Treatment of depression in primary care -: Where we are, where we can go

Depressive and anxiety disorders are major public health problems affecting approximately 16 and 20 million Americans respectively.(1) Two of the most prevalent disorders, major depression and panic disorder, have been shown to be associated with medically unexplained physical Symptoms(2,3) (ie, pain and fatigue), decrements in functioning and quality of life,(3,4) and increased medical utilization and Costs. (3,5) Patients with chronic medical illnesses have higher rates of depression and anxiety and these comorbid psychiatric disorders are associated with poor adherence to medical regimens and adverse medical outcomes.(6) Earlier research documenting low rates of recognition and treatment of depression prompted public awareness efforts including the NIMH Depression Awareness and National Anxiety Awareness Programs, Depression and Bipolar Support Alliance and Anxiety Disorders Association of America screening programs, and pharmaceutical company direct-to-consumer advertising (DTCA). In this issue of Medical Care, papers by Sherbourne(7) and Edlund(8) have shown that approximately 50 to 60% of respondents from the Healthcare for Communities Study with a mental health or substance abuse diagnosis received screening for their disorder over a 12 month period. The paper by Katon and colleagues similarly showed that approximately 50% of patients with diabetes and major depression received an accurate diagnosis or any form of treatment in the prior year.(9) Blanco and colleagues reported that primary care physicians initiate medication treatment of panic disorder as often as do psychiatrists.(10) These data agree with modem era data suggesting that rates of recognition and treatment initiation for common mental disorders in primary care have increased over the last decade from 25 to 33% to as high as 60%.(11,12) Unfortunately, quality and continuity of care among those accurately diagnosed lags behind recognition. Donahue and colleagues found little effect of direct-to-consumer advertising on duration or continuity of treatment.(13) Among insured patients with both diabetes and depression, Katon and colleagues found that only 30% received adequate antidepressant treatment and fewer than 10% made 4 or more psychotherapy visits.(9) While public awareness campaigns and educational efforts focused on health care providers over the past 2 decades may have improved recognition of common mental disorders and initiation of treatment, particularly in primary care, these efforts seem to have had little effect on quality of treatment.