While family physicians play a leading role in caring for patients with major depression, the quality of that care that could be greatly improved. A 1997 to 1998 survey of a national sample of adults with depressive or anxiety disorders revealed that 83% of these patients visited a health care provider.1 Of this total, 84% were treated by primary care clinicians, compared with 16% who were treated by mental health professionals. However, about 90% of those cared for by mental health professionals received treatment that met criteria for adequacy outlined in treatment guidelines, compared with 19% of those cared for by primary care professionals.
A critical role for family physicians is to integrate treatment of depression with that of other conditions, especially in light of the association of depression with a variety of chronic diseases. The Institute of Medicine has concluded that depression is strongly associated with the occurrence of, and death following, myocardial infarctions.2 In diabetes, depression is associated with a 2% increase in glycosylated hemoglobin levels3 and can predict occurrence of diabetic complications. Additionally, chronic illnesses may, in themselves, exacerbate depression several fold.
Primary care clinicians are ideally positioned to serve as the central health care providers for patients with major depression. These physicians have many attributes that support this role, including their longitudinal relationship with patients, response to undifferentiated problems, frequent use of the biopsychosocial model, and ability to integrate care of mental and medical conditions. However, challenges in fulfilling this role also exist, including difficulties in recognizing patients with major depression, developing an adequate diagnostic initial assessment, implementing effective short- and long-term treatment and management strategies, and integrating care of depression with that of other conditions affecting patients.4 This article will review each of these challenges.
Recognition of major depression
DeGruy has eloquently described the barriers to recognition and management of mental disorders in primary care, including infrequent use of diagnostic criteria, concern regarding treatment effectiveness, availability of time and resources, the presence of other pressing clinical problems, and issues of third-party reimbursement and other organizational concerns.4
Family physicians and their patients often do not recognize somatic symptoms as originating from depression. In one study, primary care physicians correctly identified 94% of depressed patients presenting with psychological complaints, but they failed to recognize the psychiatric nature of somatic complaints in about half of the patients. This finding is of concern because 83% of depressed patients presented with somatic complaints.5
The attribution patients assign to their problems can also contribute to lack of recognition. In one general practice study, patients’ attributions were classified as somatizing (5%), psychologizing (23%), normalizing (48%), or no predominate attribution (24%).6 For example, patients in this study might attribute fatigue to anemia (somatizing), emotional exhaustion (psychologizing), or being over-extended (normalizing). The likelihood of a missed diagnosis in patients who met criteria for depression or anxiety was strongly associated with attribution: Physicians diagnosed 72% of psychologizing patients accurately, but they reported a correct diagnosis in only 17% of somatizing patients, 15% of normalizing patients, and 31% of patients with no predominate attribution.
Initial diagnostic assessment
The United States Preventive Services Task Force suggests that primary care physicians screen for major depression. The Task Force recommends using 2 simple questions about mood and anhedonia (Table 1) that are generally as effective as longer instruments.7 The Patient Health Questionnaire-9 (PHQ-9) or the longer Prime-MD can be used for further evaluation of patients who respond positively to either question, thus helping to both confirm the diagnosis of depression and measure severity.8,9 Other instruments include the Beck Depression Inventory,10 the Zung scale,11 and the General Health Questionnaire.12 These tools take longer to administer, are not specific in measuring the criteria for major depression, and do not measure severity well.
In family practices, pregnant and postpartum women represent a special population at increased risk for depression.13 About 5% of middle class women and up to one quarter of low income women experience postpartum depression.14 In about half, onset of the depressive disorder occurs before delivery.15 Women who have previously suffered postpartum depression are at high risk, as are those with histories of depression or premenstrual dysphoric disorder. The Edinburgh Postnatal Depression Scale is a useful 10-item self-report instrument available in Spanish and English (Table 1).16,17 Similar instruments have not been developed for pregnant women.
A patient who responds positively to the 2 screening questions in Table 1 or to another screening approach should be further evaluated to confirm the diagnosis of major depression. Many primary care clinicians do this through unstructured history taking. Others use an instrument such as the previously discussed PHQ-9. This tool offers an advantage because it provides a reliable symptom assessment, measures severity, and can be repeated over time to evaluate therapeutic response.8