1. Background
Depression is a mood disorder manifested by depressed mood, pessimism, anhedonia, low energy, psychomotor retardation, and low self-esteem (1). Depression is the most common psychiatric disorder and is associated with a number of physical illnesses (2). Unipolar depression was the fourth leading cause of disability in the world in 1990; moreover, it is predicted that it will have been the second leading cause of death after cardiovascular disorders in 2020 (3). Depression is common among the patients seeking treatment from medical practitioners with different specialties, clinics, hospitals, and primary care centers; meanwhile it often goes undiagnosed especially when co-existing physical disease is the main complaint. Un-diagnosed depression can also prolong the recovery from physical illness and worsen the prognosis. Therefore, all physicians should be able to diagnose and treat its mild forms (2).
Recent surveys show that 20% of Iran’s population suffers from one psychiatric disorder in which depression and anxiety have a higher prevalence.
Stigmatization is a major issue associated with psychiatric diseases in Iran. Physicians should give sufficient information about the nature, diagnosis, and treatment of this disorder to the patients as well as their caretakers to prevent the possible issue of stigmatization (4-6).
Depression is usually treated medically; meanwhile evidence shows that depression is undertreated in the primary care centers. On the other hand, it is shown that if depression is treated optimally in the primary care centers, the prognosis and treatment outcome will be much more effective. Psychotherapy methods such as problem solving are also useful for mild to moderate depression. If the patient prefers this method, it can be an appropriate surrogate for medical treatment (2). Depression constitutes 10% of office-practice patients in the United States; besides, 15% of medical ward’s patients (hospitalized cases) also have depression (4).
This study was designed to investigate the knowledge and attitude of non-psychiatrist physicians about treatment of depressed patients, in Bou-Ali and Amir-Almomenin hospitals in Tehran.
2. Patients and Methods
A cross-sectional study was made of all physicians practicing at Bou-Ali and Amir-Almomenin hospitals (training hospitals of Islamic Azad University). A questionnaire was developed based on the relevant references. The questionnaire consists of four sections: 1) Demographic data consisting of age, gender, and years of experience as their medical practice (following graduation from medical school), and their specialty area. 2) Questions about their knowledge 3) Questions about their attitude 4) Questions in regard to their therapeutic approach. Physicians were asked to fill the forms after given appropriate time (15 minutes).
20 voluntary physicians filled the questionnaire with 2 weeks interval to assess its reliability. Interclass coefficient of the questions ranged from 0.81 to 0.87 with a median of 0.84. Content validity of the questionnaire was evaluated by some three faculty members of the psychiatry department. The figure for Cornbach’s alpha of the questionnaire was 0.77. For the calculation of Knowledge score, a score of 1 is given to each “yes” response and 0 to the “no” ones. In terms of attitude, scores of 5, 10, 15, and 20 were given to the “strongly agree”, “agree”, “disagree”, and “strongly disagree” responses, respectively.
Descriptive statistics was used to run the data. Interclass coefficient and Cronbach’s alpha of the questionnaire were measured to assess reliability and validity. Chi square test was used for compassion among groups. Analysis was performed using SPSS software. At the P < .05 level of significance, the result was accepted.
3. Results
Forty-four questionnaires were filled by physicians. Fifty-one percent of physicians were male. Forty-seven percent were in surgical specialties (Obstetrics/gynecology, general surgery, neurosurgery, otolaryngology, ophthalmology, and urology), 52.3% were in medical specialties (Internal medicine, pediatrics, neurology, cardiology, radiotherapy-oncology, radiology, dermatology, and general practitioner.
Answers to the questions on knowledge of the physicians are summarized in Table 1. Physicians’ knowledge score about the treatment of depression was 6.7 ± 0.95. Physicians’ attitudes towards depression are shown in Table 2. Score of attitude of the physicians about depression was 103.75 ± 1.5.
Table 1.Length of Practice Following Graduation Among Physicians in the Study
| Gender \Length of practice, y | < 10 | 11 - 15 | 16 - 20 | > 20 | Sum |
|---|---|---|---|---|---|
| Female | 5 | 11 | 4 | 0 | 19 |
| Male | 6 | 10 | 3 | 5 | 24 |
| Sum | 11 | 21 | 7 | 5 | 44 |
Table 2.Knowledge of the Physicians about Treatment of Depression
| Question | Correct Answer, No. (%) | Incorrect Answer, No. (%) |
|---|---|---|
| Can depression cause physical symptoms? | 44 (100) | 0 (0) |
| May depression recur after treatment | 44 (100) | 0 (0) |
| Does depression affect social & functional performance of patient? | 44 (100) | 0 (0) |
| May severe depression be a manifestation of a medical disease? | 42 (95.4) | 3 (4.6) |
| How long unsuccessful psychotherapy should be continued before medical therapy becomes necessary? | 6 (13.6) | 38 (86.4) |
| How long does it take for anti-depressants to show their effect? | 10 (22.7) | 34 (77.3) |
| Are anti-anxiety and sedatives equally effective in the treatment of depression | 34 (77.3) | 10 (22.7) |
| Which class of anti – depressant medications have highest rate of complications? | 29 (65.9) | 15 (34.1) |
Table 3.Attitude of the Physicians about Treatment of Depression
| Question | Strongly Agree, No. (%) | Agree, No. (%) | Disagree, No. (%) | Strongly disagree, No. (%) |
|---|---|---|---|---|
| I am responsible for identifying the depression in all my patients | 6 (13.6) | 22 (50) | 15 (34.1) | 1 (2.2) |
| Treatment of my patient’s depression is my duty. | 6 (13.6) | 22 (50) | 15 (34.1) | 1 (2.2) |
| I can perfectly manage a depressed patient | 3 (6.8) | 9 (20.4) | 27 (61.4) | 5 (11.4) |
| I refer my patient to a psychiatrist. | 32 (72.9) | 9 (20.4) | 2 (4.5) | 1 (2.2) |
No significant difference was observed in total knowledge score of physicians in different specialties (P < 0.05) .There is no significant difference between male and female physicians considering the knowledge, attitude, of therapeutic approach (P < 0.5).
4. Discussion
This study shows that non-psychiatrist physicians show a moderate knowledge, attitude, towards treatment of depression. Similarly, a study in Zahedan showed that knowledge of general physicians about the efficacy and prescribing new drugs have been relatively low.
In a study performed in Taiwan, only one-third of physicians believed in solely medical management; however, 70% of our physicians believe in solely pharmacotherapy. This implies that non-psychiatric physicians generally do not believe or are not aware of these treatment modalities. It seems that non- psychiatric physicians consider depression similar to that of physical illness, and they treat it with the similar therapeutic approach. This is further highlighted by relatively poor performance in questions regarding psychotherapy (3-8).
In another study, only 50% of physicians were confident about their diagnosis of depression; on the contrary, in the findings of our study where 11% of physicians were confident about their diagnosis of depression, approximately 61% had low confidence about their diagnosis and 27% could not diagnose the depressed patients (3, 4). It seems that, in comparison with the research performed in Taiwan, our physicians are less confident in diagnose and treatment of depression. Comparing the study in Taiwan mentioned above, our physicians had better knowledge about the pharmacotherapy of depression (65% versus 50%). Physicians in our study were not very knowledgeable about specific indications of these drugs as jugged by lack of knowledge about the similar activities of anti-anxiety and anti-depressant medications, as well as the time needed for them to have effect. Therefore, it is suggested to run re-educational programs regarding diagnosis of depression and the need for psychiatric consultation (3-5). We did not find a significant relation between therapeutic approach and the level of knowledge. This implies that probably our non-psychiatrists will treat patients without proper insight, which is of concern and should be further evaluated.
It is noteworthy that a large number of physicians studied did not correctly answer the pharmacology questions, 63% of them wrongly answered the question on the “time to take effect” of antidepressants. Meanwhile, 65% of the subjects identified MAOIs as the medication with highest complication rate.
Physicians of medical specialties, surgical specialties, and general practitioners were not significantly different considering the attitude, knowledge and approaches, which is in line with the fact that these groups had comparable education areas about depression in their medical trainings and also continues medical education programs following graduation. In this study, 72% believe they are not capable of managing depression in their patients, also 90% of respondents reported that they would ultimately refer the depressed patients to a psychiatrist. In a dissertation written in Zahedan, general practitioners used the referral system less frequently comparing to that of the study we have made (3, 8).
Physicians had little information regarding psychotherapy and the time that it needs to take effect, which is similar to other reports. Therefore, we suggest better discipline in this regard.
Maybe this problem is rooted in the fact that in our country depression is not yet considered as a serious health problem and non-psychiatrist physicians with variable level of knowledge treat patient in various approaches. This may lead to confusion and complications for the patient.
In conclusion, this study highlights the low level of knowledge of physicians about depression. Further studies are of paramount importance to assess the efficacy of interventions applied to improve current situation.
