Articles

RESEARCH ARTICLE

“Doctor, my back hurts and I cannot sleep.”

Depression in primary care patients: Reasons

for consultation and perceived depression

stigma

Ines HeinzID 1,2*, Sabrina Baldofski1, Katja Beesdo-Baum3,4, Susanne Knappe3,4,

Elisabeth Kohls 1☯

, Christine Rummel-Kluge 1☯

1 Department of Psychiatry and Psychotherapy, Medical Faculty, University Leipzig, Leipzig, Germany,

2 German Alliance Against Depression, Leipzig, Germany, 3 Behavioral Epidemiology, Institute of Clinical

Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany, 4 Center for Clinical

Epidemiology and Longitudinal Studies, Technische Universität Dresden, Dresden, Germany

☯ These authors contributed equally to this work. * [email protected]

Abstract

Background

General practitioners (GPs) play a significant role in depression care. Recognition of

depression is crucial for adequate treatment but is impeded by a high portion of depressed

patients only reporting physical symptoms to their GP. Among the many reasons for this

phenomenon is mental health stigma. We investigated how patients with depression differed

from patients without depression regarding the types and number of complaints presented

to their GP, as well as their depression stigma. For the subgroup of patients with depression,

potential associations between perceived depression stigma and number and types of pre-

sented complaints were investigated to see if these might reflect the patient’s intention to

conceal mental health symptoms due to fear of being stigmatized by others. Further, we

investigated if perceived depression stigma is related to depression treatment.

Methods

Data on depressive symptoms (assessed by the Depression Screening Questionnaire;

DSQ), depression stigma (assessed by the Depressions Stigma Scale; DSS), type of com-

plaints reported to the GP and treatment-related factors were collected from 3,563 unse-

lected primary care patients of 253 GPs in a cross-sectional epidemiological study (“VERA

study”) in six different German regions. Data of a total of 3,069 patients was used for analy-

sis on complaints reported to the GP (subsample of the VERA study), and for 2,682 out of

3,069 patients data on a stigma questionnaire was available.

Results

Nearly half of the primary care patients with depression (42.2%) reported only physical com-

plaints to their GP. Compared to patients without a depression diagnosis, patients with

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OPEN ACCESS

Citation: Heinz I, Baldofski S, Beesdo-Baum K,

Knappe S, Kohls E, Rummel-Kluge C (2021)

“Doctor, my back hurts and I cannot sleep.”

Depression in primary care patients: Reasons for

consultation and perceived depression stigma.

PLoS ONE 16(3): e0248069. https://doi.org/

10.1371/journal.pone.0248069

Editor: Kenji Hashimoto, Chiba Daigaku, JAPAN

Received: October 6, 2020

Accepted: February 18, 2021

Published: March 5, 2021

Copyright: © 2021 Heinz et al. This is an open access article distributed under the terms of the

Creative Commons Attribution License, which

permits unrestricted use, distribution, and

reproduction in any medium, provided the original

author and source are credited.

Data Availability Statement: All relevant data are

within the manuscript and its Supporting

Information files.

Funding: Data for this study was obtained through

the VERA Project that was financially supported by

the German Federal Ministry of Health

(Bundesgesundheitsministerium) under the grant

number II A 5- 2513 FSB 011 (grant recipient

KBB). The sponsors had no influence on study

design, data collection and analysis, decision to

publish, or preparation of the manuscript.

depression reported twice as many complaints to their GP with a mean of 2.02 (1.33) vs. 1.2

(0.69), including a more frequent combination of physical and mental symptoms (28.8% vs.

3.5%). Patients with depression showed higher total stigma compared to patients without

depression, Mdn = 48 (IQR 40–54) vs. Mdn = 46.3 (IQR 29–53), due to higher perceived

stigma, Mdn = 27 (IQR 21–32) vs. Mdn = 25.9 (IQR 20–29). Perceived stigma was associ-

ated with male gender (beta -.14, p = .005) and a lack of pharmacological treatment (beta

-.14, p = .021) in patients with a depression diagnosis.

Conclusion

The number of complaints presented to the GP might function as a marker to actively

explore depression in primary care patients, in particular when both physical and mental

symptoms are reported. Perceived depression stigma should also be addressed especially

in male patients. Further research should clarify the role of perceived stigma as a potential

inhibitor of pharmacological treatment of depression in primary care.

Introduction

Depression is among the leading causes for disability-adjusted life years [1]. Effective and evi-

dence-based treatments are available [2], nevertheless more than 50% of patients do not

receive depression-specific treatment [3, 4], or else experience delays to treatment due to a

variety of reasons [5, 6]. Among them are both structural and financial barriers, as well as a

low perceived need for professional help and fear of being stigmatized [5–7].

General practitioners (GPs) play a significant role in the detection, diagnosis, referral and

treatment of depression, which is defined by a high point-prevalence of depressive episodes in

primary care patients of 8–17% [8, 9]. This result was recently confirmed in an epidemiological

study of primary care patients in Germany with a point-prevalence of 14.3%, according to self-

reports [10]. Moreover, the majority of individuals with depression are being treated in pri-

mary care rather than in specialized care, while the treatment of depression according to

guidelines depends heavily on a correct diagnosis (e.g. [4]). Studies in primary care settings

have shown that only every second patient with depression is diagnosed correctly [10].

Several reasons for the false-negative detection of depression are discussed in the literature,

such as heterogeneous depression symptoms, lacking objective laboratory markers, time

restrictions and lacking reimbursements in primary care settings that impede the necessary

exploration and evaluation for a differential diagnosis [10, 11]. Further, studies revealed that

44–69% of patients with depression report only their physical symptoms [12–14]. Other stud-

ies have shown that both a correct GP diagnosis and further adequate treatment rely heavily

on the symptoms reported by the patient during consultation [10, 13, 15, 16]. The detection

rate for individuals that report only physical symptoms is therefore much lower than for those

that report physical and mental symptoms [15].

Different reasons for the association between depression and patients reporting mainly

physical instead of mental complaints have been discussed, among them the stigma associated

with the depression. Depression stigma might result in defense mechanisms such as masking

certain symptoms and emphasizing somatic aspects so as to disguise mental health problems

that may require treatment in anticipation of negative consequences [14, 16, 17].

Stigma is described as a discrediting attribute (e.g. physical attribute, religion, skin color,

mental health disorder) by which the carrier deviates from the expected social norm [18].

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Competing interests: We declare the following

competing interests: CRK received lecture

honoraria from Recordati and Servier outside and

independent of the submitted work. This does not

alter our adherence to PLOS ONE policies on

sharing data and materials. KBB, SK, EK, SB and IH

have nothing to declare.

Among the leading concepts of stigma is the one developed by Link and colleagues, describing

stigma by use of the following five interrelated components: 1. labeling (creating labels for

social salient attributes), 2. stereotyping (linking those labels to undesirable characteristics), 3.

separating (the labeled, stigmatized group), 4. emotional reaction (of stigmatizers as well as

stigmatized persons influencing their subsequent behavior), and 5. status loss and discrimina-

tion (of stigmatized persons) [19]. Another often cited concept of stigma was developed by

Corrigan [6], who defined stigma with three core components of stereotypes, prejudices and

discrimination, while distinguishing between two types of stigma: Public stigma, which refers

to the (discriminating) reactions of the society towards a stigmatized person or group (e.g.

withholding a job) based on stereotypes (e.g. “Individuals with depression are incompetent.”),

and prejudices (believing in these stereotypes) [6, 20]. When public stigma is internalized by

an individual belonging to the stigmatized group, it may result in self-stigma [6, 21, 22],

thereby lowering the individual’s self-esteem [20, 23]. This process appears to be moderated by

further factors, e.g. if an individual is conscious about the public stigma [24] and in agreement

with public stigmatizing attitudes [20]. Two further related types of stigma have been found in

the literature: Personal stigma, which describes a person’s attitudes toward a mental health dis-

order regardless of whether he/she belongs to the stigmatized group [7, 25, 26], and perceived

stigma, which is related to public stigma and describes an individual’s belief about public atti-

tudes towards a mental health disorder [6, 7, 26–28]. Some authors have used public and per-

ceived stigma synonymously [7, 29]. Beside the different types and concepts of stigma,

different measures exist to assess the various stigma types [19, 21].

Several studies and theories can be found in the literature describing the association between

different stigma types and help-seeking for mental health disorders. Despite mixed results, there

is evidence that different types of stigma can influence different stages of the help-seeking process

(e.g. [7, 30, 31]). Self-stigma appears to be associated with less help-seeking intentions and behav-

iors at an early stage of the help-seeking process. Studies assessing self-stigma via the Self-Stigma

of Seeking Help (SSOSH) scale [31, 32] or by the Internalized Stigma of Mental Illness (ISMI)

scale [33] have also found that being labeled “mentally ill” may pose a potential threat to an indi-

vidual’s self-esteem. Like self-stigma, there is some evidence that personal stigma may also impact

help-seeking at an early stage, e.g. by not appraising symptoms as a mental health problem and a

perceived need for professional help. Schomerus and colleagues [30] assessed personal stigmatiz-

ing attitudes by observing participants’ attitudes of blaming mentally ill people (according to the

Self–Stigma of Mental Illness Scale (SSMIS) [34]), their discrimination of mentally ill people and

the social distance they maintain towards them (Social Distance Scale, [35]). The authors con-

cluded that participants who supported discrimination or blaming a person with a mental illness

showed lower self-identification of having a mental health problem themselves, as well as a lower

perceived need for help. Likewise, Griffith and colleagues reported that within a sample of 2,000

Australian adults, a positive association was found between personal depression stigma, assessed

with the DSS [25, 27], and the belief to deal with depression alone [26].

While personal stigma has been shown to impair early stages of help-seeking, i.e. avoiding

professional help, perceived and public stigma do not appear to have comparable effects on ini-

tial help-seeking [7, 17, 21, 22, 29, 30, 33]. Schomerus and colleagues [22] assessed a person´s

beliefs about public attitudes towards seeking psychiatric help with use of the 17-item ADSP

scale (anticipated discrimination when seeing a psychiatrist), revealing no association between

beliefs and help-seeking intentions. Meanwhile, the authors also found that participant´s per-

sonal attitudes, assessed by their desire for social distance, decreased their help seeking inten-

tions. A systematic review on active help-seeking and mental-health related stigma obtained

similar results: public stigma, mainly assessed with the Perceived Devaluation Discrimination

Scale [36] and its adaptations, was not linked to active help-seeking [7]. Similar results have

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been reported for perceived stigma, which was assessed with the Perceived Devaluation Dis-

crimination Scale, and which was not found to be associated with barriers to depression care

such as a low perceived need, negative treatment expectations or treatment seeking attitudes

and behaviors [29, 33]. However, in these same studies, self-stigma, assessed by the 29-item

Internalized Stigma of Mental Illness (ISMI) scale [37], showed a strong association with barri-

ers to care and treatment seeking attitudes and behaviors respectively.

Some studies have indicated that perceived stigma may also be a relevant factor in later

stages of the help-seeking process by impeding engagement in and maintenance of depression

treatment as well as treatment outcomes [38–40]. However, the full scope of the influence of

perceived stigma remains unknown.

The current study investigates depression stigma in a large sample of primary care patients

in Germany with and without depression (based on self-reports) as well as their reported com-

plaints to the GP (including type and number of complaints). To our knowledge, there are

only two studies available that have investigated whether primary care patients with depression

differed from primary care patients without depression in regard to the number of reported

complaints to their GP [14, 41]. Both studies reported a higher number of physical complaints

reported to the GP by patients with depression with a mean of 4.4 (SD = 4.2) and 4.5 (SD = 2.3) respectively, compared to patients without depression with a mean of 1.2 (SD = 1.9) and 1.8 (SD = 1.3) respectively.

Based on previous literature, we state the following hypotheses:

1. In line with previous findings regarding reported complaints to the GP, we assume that

patients with depression will present more physical than mental complaints, as well as more

symptoms in total, in comparison to patients without depression [14, 41].

2. Patients with depression will not differ in personal depression stigma from patients without

depression, as personal depression stigma has been reported to deter help-seeking at an

early stage (i.e. the wish to deal with the problem alone instead of seeking professional help,

e.g. from a GP [26]).

3. With regard to perceived depression stigma, patients with depression will show higher stigma

scores than patients without depression, as has been found in other studies [25, 41, 42].

4. Further, for the subgroup of patients with depression, we will explore to which degree per-

ceived depression stigma is relevant at this stage of the help seeking process (consulting a

GP). This will be determined through associations between the number and types of

reported complaints for consultation (mental vs. physical), as well as the factors related to

the treatment of depression (type of treatment, help-seeking behaviors and/or referral to

specialized care).

Materials and methods

Sample and procedures

As part of a cross-sectional epidemiological study investigating the diagnosis and treatment of

depression in the primary care setting in Germany (VERA study), 269 randomly selected GPs

of six regions in Germany (Dresden, Leipzig, Frankfurt/ Kassel/ Fulda, München, Berlin,

Hamburg) stratified by location (city, town, rural) were recruited to participate in a survey at

the end of 2013 and the beginning of 2014 (response rate 5.8%). These regions were selected

based on their representativeness for the heterogeneous geographical situation within the fed-

eral territory of Germany. In total, 253 GPs and 3,563 unselected patients (response rate 55.9%

of suitable patients) took part in the survey by completing a GP and a patient questionnaire,

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respectively. The patient questionnaire consisted of a compulsory Part A and a voluntary Part

B. Part A contained the Depression-Screening-Questionnaire (DSQ; [43]) and asked patients

to state the complaints for which they consulted their GP. Meanwhile, Part B contained the

Depression Stigma Scale (DSS; [27, 28]). As illustrated in Fig 1, 64 of the 3,563 unselected

patients were excluded (no patient questionnaire available), resulting in 3,499 patients with

questionnaire data suitable for analysis. Another 132 cases were excluded because there was no

corresponding GP questionnaire. Of the remaining 3,367 patients, 298 cases were excluded

due to missing data in the DSQ items and/or items to assess complaints to consult the GP for

this analysis. Therefore, the final sample in which we analyzed complaints reported when con-

sulting a GP with regard to depression diagnosis consisted of 3,069 patients. Of these patients,

387 cases were excluded due to missing data in the DSS. Depression stigma analysis were

therefore performed for a sub sample of 2,682 patients (see results section). A detailed descrip-

tion of the design of the VERA study can be found elsewhere [4, 10].

Written informed consent was obtained prior to study participation from all participating

GPs and patients. The study was approved by the ethics committee of the Technische Universi-

tät Dresden on 2013.10.07 under the reference number EK 392102013 and according to the

Declaration of Helsinki.

Instruments

Sociodemographic data. Sociodemographic information including age (in years), gender,

marital and occupational status was collected. Marital and occupational status was dichoto-

mized into “single” vs. “not single” and “occupied” vs. “not occupied”, respectively.

Fig 1. Flow chart of sampling process.

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Depression diagnosis. Depressive symptoms were rated by patients according to ICD-10

criteria using the Depression-Screening-Questionnaire (DSQ; [43]). In total, 12 items regard-

ing depressive symptoms during the preceding 2 weeks were rated on a three-point Likert-

scale (0 = “not at all”, 1 = “sometimes”, 2 = “most of the days”). If at least 3 items were

endorsed with “most of the days” and the sum score was higher than 7 (i.e. at least 4 symptoms

were present), the study diagnosis “depression” was coded (according to [44]). Depression

severity was rated as follows: “mild depression” if at least 3 items were indicated for “most of

the days” and the sum score exceeded 7, “moderate depression” if at least 5 symptoms were

indicated for “most of the days” and the score exceeded 11, and “severe depression” if at least 7

symptoms were indicated for “most of the days” and the score exceeded 16 (according to [4]).

Depression severity was dichotomized into “mild” vs. “moderate or severe”. The DSQ demon-

strated good internal consistency (Cronbach’s alpha of 0.83) as well as high inter-rater reliabil-

ity (kappa = 0.84–0.89) in a German study with primary care patients [45].

Complaints reported to the GP. Patients provided information regarding the complaints

they reported during their consultation with a GP through use of a multiple-choice question-

naire containing seven response categories (physical complaints or illnesses; sleeping prob-

lems; pain; depression or depressiveness or desperation; anxiety problems; other mental health

problems; another reason). Multiple answers were possible. For the category “another reason”,

follow up appointment and referral due to any emergency were given without asking for the

type of complaint. “Physical complaints” were counted if a patient indicated a physical com-

plaint or illness, sleeping problems or pain as the reason they consulted the GP. “Mental com-

plaints” were counted if a patient indicated they sought help from a GP for either depression,

depressiveness or desperation, anxiety problems or other mental health problems. “Physical

and mental complaints” were counted if a patient indicated at least one reason from each of

the aforementioned categories. The items used to assess complaints reported to the GP were

developed by the researchers (psychologists, senior psychiatrists and GPs), as there was no

established instrument available.

Depression treatment and treatment-related factors. Patients who endorsed at least 2

DSQ items with either “sometimes” or “most of the days” were asked to document their cur-

rent and planned future treatment of depression. In addition, GPs provided information for

each patient regarding the type of treatment he/she had received prior to the reference date

(i.e. the day when the questionnaires were completed), as well as any other treatment of

depression. In order to maximize sensitivity in identification, treatments were assumed to be

present if they were mentioned by the patient and/or the GP. Treatment was categorized

according to Trautmann [4] into (1) psychotherapy, (2) antidepressants, (3) other treatment,

and (4) no treatment. According to the National Disease Management Guidelines, Unipolar

Depression, the evidence-based recommendations for diagnosis and treatment of unipolar

depression in Germany [46] with either psychotherapy or antidepressants are indicated to

treat mild to moderate depression, whereas a combination of both is indicated in the case of

severe depression. For a more detailed description of the categorization of treatments, please

refer to Trautmann [4] (supplementary material, eTable 1).

To assess referral to and/or help-seeking from specialized care (i.e. psychiatrist, psychother-

apist, inpatient treatment), patients were asked if their GP had referred them to specialized

care or if they had sought specialist help by themselves due to their depressive symptoms.

Depression stigma. Attitudes towards depression were assessed by the standardized

Depression Stigma Scale (DSS), a commonly used instrument to assess depression stigma in

the general public as well as depressed individuals [27, 28]. The DSS measures perceived and

personal stigma with 18 items which are scored on a five-point Likert Scale ranging from 1 =

“strongly disagree” to 5 = “strongly agree” [28]. Items cover common prejudices including

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depression as weakness of character or personal fault, unpredictability and dangerousness,

shame, avoidance, and discrimination. For nine items the participant indicates to what extent

he/she agrees with a statement reflecting personal depression stigma (e.g. “Depression is a sign

of personal weakness.”). In the remaining nine items, the participant rates what he/she thinks

the broad public believes about these same statements (e.g. “Most people believe that depres-

sion is a sign of personal weakness”), thereby reflecting perceived depression stigma. Higher

sum scores on each subscale (range 9–45) and as a total score (range 18–90) indicate more stig-

matizing attitudes. The DSS has shown high test-retest reliability as well as moderate to high

internal consistency across various countries and in different populations (Cronbach´s alpha

ranging from .70 - .82 for subscales and total scale) [25, 28, 47–49]. We used the German ver-

sion of the DSS [49], which has been translated both forward and back from the original

English DSS in accordance with the guidelines of the World Health Organization [50] by a

native German speaker and a German mental health professional. The DSS factor-structure

depends on language, sample and cultural context and was subject to previous studies [48, 51–

54]. To date, the factor-structure of the German version of the DSS has not been investigated.

Statistical analysis

Statistical analyses were performed using IBM SPSS Statistics version 25.0. A two-tailed α = 0.05 was applied to statistical testing. First, to examine group differences between patients with

and without a depression diagnosis, χ2 tests were used for categorical variables (gender, marital status, occupational status and reported complaints). Bonferroni correction was applied for

post-hoc analysis in case of multiple tests. Group differences for continuous variables were

analyzed using Mann-Whitney U tests, as all continuous outcome variables (age, number of reported complaints per patient, DSS sum score and subscale scores) were non-normally dis-

tributed, as indicated by the Shapiro-Wilks test (all p < .05). Additional exploratory analyses of covariance (ANCOVAs) examined group differences in DSS sum scores and subscale

scores, respectively, when adjusting for age, gender and marital status.

Second, in order to examine whether sociodemographic and treatment-related factors pre-

dicted DSS perceived stigma scores (dependent variable) in the subgroup of patients with

depression, a multiple linear regression analysis was applied with the following predictor vari-

ables: age, gender, severity of depression (according to self-report DSQ), number and type of

complaints reported to the GP, help-seeking from specialized care and depression treatment.

Categorical variables with more than two categories (depression severity, complaints and

depression treatment) were recoded into binary dummy variables. The variable “treatment

according to guidelines”, which combines the type of depression treatment and depression

severity, was initially included in the regression analysis but did not become significant. There-

fore, depression severity and treatment were included as separate predictors since their poten-

tial association with perceived stigma is of great practical interest. All predictor variables were

entered simultaneously. The dummy variables for “no treatment” and “reporting only physical

complaints to the GP” had to be excluded from the regression analysis due to multicollinearity.

All effect sizes were interpreted as suggested by Cohen [55], i.e. 0.2 was considered a small

effect, 0.5 a medium, and 0.8 a large effect.

Results

Sample

At the reference date, 430 out of 3,069 patients (14.0%) reported a current depressive episode

according to the ICD-10 criteria, i.e. they received a depression diagnosis based on the DSQ.

Of these patients, 261 (60.7%) reported a mild depressive episode, 114 (26.5%) reported a

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moderate depressive episode and 55 (12.8%) reported a severe depressive episode. Differences

between patients with (n = 430) and without (n = 2,639) depression with regards to sociode- mographic information, depression stigma and complaints reported to the GP are displayed in

Table 1. All analyses of depression stigma were conducted for a reduced sample due to missing

data: 2,357 (76.8%) participants of the total sample (3,069) answered all DSS items without

missing values. For 712 patients with missing values in the subscales, data was computed by

the patient´s subscale mean score for non-missing items if the patient answered at least 7 out

Table 1. Sociodemographic characteristics, depression stigma and complaints reported to the GP in patients with and without depression.

Patients with depression a

(n = 430) Patients without depression

(n = 2,639) Test Effect size

N (%) or M (SD) N (%) or M (SD) Age (years) 50.22 (15.81) 53.9 (17.12) U = 489,994.50 r = .08

p < 0.01 Gender

b

Male 137 (31.9%) 1,061 (40.2%) χ2 (1) = 10.89 φ = .06 Female 293 (68.1%) 1,576 (59.8%) p = .001

Marital status b

Not single 210 (49.8%) 1,561 (60.0%) χ2 (1) = 15.73 φ = .07 Single 212 (50.2%) 1,040 (40.0%) p < .001

Occupational status b

Occupied 254 (60.2%) 1,572 (60.0%) χ2 (1) = .03 φ = .00 Not occupied 168 (39.8%) 1,020 (39.3%) p = .858

Number of reported complaints per patient 2.02 (1.33) 1.2 (0.69) U = 362,665.50 r = .25 p < .001

Type of complaints reported to the GP 430 (14%) 2,639 (86%) χ2 (4) = 449.81 φ = .38 p < .001

Number of patients only stating physical complaints 190 (42.2%) 1560 (59.1%) χ2 (1) = 33.62 φ = .11 p < .001

Number of patients only stating mental complaints 42 (9.8%) 59 (2.2%) χ2 (1) = 65.90 φ = .15 p < .001

Number of patients stating physical and mental

complaints

124 (28.8%) 93 (3.5%) χ2 (1) = 360.57 φ = .34 p < .001

Number of patients stating no complaints 19 (4.4%) 213 (8.1%) χ2 (1) = 7.06 φ = .05 p = .008

Number of patients with other reasons c

55 (28.8%) 714 (27.1%) χ2 (1) = 40.07 φ = .11 p < .001

Depression stigma b Median (IQR) Median (IQR)

DSS sum score 48 (40–54) 46.3 (29–53) U = 420,759.50 r = .00 p = .047

DSS personal stigma 20 (16–24) 20.25 (16.9–25) U = 441,133.00 r = .03 p = .118

DSS perceived stigma 27 (21–32) 25.9(20–29) U = 399,821.50 r = .08 p < .001

N = Number of patients; % = percent calculated for valid cases; M = mean; SD = standard deviation; DSS = Depression Stigma Scale. a

according to DSQ self-report. b

reduced sample size due to missing data, valid percentage are reported. c

follow up appointments and emergency cases

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of 9 (78%) subscale items according to Dardas [56]. Thus, 325 patients with missing data met

these criteria for data imputation, resulting in a total sample of 2,682 patients with DSS scores.

Patients with depression were significantly younger, more likely to be female, more fre-

quently single (small effects, all p < .01) and reported an average of 2 (vs. 1) complaints to their GP (small effect, p < .001), when compared to patients without depression. Regarding the com- plaints reported to the GP, 190 (42.2%) patients with depression reported physical complaints

only, 42 (9.8%) reported mental complaints only and 124 (28.8%) consulted the GP due to men-

tal and physical complaints. Patients with depression significantly differed in all 3 categories

from patients without depression (small to medium effects, all p < .001, see Table 1). Further, both subsamples differed in perceived depression stigma scores and depression

stigma sum scores, with higher scores in patients with depression (small effect, p < .001 and p = .047). No differences were found for occupational status and personal depression stigma scores (p > .05). Three additional exploratory ANCOVAs with DSS sum scores and subscale scores as outcome variables did not result in changes in the significance of results when includ-

ing age, gender and marital status as covariates.

Results of an exploratory linear regression analysis for the subgroup of patients with depres-

sion are presented in Table 2.

Male gender (p = .005) and less frequent pharmacological treatment (p = .021) predicted higher scores of perceived depression stigma in patients with depression. The other predictors

were unrelated to perceived depression stigma (all p > .05). The overall model fit was R2 = 0.06 (adjusted R2 = 0.03).

Discussion

Almost half of the primary care patients with depression reported mostly physical complaints

to their GP. Compared to patients without depression, patients with depression reported

Table 2. Linear regression for predictors of perceived depression stigma.

DSS perceived stigma score (n = 391a) Variable Unstan-dardized β SE Standar-dized β 95% Confidence Interval (CI) t p Age -.07 .04 -.10 -.141, .010 -1.70 .091

Gender -3.53 1.24 -.14 -5.993, -1.062 -2.81 .005

Depression severity b

-.13 .87 -.01 -1.844, 1.582 -.15 .880

Number of reported complaints to consult the GP 1.27 .71 .14 -.127, 2.667 1.79 .075

Number of patients only reporting mental complaints 1.97 2.09 .05 -2.130, 6.072 .95 .345

Number of patients reporting physical and mental complaints .62 1.92 .02 -3.148, 4.386 .32 .75

Number of patients with different reasons c

2.24 1.95 .06 -1.585, 6.073 1.15 .25

Number of patients reporting no complaints 3.23 3.14 .06 -2.936, 9.393 1.03 .304

Only pharmacological treatment -4.97 2.15 -.14 -9.189, -.747 -2.31 .021

Only psychotherapeutic treatment -3.65 2.02 -.11 -7.617, .314 -1.81 .071

Combination treatment -3.41 1.86 -.12 -7.086, .247 -1.83 .068

Any treatment other than pharmacological or psychotherapeutic -1.64 1.66 -.06 -4.903, 1.625 -.99 .324

Referral to and/or help-seeking from specialised care -.06 1.30 -.01 -2.613, -2.503 -.04 .966

R2 (R2 adjusted) .06 (.03) F 1.94 p = .025

a reduced sample size due to missing data.

b depression severity dichotomized into “mild” vs. “moderate or severe”.

c patients in emergency cases, coming for referral, prescription, or follow-up appointment only.

https://doi.org/10.1371/journal.pone.0248069.t002

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significantly more complaints, as well as a more frequent combination of physical and mental

complaints. Patients with depression did not differ from patients without depression regarding

personal depression stigma but showed higher perceived depression stigma and therefore

higher stigma scores in total.

Patients with depression presented significantly less exclusively physical complaints to their

GP than patients without depression. Nevertheless, 40% of patients with depression did not

report any mental health symptoms to their GP. Only 1 out of 10 patients with depression indi-

cated that they consulted their GP due to (only) mental complaints (according to hypotheses

1). In comparison, one third of patients with depression reported a combination of mental and

physical complaints. The large proportion of patients with depression who reported only phys-

ical complaints is aligned with findings of previous studies, including a study of German pri-

mary care patients with depression, wherein 57% of patients reported only somatic symptoms

[13], as well as an international study in which a range of 45–95% of primary care patients

with depression exclusively reported somatic symptoms to their GP [14]. Further, the combi-

nation of different complaints, i.e. mental and physical symptoms, appears to be an important

indicator for depression, as patients without depression reported this combination of symp-

toms significantly less frequently than patients with depression. In addition, depressive

patients reported twice as many complaints in total during their consultation with the GP, in

comparison to patients without depression. Our results thereby provide further evidence for

this phenomenon which has previously been reported by only a handful of studies with com-

parable ratios [14, 41].

The relevance of patients with depression reporting mainly physical symptoms, as well as

their nondisclosure of mental symptoms has been widely discussed in the literature. Contrib-

uting factors to this phenomenon may include: attributing depressive symptoms to somatic

causes [15, 57], believing somatic symptoms to be a core component of depression, a lack of

trust in primary care providers regarding the care of depression, fear of being placed on anti-

depressants, as well as stigma surrounding depression [14, 16, 58, 59].

In our sample, personal depression stigma was comparable between patients with and with-

out depression (according to hypothesis 2). Prior studies investigating path models of help-

seeking concluded that personal stigma may affect help seeking behavior at an early stage, e.g.

recognizing and appraising symptoms, a perceived need for help [7, 30, 60], and the desire to

deal with the problem alone [7, 26, 30]. This implies that the current study may have predomi-

nantly investigated patients with comparably low personal depression stigma, since these

patients may have identified or recognized their symptoms as being related to a mental illness

or else perceived a need for treatment which was followed by the intention and respective

action to seek help, which in our study was the consultation with a GP.

Perceived depression stigma was significantly higher in patients with depression as com-

pared to patients without depression (according to hypothesis 3), which is similar to the results

of previous studies measuring perceived stigma with the corresponding DSS subscale [25, 41,

42] and the Stigma Scale for Receiving Psychological Help (SSRPH) [41]. This suggests that

individuals with depression may experience stigmatization from their community due to their

diagnosis or, in case of first-time help seeking, are more sensitive to such events [22, 25].

It is also conceivable that the choice of primary care setting could have been influenced by

patients´ perceived stigma, as consulting a GP does not provide the same level of branding

someone as mentally ill as is associated with the consultation of other mental health specialists

[6, 17, 21, 61]. On the other hand, accessing a GP in Germany is much easier compared to spe-

cialized care, especially in rural areas where the density of mental health professionals is com-

parably low. Thus, an appointment in primary care can usually be arranged at short notice and

without waiting time. As we did not assess patients´ reasons to choose primary care providers,

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no conclusions on perceived stigma as a potentially influencing factor on the choice of care

provider can be drawn from this study.

Higher scores of perceived stigma were unrelated to the type of complaints reported to the

GP in our study, i.e. fearing negative consequences of a depression diagnosis by others did not

correlate with the reporting of predominantly physical symptoms or the non-disclosure of

mental symptoms in primary care settings. Simon [14] reported that in a sample of primary

care patients with depression, the majority of patients reporting only somatic complaints

(60%) did not deny depressive symptoms when asked. The authors argued that reporting phys-

ical symptoms to a GP might function as an “admission ticket” to primary care, as GPs are not

commonly seen as the appropriate person to talk to about depression symptoms [16, 58, 62,

63]. In this case, perceived stigma plays a minor role with regards to complaints presented to

the GP.

Examining the treatment for depression within our sample, patients with depression and

higher scores of perceived stigma were less frequently treated with psychopharmacological

medication. Our findings match those of previous studies, which reported lower initiation of

pharmacological treatment and lower antidepressant medication adherence for individuals

with depression who reported higher perceived stigma [21, 38, 40], as assessed with the Per-

ceived Devaluation Discrimination Scale [36]. Since the assessment of perceived stigma was

different and given the low percentage of variance explained by the regression model in our

study, conclusions should be drawn with caution if and to what extent the fear of belonging to

a stigmatized group when receiving pharmacological treatment for depression conflicted with

the need for treatment [38]. Nevertheless, this finding is particularly important for patients

with severe depression, as antidepressant medication is typically recommended for this group,

either independently or in combination with psychotherapy.

Findings in the literature have indicated either no consistent gender differences in per-

ceived stigma (e.g. [25, 39], higher perceived stigma in females [25, 42, 47, 56], or higher per-

ceived stigma in males [64]. However, former studies on gender differences have been

heterogenic regarding samples, cultural context and measures used to investigate stigma [64].

As a result, the conclusion of our study that male primary care patients with depression are

more likely to be influenced by public attitudes than female patients requires further research.

Nevertheless, perceived depression stigma may have an effect on medication adherence [40].

Therefore, GPs should pay special attention to male patients so as to address and manage the

anticipated negative effects of treatment.

Perceived stigma is only one type of mental health stigma and help-seeking is a complex

process that is influenced by a variety of different factors, including patient and illness charac-

teristics [25]. Perceived stigma does not appear to prevent primary care patients from consult-

ing a GP, even if we cannot yet draw conclusions on whether a patient associates his/her

complaints with a mental health disorder or with depression. The question of whether per-

ceived stigma influences the types of complaints reported, as well as how many complaints are

reported by patients in primary care settings requires further research. In later steps of the

help-seeking process, perceived stigma may hamper the treatment of depression, in particular

pharmacological treatment and treatment for male patients. This should therefore be

addressed in future studies.

Conclusion

This study provides evidence for the importance of physical complaints reported by patients

with depression in primary care settings, in light of the small number of patients disclosing

mental symptoms. The study further emphasizes the importance of the number of complaints

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reported by patients as a potential marker for a depression. GPs should take note of patients

reporting multiple complaints, particularly if this includes a combination of physical and men-

tal complaints, and consider screening these patients for an underlying depression. Further to

this, we suggest GPs should also address patients´ concerns about public attitudes towards

depression and provide support to overcome them [11], particularly as pharmacological treat-

ment may be influenced by the anticipation of negative consequences [38]. Broad awareness

campaigns should include a focus on primary care settings as appropriate sources for depres-

sion care and individuals should be encouraged to disclose mental symptoms within this set-

ting [16].

Future stigma research should focus on the different types of stigma, as well as the various

stages of the help-seeking process. These studies should also take covariates into account (e.g.

awareness of services, believing in treatment efficacy [31], and believing in a continuum of

symptoms from health to illness [65]), so as to tailor individual interventions according to the

respective stage of an individual’s help-seeking process.

Strengths and limitations

Our study provides further evidence for the importance of the number of complaints primary

care patients with depression report to their GPs. These findings are of great practical rele-

vance, as patients with and without depression differ significantly in how many complaints

they report. To date, there have been only two studies making mention of this phenomenon.

Further, to our knowledge there has been no prior research regarding the association between

the number and the type of complaints reported (physical vs. mental) and their association

with perceived depression stigma. However, this study may also have had a number of limita-

tions. Due to the cross-sectional design of the study, no causal inferences can be drawn. Fur-

ther, as participation in the study was voluntary, a selection bias may have occurred and as a

result, patients with lower stigma may have been overrepresented in our sample. Social desir-

ability bias when answering the DSS might also have been an issue, resulting in an underesti-

mation of depression stigma within our sample. Moreover, the factor structure of the German

version of the DSS has not been replicated and its psychometric properties require further

research. Depression diagnosis was based on self-report assessments with the DSQ, and a

potential bias may have occurred. We did not include GP diagnoses in our analyses, as this

could have significantly reduced our sample size. Further, from a clinical point of view, the

patients’ subjective condition was our main area of interest. Since we did not assess the specific

type of complaints for patients who self-referred to the GP for immediate care (i.e. emergency

case) or for follow-up appointment, a potential bias cannot be ruled out. Finally, when predict-

ing perceived stigma we were not able to control for all potential influencing factors (e.g. men-

tal health literacy) in a systematic way.

Supporting information

S1 Dataset. Study data to reproduce the results.

(XLSX)

Acknowledgments

We thank Melissa-Claire Daugelat of the Technische Universität Dresden for language editing.

We acknowledge support from Leipzig University for Open Access Publishing.

PLOS ONE Reasons for consultation and perceived depression stigma in primary care patients

PLOS ONE | https://doi.org/10.1371/journal.pone.0248069 March 5, 2021 12 / 16

Author Contributions

Conceptualization: Ines Heinz, Katja Beesdo-Baum, Susanne Knappe, Christine Rummel-

Kluge.

Data curation: Ines Heinz.

Formal analysis: Ines Heinz, Sabrina Baldofski.

Funding acquisition: Katja Beesdo-Baum.

Investigation: Ines Heinz, Katja Beesdo-Baum, Susanne Knappe, Christine Rummel-Kluge.

Methodology: Ines Heinz, Christine Rummel-Kluge.

Project administration: Katja Beesdo-Baum, Susanne Knappe.

Supervision: Elisabeth Kohls, Christine Rummel-Kluge.

Validation: Sabrina Baldofski, Elisabeth Kohls, Christine Rummel-Kluge.

Visualization: Ines Heinz.

Writing – original draft: Ines Heinz.

Writing – review & editing: Ines Heinz, Sabrina Baldofski, Katja Beesdo-Baum, Susanne

Knappe, Elisabeth Kohls, Christine Rummel-Kluge.

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