Hong Kong Physicians' Views on Who Should Treat Mild Depression

To the Editor: Hong Kong's health care system is pluralistic: an individual can consult any private physician, including a specialist, for an illness. Currently, primary care in Hong Kong is provided mainly by physicians in private practice (solo practitioners, group practices similar to health maintenance organizations, and general outpatient clinics in private hospitals), and not all of these physicians have specialty training in family medicine. Physicians in various specialties have diverse training experiences, which may affect how they manage depression. As part of our study to look into the need to promote family medicine in Hong Kong (1,2), we explored physicians' views on who should deliver initial treatment to a patient with mild depression. Our aim was to understand the attitude of physicians in general and particularly of specialists practicing primary care.

Our study used a combined qualitative and quantitative approach, with a clinical vignette describing a patient with mild depression. Seven purposively recruited focus groups of 42 physicians from various specialties were conducted. A questionnaire survey was then sent to all registered physicians in Hong Kong.

A total of 2,310 questionnaires were returned (response rate of 23%). When missing data were excluded from percentage calculations, there were responses from 1,641 men (71%) and 667 women (29%). The mean±SD number of years after graduation from medical school was 20.4±12.33. A total of 1,380 of the respondents (64%) were on the specialist register, 1,285 (57%) were in public service, and 1,117 (51%) were in a community setting.

A total of 2,288 respondents answered the item on depression; 540 (24%) endorsed referral of the patient to a psychiatrist and 518 (23%) to a family physician; 1,230 (54%) endorsed managing the patient themselves. Of the 162 family medicine specialists, 161 (99%) stated that a patient with mild depression should be managed by a family physician. Eleven (16%) of the 68 psychiatrists shared this view.

When family physicians and psychiatrists were excluded from the calculations, 383 (34%) of the other 1,136 physicians on the specialist register endorsed managing the patient themselves without referral, 396 (35%) endorsed referring the patient to a psychiatrist, and 357 (31%) endorsed referral to a family physician. A total of 181 (56%) of the 322 specialists in internal medicine endorsed managing the patient themselves, as did 55 (51%) of the 108 pediatricians, 17 (49%) of the 35 specialists in community medicine, 39 (27)% of the 144 surgeons, eight (24%) of the 34 otorhinolaryngologists, nine (23%) of the 39 pathologists, 25 (21%) of the 117 specialists in obstetrics and gynecology, and 11 (18%) of the 61 radiologists. Physicians in private practice were more likely than those in public practice to endorse managing the patient themselves (68% versus 43%). The consensus of physicians in the focus groups was that a good physician-patient relationship and knowledge of the patient, rather than the type of specialty, carried more weight in their choice of initial treatment for mild depression.

Our findings indicate that in a pluralistic health system, physicians from a range of specialties may treat depressed patients. Many of the physicians in our study endorsed referral of depressed patients to either family physicians or psychiatrists. However, a significant proportion who were neither generalists by training nor psychiatrists, especially those in private practice, endorsed management of the patient themselves. All doctors should ensure their competence in treating mild depression before they decide to manage patients with this disorder.