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Depression can be treated effectively in primary care settings with proper controls and specialty consultation

In today's health care environment, primary care physicians are being called upon to treat most forms of major depression before they can refer patients for specialty care. The depression guideline sponsored by the Agency for Health Care Policy and Research and published in 1993 was based primarily on research done in psychiatric settings. To update these recommendations, several individuals who participated in development of the original guideline recently reviewed studies published between 1992 and 1998 on treatment of depression in primary care settings.

They concluded that both antidepressant medication and depression-specific psychotherapy remain efficacious when transferred from psychiatric to primary care settings. Most patients can be treated successfully in primary care with regular followup and monitoring to assess treatment response, make necessary adjustments in medication or dosage, and determine whether referral to a specialist is needed. However, this approach requires properly organized treatment programs and a prominent role for the mental health specialist as an educator, consultant, and primary provider for the more severely ill.

Studies show that antidepressant medications prescribed for acute and continuing treatment of depressed primary care patients are associated with a 50 to 60 percent decrease in depressive symptoms, similar to that found for psychiatric patients. Also, recent studies of the use of cognitive, behavioral, or interpersonal psychotherapy for depression suggest that their efficacy (46 percent, 55 percent, and 52 percent, respectively) does transfer from specialist to generalist settings. Nevertheless, these authors caution that the therapeutic intensity required to monitor depressed patients is difficult to achieve in primary care practice, and it requires provider acceptance of new treatment strategies.

For more information, see "Treating major depression in primary care practice: An update of the Agency for Health Care Policy and Research practice guidelines," by Herbert C. Schulberg, Ph.D., Wayne Katon, M.D., Gregory E. Simon, M.D., and A. John Rush, M.D., in the December 1998, Archives of General Psychiatry 55, pp. 1121-1127.

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