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Depression: Implications for State and Local Healthcare Programs

Identification & Treatment


Helen Burstin, M.D., M.P.H., Director, Center for Primary Care Research, Agency for Healthcare Research and Quality

Junius Gonzales, M.D., Chief, Services Research and Clinical Epidemiology Branch, Division of Services and Intervention Research, National Institute of Mental Health, Bethesda, Maryland

Policymakers face a wide array of problems when trying to determine how to best develop legislation around the issues of depression. One of these difficulties is the relatively low rates of diagnosis and treatment of depression in primary care settings, despite the fact that patients often go to their primary care provider with depressive symptoms.

Primary care providers and delivery systems face significant challenges in trying to provide the most effective care for their patients. These challenges include:

  • Difficulties in detecting and accurately diagnosing depression or depressive symptoms.
  • The use of medication as the primary method of treatment for those diagnosed with depressive symptoms.
  • Incorrect prescribing practices by physicians.
  • Patients not continuing medication for more than 30 days (the minimum amount of time that it takes for medication to make an impact on a patient).
  • Diagnosed primary care patients not following up with specialty mental health practitioners for more than one visit.
  • High rates of recurrence/relapse due to discontinuation of medication.

Depression has been shown to be the second most common diagnosis in the primary care setting. However, recent studies by Dr. Ken Wells and others have found that only 16 percent of all patients with depression are actually being treated by their primary care physician (PCP). Therefore, improvement in diagnosis and treatment mechanisms in the primary care setting is critical.

Significant emphasis was placed on the reasons why depression goes undiagnosed in the primary care setting. Some of the key reasons for this problem include:

  • Lack of knowledge or training on the part of the provider.
  • Inadequate compensation for PCPs for the treatment of depression.
  • Lack of patient recognition that they have depression.
  • High costs associated with visits and medication.

Some studies report that up to 50 percent of the patients that need care for depression are not getting diagnosed or are not being compliant with recommended treatments. According to Drs. Burstin and Gonzales, there are potential ways to improve care within the primary care setting. They suggest the following methods:

  • Involvement of psychiatrists in the training of primary care physicians, so that PCPs have effective specialty training and are more aware of how depression presents itself in the primary care setting.
  • Improvement of reimbursement rates for mental healthcare in primary care settings.
  • Recognition of cultural barriers and differences (as well as special populations). Medical outcomes data show that PCPs are less likely to diagnose depression in certain subsets of the population (i.e., black persons, Hispanic persons, and men).
  • Education on how to address depression as a comorbidity one of the many other common medical illnesses (e.g., heart disease, diabetes).

New organizational models of care are being shown to have a positive impact on the diagnosis, treatment, and care of depression. Dr. Wayne Katon has seen success in his Collaborative Care model, which focuses on collaboration between psychiatry and primary care. This program has seen improvement in outcomes and has had success with recruitment and retention; however, it has been criticized for its lack of generalizability to the greater population.

The Partners in Care Program, established by Dr. Ken Wells, also has experienced some success. This program explored the issue of diagnosis in the primary care setting with the goal of improving rates of initiation and adherence to appropriate antidepressant medication or psychotherapy for depression. The strengths of this program include the use of multisite heterogeneous primary care sites and a large sample size. The Partners in Care Program has seen improved outcomes after 12 months, but the study does have limitations: Costs are high, and a significant proportion of the intervention group has yet to show any improvement in outcome.

Dr. Gonzales highlighted another study that focuses on academic detailing to improve care. In this study, researchers conducted interviews to investigate baseline knowledge and motivations for prescribing patterns and then worked to stimulate physicians to participate in educational interactions to improve practice patterns.

Many depression interventions that are being tried in primary care are cost-effective, though additional research needs to be done to determine the long-term outcomes and effectiveness of these interventions.


Wells KB, Sherbourne C, Schoenbaum M, Duan N. Impact of disseminating Quality Improvement Programs for Depression in Managed Primary Care. JAMA 2000;283(2):212-20.

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