Clinician Burden and Depression Treatment: Disentangling Patient- and Clinician-Level Effects of Medical Comorbidity

BACKGROUND: Efforts to improve primary care depression treatment have assessed strategies across heterogeneous groups of patients, but few have examined clinician-level influences on depression treatment. OBJECTIVE: To examine clinician characteristics that affect depression treatment in primary care settings, using multilevel ordinal regression modeling to disentangle patient- from clinician-level effects. DESIGN: Secondary analysis from the Quality Improvement in Depression Study dataset. PARTICIPANTS: The participants were 1,023 primary care patients with depression who reported on treatment in the 6-month follow-up and whose clinicians (n = 158) had at least 4 patients in the study. MEASUREMENTS: Primary outcome variable was depression treatment intensity, derived from assessment of concordance with AHCPR depression treatment guidelines based on patient- reported data on their treatment. Primary independent variable was clinical practice burden for treating depression, derived from patient- and clinician-reported composite measures tested for significant association with clinician-reported practice burden. RESULTS: Clinicians who treat patients with more chronic medical comorbidities perceive less burden from treating depressed patients in their practice (Spearman's rho=-.30, p<.05). Clinicians who treat patients with more chronic medical comorbidities also provide greater intensity of depression treatment (adjusted OR=1.44, p=.02), even after adjusting for the effects of patient- level chronic medical comorbidities (adjusted OR=0.95, p=.45). CONCLUSIONS: Clinicians who provide more chronic care also provide greater depression treatment intensity, suggesting that clinicians who care for complex patients can integrate depression care into their practice.