Physician demographics and decision making in the diagnosis and treatment of major depressive disorder and premenstrual dysphoric disorder

Major Depressive Disorder (MDD) is underdiagnosed and undertreated in primary care, but little is known about physicians' practices regarding Premenstrual Dysphoric Disorder (PMDD). The current study investigated aspects of gynecologists' decision making regarding the diagnosis and treatment of MDD and PMDD using written questionnaires and descriptive scenarios as analogues to clinical cases. Demographic variables, attitudes toward MDD and PMDD, beliefs about antidepressant medications, diagnostic probability judgments, decision maker confidence, diagnostic reasoning strategies, use of prior probability data, and self-reported treatment patterns were examined. Differences between MDD and PMDD in reasoning and judgment were also investigated. Signal Detection Theory, Bayes's Theorem and Expected Utility Theory were used to conceptualize key issues, formulate hypotheses and inform analyses. Postal questionnaires were mailed to 997 practicing gynecologists from across the United States. Questionnaire recipients were randomly assigned to one of eight analogous versions of a questionnaire that contained multiple sections. Approximately 36% (N = 335) of the questionnaires were completed and returned. Respondents indicated more responsibility for and confidence in their ability to treat PMDD than MDD. Younger physicians, female physicians and those who self-identified as primary care providers more strongly endorsed certain attitudes that may be associated with a greater tendency to diagnose and treat MDD in practice. Personal experience with PMDD had a significant impact on attitudes. Significant differences between MDD and PMDD in self-reported treatment decisions were found. Pessimism about antidepressants did not appear to impact treatment decisions. Diagnostic probability judgments were significantly more accurate for PMDD than MDD, but respondents were significantly more confident about probability judgments of MDD than PMDD case scenarios. For MDD, less accurate respondents placed comparatively more importance on somatic complaints, and were less likely to prioritize case data according to DSM-IV criteria. In contrast, both more and less accurate respondents appeared to make use of similar, and fairly valid, reasoning strategies regarding PMDD. Respondents did not make meaningful use of prior probability data when it was made available to them. Certain clinician variables appear to constitute biasing factors in decision making, and may contribute to underdiagnosis and undertreatment of MDD, but not PMDD in gynecologic practice.