Treating Depression in Primary Care: Practice Applications of Research Findings

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Original Research

Treating Depression in Primary Care: Practice Applications of Research Findings

J Fam Pract. 2001 June;50(6):535-537

References

1. Depression Guideline Panel. Clinical practice guideline number 5: depression in primary care. Volume 2: treatment of major depression. Rockville, Md: US Department of Health and Human Services, Agency for Health Care Policy and Research; 1993. AHCPR publication no. 93-0550.

2. Schulberg H, Block M, Madonia M, Scott C, Lave J, Rodriguez E, Coulehan J. The “usual care” of major depression in primary care practice. Arch Fam Med 1997;61:334-39.

3. Lin E, Katon W, Simon G, et al. Achieving guidelines for the treatment of depression in primary care: is physician education enough? Med Care 1997;35:831-42.

4. American Psychiatric Association. Practice guideline for major depressive disorder In adults. Am J Psychiatry 1993;150 (suppl):S1-26.

5. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder (revision). Am J Psychiatry 2000;157 (suppl):1-45.

6. Schulberg H, Katon W, Simon G, Rush A. Treating major depression in primary care practice: an update of the AHCPR practice guidelines. Arch Gen Psychiatry 1998;55:1121-27.

7. Schulberg H, Pilkonis P, Houck P. The severity of major depression and choice of treatment in primary care practice. J Consult Clin Psychol 1998;66:932-38.

8. Wells K, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA 2000;283:212-20.

9. Callahan C, Hendrie H, Dittus R, Brater C, Hui S, Tierney W. Improving treatment of late-life depression in primary care: a randomized clinical trial. J Am Geriatr Soc 1994;42:839-46.

10. Schulberg H, Magruder K, deGruy F. Major depression in primary medical care practice: research trends and future priorities. Gen Hosp Psychiatry 1996;18:395-406.

11. Brown C, Schulberg H, Sacco D, Perel J. Effectiveness of treatments for major depression in primary medical care practice: a post hoc analysis of outcomes for African American and white patients. J Affect Disord 1999;53:185-92.

12. Katzelnick D, Simon G, Pearson S, et al. Randomized trial of a depression management program in high utilizers of medical care. Arch Fam Med 2000;9:345-51.

13. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA 1995;273:1026-31.

14. Katon W, Robinson P, Von Korff M, Lin E, et al. A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry 1996;53:924-32.

15. Katon W, Von Korff M, Lin E, et al. A randomized trial of stepped collaborative care for primary care patients with persistent symptoms of depression. Arch Gen Psychiatry 1999;56:1109-15.

16. Simon G, Von Korff M, Rutter C, Wagner E. Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care. BMJ 2000;320:550-54.

17. Hunkeler E, Meresman J, Hargreaves W, et al. Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. Arch Fam Med 2000;9:700-08.

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19. Schulberg H, Bryce C, Chism K, et al. Managing late-life depression in primary care practice: a case study of the health specialist’s role. Int J Geriatr Psychiatry. In press.

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Uncomplicated cases of depression are effectively treated with presently available interventions, but we are less successful in treating patients whose particular clinical or demographic characteristics make their depression atypical. The resulting uncertainties have stimulated clinical trials of interventions for co-existing Axis I and II psychopathology, double depression, minor depression and dysthymia, and mood disorders that co-exist with physical illnesses. Treatments compatible with the specific needs and expectations of racial or ethnic minorities are also the focus of clinical trials.¹¹

Ambiguities also persist as to which patient subgroups require particular treatment decisions. For which patients is “watchful waiting” the appropriate treatment, and which patients require immediate referral to a mental health specialist? Also, patient subgroups requiring customized interventions are made up of high users of medical care¹² and nonresponders to initial treatments. Collaborative care in which primary care physicians and mental health specialists co-manage patients^13,14 and stepped care in which the intensity and content of treatment are guided by initial outcomes¹⁵ are emerging as effective approaches to depression care. Of particular interest with regard to stepped care is the relationship between the intensity of treatment and clinical outcome (ie, the marginal point at which optimal cost-effectiveness is achieved).

Treatment Follow-Through

Efficacious treatments are necessary to improve the care of depression, but it is equally vital that patients follow through with these treatments. Efforts such as psychoeducation, motivational strategies and family involvement may improve fuller patient participation. However, we still do not adequately understand the influence of such variables as socioeconomic status, race, and ethnicity on treatment participation. More specifically, do patients with particular characteristics enter treatment with implicit or explicit expectations at variance with the actual treatment process? Studies of the congruence between a patient’s illness model and the treatment offered by the physician are recommended.

Monitoring Clinical Course and Outcome

A depressive episode’s acute phase typically attracts much clinical scrutiny from primary care physicians and other providers. However, this scrutiny must extend well beyond the initial 6 to 12 weeks of acute-phase treatment, since mood disorders are often chronic in nature. As this growing awareness extends the duration for monitoring mood disorders, various clinical and practical decisions will be required since all too scarce resources are needed to longitudinally assess a patient’s depressed state and level of functioning. A specific schedule is needed, given that the time frame for improved social functioning exceeds that for symptom resolution. Also, decisions are required with regard to how the information needed for monitoring purposes will be obtained. In-person assessments are preferable but impractical when patients live at a distance from the health center, have limited mobility, or find it inconvenient to miss work. It is of interest, therefore, that relatively efficient telephone follow-up assessments yield reliable and valuable information.^16,17

Revising the Structure of Care

Although refined treatments can improve patient outcomes, more fundamental change in the structure of ambulatory medicine is needed if desired outcomes are to be regularly achieved.¹⁸ This perspective questions the present structure of primary care as it pertains to treating depression. For example, given the constraints imposed by the typical brief 10- to 15-minute physician-patient encounter, is the leadership of primary care willing to sanction structural changes more conducive to the treatment of depression? Can the leadership judge proper management of mood disorder an opportunity to improve the patient’s health rather than an additional task imposed on already overburdened physicians?

A central element in the needed structural change is the creation of fiscal and cultural incentives to match such disincentives as capitated coverage and mental health carve-outs. A second structural element potentially amenable to change is the role of nurses and social workers already functioning within primary care settings. Can they expand their job description to include responsibility for depressive disorders, as well as such conditions as hypertension, diabetes, and asthma, and perhaps even come to serve as chronic disease specialists?¹⁹ Various studies are analyzing the tasks to be performed routinely by nurses, such as monitoring a patient’s adherence to prescribed antidepressant medication regimens; assessing patients’ clinical status, providing feedback to primary care providers, ensuring that guideline-based services are provided, and conveying interest and concern to depressed patients who may feel helpless and even hopeless.²⁰

Conclusions

Modified treatment algorithms can enhance the effectiveness of available interventions, but questions about their compatibility with the present organizational structure of primary care practice ultimately must be confronted and resolved. The manner in which this occurs will determine whether research findings from the laboratory can be transferred to the ambulatory medical setting in ways that benefit the large numbers of depressed patients in primary care settings.