Years ago, if someone thought about mental health care, he or she might have imagined a pipe-smoking psychiatrist listening to a reclining depressed patient from his leather armchair. Today, Depression is more likely to be treated by a primary care doctor who might not have time to sit down at all.
Identifying and treating depression is challenging in a busy primary care office, where waiting rooms might be filled to capacity every day. And there are concerns that depressed patients treated by primary care doctors, unlike those seen by mental health professionals, do not receive needed psychotherapy and close monitoring of their use of antidepressant medications.
But some experts say that the primary care setting has the potential to help people find long-term relief from depression.
Why Depression Is a Primary Care Problem
One reason researchers are interested in improving mental health care in primary care is that, currently, most men and women with depression are not getting the treatment that they need. Results of a national survey on major depression that was published in 2003 in the Journal of the American Medical Association showed that only about half of people with major depressive disorder received treatment.
Before patients can get treatment, someone has to recognize that they are depressed-and that job usually falls to the primary care provider.
“Most people don’t see a mental health professional even if they have major depression or anxiety, so the primary care doctor is often the only point of contact,” says Donna McAlpine, PhD, an assistant professor at the division of health services research and policy at the School of Public Health at the University of Minnesota. “We want to make sure more primary care doctors recognize depression and anxiety in their patients.”
Research suggests that once Depression is identified, most people stick with their primary care doctor for treatment.
“People are comfortable with their primary care doctors,” says Kenneth B. Wells, MD, MPH, center director at the University of California, Los Angeles Neuropsychiatric Institute and Hospital. “We’re all creatures of habit, and there’s still a stigma attached to getting mental health care.”
Additionally, Dr. Wells says, psychotherapy with a mental health professional is rarely covered appropriately by insurance. And even if people do have adequate insurance coverage for mental health services-and they obtain a referral to a mental health professional-they end up not following up on the referral unless a primary care office nurse follows up with them. Moreover, in some parts of the country, mental health professionals are hard to find.
Is It Good Enough?
Fortunately, depression is more likely to be picked up in primary care office today than it was in the 1980s and 1990s. According to Dr. McAlpine, doctors can often identify people who are at high risk for depression with a couple of simple questions, such as “Over the past two weeks, have you felt down, depressed or hopeless?” and “Over the past two weeks, have you felt little interest or pleasure in doing things?”
Dr. McAlpine cautions that “increased detection doesn’t always lead to improved symptoms or remission.” For symptom relief, people need evidence-based treatment. Over the last decade, medications, such as antidepressants and anti-anxiety drugs, have been replacing psychotherapy as the primary method of treatment, especially in primary care settings.
Ideally, patients would have a choice between the two approaches.
“In most studies, psychotherapy and antidepressant medication are roughly equally effective, so patients and providers face a choice,” Dr. Wells says. “Not all types of treatment work for everyone. There are also different costs and side effects for each type of treatment.”
Certain people may need both psychotherapy and antidepressant medication.
“The combination of psychotherapy and antidepressant medication seems best for people with more severe and chronic depression,” Dr. Wells says. “It used to be thought that only antidepressant medication reduced the likelihood of a recurrence or repeat episode, but now there is increasing evidence of such benefits for maintenance psychotherapy.”
Patients who are on medication and in psychotherapy will likely benefit from the close follow-up they receive in therapy. For some patients, such as teenagers taking antidepressants-who may be at increased risk for suicide-close monitoring could be lifesaving.
According to Dr. Wells, certain people on antidepressants who are not followed closely may stop taking the medication in the first few weeks because of side effects, such as fatigue or loss of sex drive, that might have gone away in time, or with a switch in dosage or medication type. Others stop taking the drug because they are feeling better, but quitting too soon may lead to a quick recurrence of the depression.
At the same time, some people with mild depression or anxiety are being over-treated with medication.
“Increasingly, we’re putting people on psychotropic drugs who might not need medical treatment,” Dr. McAlpine says. She observes that some of these patients might recover by themselves, or might benefit instead from therapy, pastoral counseling or a support group.
Improving Primary Care Programs
Studies show that improvements in mental health care in primary care offices can help patients with depression. For example, a study known as Partners in Care, conducted by Dr. Wells and colleagues, demonstrated that access to short-term psychotherapy, such as in-house mental health professionals, as well as medication management within the primary care setting, was feasible and effective.
For now, some primary care offices are providing such services. Many have yet to offer in-house mental health providers, or collaborate with mental health providers in other ways, in part, because they may not recover the costs from insurance providers.
But that should not stop people who feel like they might be depressed from talking to their primary care doctor.
“If someone thinks they have depression, they should tell their doctor about their symptoms and ask about what treatment options might work for them,” Dr. Wells says. “And they should stay in touch with their doctor, so they have the greatest chance of getting well quickly.”
Revision date: June 14, 2011
Last revised: by Andrew G. Epstein, M.D.