treatments for depression

are complicated m the profile: ECT is not endorsed m this profile and the physicians believe

that patients shodd be h e h t when considering phannacologiod trea-ts. However, the

use of medications m treatmg this ilhiess is warrante& The mteresting hding in this parti&

pro& are the attitudes ofthese physicians t o w d psychiatry and psychiatrists: psychiatrists

tend to overPnatyse human behanot and psychiatry is an miprecise discipline. These two

notions cont&ute to the stigmatization of pqcbiatry. Perhnpq a more coliaborative

relationship with psychiatrists might help break d o m these stigmas.

Attitudes regarding shared care

These fhmity physiciaas strongly endorse sharing the care of depressed patients with

psychiatrists. Sharing the care ofdepressed patients, however, does not occur to the

satiPfaction of fimi& physicians. This dissatidàction with th& relPtionship with psychiatrists

was mentioned in the focus group and mterview data and was echoed in all attitude profiles

generated by dual scaling anaiysis. These hdmgs fiom Ontario fiut@ physicians are in

agreement with the re&s fhm international studies on the attitudes of fàmiiy physicians.

In theory, faiaihr physicians and psychiatrists are natural paztners in the treaîment of not O*

depression, but aiî mental disorders that are seen m the primary care environment. Howwer,

the miprovernent of the relationship between these two professions cannot occur until the

attitudes of both parties towards this model are examhed. We have a greater understanding of

the attitudes of f h d y physician towards the a d roles and desired roles of family physicians

m the treatment of depredon. Howwer, attitudes held by psychiatrists towards this model of

shared care requires Mer mvestigation.

The problem of accessing psychiatrists is of great concem to these physioians. A working

goup was constructed in 1996 consihg ofmembers fiom both the Canadian Psychiatrie

Association (CPA) and the Coilege o f F e Physicians of Canada (CFPC) to address the

68

issue of shared care and d e recommendations for the iniplementation ofthis modeL Each of

the strategies recommended by this group involve breachhg the conmnincation gap and

sohriag the accessiility problem noted by these family physicians. Strategies inciude

encouraging vists by psychiatrists to E.Müy physicians' offices and the clarification of

respective roles and responsibilities in wery situation where care is bemg shared. This

provides an exceptional oppommity for medical educators to aid in the iinplementation of this

mode1 For example, by creating new, innovative initiatives for f h d y physicians whioh

address mental mess in their practice, medicd educators are accomplishmg two important

tasks; firstly, linkages between fjrmüv physicians and psychiatrists are developed or

strengthened More inipoltantiy, family physicians are &en the oppommity to receive direct

feedback Eom psychiatrists on thea treatment strategies.

A note to echrcators

Educators are weil aware of the importance of asseshg the needs of th& lemers. One of the

beneficial cr3nsequences ofproduchg thip paper has been the discovery of the immense vahe

of dual scaling for the purpose of assessing lemer needs.

Dual scahg does not lead to mferential conciusions. It provides a detailed picture of a

particalsr data set and does not mvoive the generaîizabitay of results. By applying a dud

scaling andysk a prion to a group of leamers, the educator is &en a muhi-dimensionai

picture of who theH leamers are. Hlaving a detaüeû profile (attitude or otheLwiSe) of leamers

a priori has inoplications for not only the düficult tasks ofprogram planning and design but

also for the evahiation of the program For example, the 146 f b d y physicians m this data set

would benefit fkom an educational initiative aimed at implementing the shared care mode1

Program planners for this course should take mto account that managirtg depression is a

problem for these physich and that there is M e reward in treatmg these patients.

Fdennore, p a r t i a h demographic variables correlate with attitudes towards shared care.

With referace to the resuits of the second research question, this c o u . may best benefit

older physicians who work primady m a hospitai settmg. In summaxy, dual scaling is a

vahiable tool which aiables the educator to assess the unperceived needs of the lemer. It is

hoped that this measurement technique be appiieâ in the fiiture for tbis purpose.

In summary, attitudes are a complex array of past experiences and present circumstances.

Measuring attitudes is a delicate undertaking. Howwer, researchers mur* realize ihat

measuring attitudes is a prominent part ofresearch mto the various fàctors which affect

change. Educators must realize that the measurement of attitudes is cruciai not o d y for

assessing unperceived needs but for the waluation of education programs. More importantly,

measuring the attaudes of nimily physicians towards depression plays a cruciai role m reaching

the ultimate goal of providmg optimal treatment for patients su i3 ig âom such a debilitatmg

iîlness.

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APPENDIX A

The Physician Attitude Swey

Please place a 'V" m the appropriate box below which best reflects your towards the following group of statements. There are no nght or wrong answers, we are only asking the extent to which you agree or disagree with these statements. Please do not put your name on this document. Thank you very much.

more infotmed about theit illnesa

II*

Patients with depnssion should appreciate the tmtment I am pmviding.

Patients with depression a n man pmblematic than other patients.

Depressed patients should k kss reluctant to treatment from a psyc hiatrist.

Depnssed patients a n mon difficult to treat than other patients.

Family rnernkn should play an important mie in the treatment of depnssed patients.

Psychotmpic medications an an effectin way to tmt depnssed patients.

Depnssed patients should help decide what treatment is kst for them.

fimiiy physkians should speak to mental healt h pmfessionals for their opinions about treatmnt.

ûepnssed patients should recciie treatment by a psychhttîst

ûepnssed patients should compiy with drug t m t m n t recommendations.

Psychiatry is unxientific.

I am satidied with the pmfessional nlationship that I have with psychiatrins.

Psychiatrirts ovennalyze humn be havior.

In Canada at prernt, tw much psychotmpic medication is used for depressed patients.

Psychiatrie consultationr for medical or surgical patients an not helpful.

It should k easier to der patients to psychiatrists for continuing care,

Patierits should be less teluctant to try psychotmpic medications as treatment.

In genenl, the fewer the rewurces (education, financbl), the higher the hci&nce of dcpnssion.

I counsel my patients with depression mon than I would like to. - - -. .- - -- - - - - -

ûepmsion is often just caused by stress. I A lot of people would met criteria for deplulion if pu askd tnough questions.

People who su f i r fmm depnssion an man cornpliant with medication than those who an psyc hot ic.

Ps$tatq is imprctise.

Patients with depnssion should see a psychiatrirt as a concurrent method of treatment.

There is no place for ECT in the treatment of &pression.

Patients who suffet fmm depnssion should be able to help themselver

It should be easier to find psychiatrists that will do consultations.

kpnssed patients should k mon willing to take psychotropic medications.

Treating my depnssed patients is rewardnig. -

y--

I like to consult with psychiatrists about depressed patients.

Psychiatrists should be mon accessible for consultations.

\

Psychiatrin's should have mon confilme in the ability of a hdy doctor to diagnose depression.

b

I am not satisfied with the contact I that I have with psychiatrîsîr

L

I would like to consult with pghhtnfis about depressed patients mon oficn than I have

1 been.

1. Gender: M F

3. Working Environment: (cucle dl that apply)

2. Year of graduation fkom medical school:

Hospital Pr. Ractice Cornmunity Health Centet Other (pltase ht):

RETURN CO- W E S l l O ~ TO THE U G m j O N DESK! T m