Depression Treatment in Primary Care

W. David Robinson, PhD; Jenenne A. Geske, PhD; Layne A. Prest, PhD; Rachel Barnacle, MS

Disclosures

J Am Board Fam Med. 2005;18(2):79-86. 

In This Article

Abstract and Introduction

Background: Depression costs the United States $40 billion annually. Primary care physicians play a key role in the identification and treatment of depression. This study focused on the treatment options recommended by physicians and whether physicians were following the recommended treatment guidelines.
Methods: We recorded treatment recommendations by examining charts for all patients with newly detected depression. The patients were from 44 family medicine practitioners and 23 general internal medicine practitioners in a Midwest university medical center setting.
Results: For both medical specialties combined, pharmacotherapy was the most widely used intervention (recommended for 52% of patients), whereas psychotherapy alone was the least frequently used intervention (recommended for 4% of patients). Family medicine practitioners recommended combination treatment (pharmacotherapy and psychotherapy) more frequently than did general internal medicine practitioners ( P = .022), and female physicians recommended combination treatment more frequently than did male physicians ( P = .010).
Conclusions: Pharmacotherapy was found to be the most widely used treatment despite current evidence-based recommendations. Barriers to effective treatment plan are discussed. The implications for mental health interventions, combination therapy, and cost offset are also discussed. Further research exploring the negotiation process during the patient-provider encounter would shed light on patient and physician factors influencing treatment decisions.

Depression is the world's fourth most prevalent health problem,[1] costing the United States $30 to $50 billion in lost productivity and direct medical costs each year.[2,3] Persons who are depressed miss work because of illness at twice the rate of the general population.[4] Health service costs are 50% to 100% greater for depressed patients than for comparable patients without depression. These increased costs are caused by higher medical utilization, not by specialty mental health care.[5,6] Additional costs associated with depression include impaired concentration, failure to advance in educational and vocational endeavors, increased substance abuse, impaired or lost relationships, and suicide.[7,8]

Primary care providers are the sole contacts for more than 50% of patients with mental illness and have thus been described as the de facto system of treatment for mental health.[9,10,11] Reliable estimates suggest that symptoms consistent with depression are present in nearly 70% of patients who visit primary care providers. Approximately 35% of patients who are seen in primary care meet criteria for being diagnosed with some form of depression, with 10% of patients suffering from major depression.[12,13,14] The prevalence of major depression is 2 to 3 times higher in primary care patients than in the overall population because depressed persons use health care more frequently.[15,16] Therefore, because of the prevalence of depressed patients in primary care, physicians need to play an active role in effectively assessing, diagnosing, and treating depression.

To ensure effective treatment of this major health issue, the Agency for Health Care Policy and Research (AHCPR), the Veterans Health Administration/Department of Defense (VHA-DOD), and the American Psychiatric Association (APA) have published evidence-based recommendations for depression treatment. In summary, pharmacotherapy and psychotherapy (combination treatment) are recommended when treating moderate to severe depression. When the depression is mild to moderate and the patient is motivated to work on psychological/ interpersonal issues, psychotherapy is warranted.[13,17,18] Schulberg et al (1999) concurred with the AHCPR guidelines and concluded that referral to a mental health specialist should be a part of depression treatment, especially when patients exhibit severe depressive symptoms (eg, suicide risk; comorbid medical, psychiatric, or substance use disorder; or failure to respond to appropriate treatment).[1] However, in an overview of the outpatient treatment of depression between 1987 and 1997, Olfson et al[19] found that, of those treated for depression in 1997, 79.4% received pharmacotherapy, 60.2% received psychotherapy, and only 48.1% received combination therapy.

The purpose of this study was to determine whether local physicians were following the guidelines described above and to explore differences between certain groups of physicians. Therefore, the study sought to answer the following questions: "What are providers recommending as treatment for depression?" and "How do recommended treatments differ between family medicine and general internal medicine physicians and between male and female physicians?" It was hypothesized, in concurrence with past research, that pharmacotherapy would be the most frequently recommended treatment by all physicians. It was also hypothesized that family physicians would be more likely than general internal physicians to prescribe a wider variety of treatments, including psychotherapy treatment in combination with medication. Finally, based on research showing gender differences in the psychosocial skills of physicians,[20,21] it was hypothesized that female physicians would prescribe alternatives to pharmacotherapy more often than male physicians.

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