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Treating Depression
Talking Among the Disciplines
Arch Fam Med. 1998;7:146-147.
DEPRESSION IS one of the great unmet health care needs in our country. Estimates indicate that up to two thirds of patients who would benefit from depression treatment are not being treated. Of those patients who are treated for depression, most receive their treatment outside the formal mental health care system and from a primary care practitioner.1 Literature examining the attitudes and depression-specific knowledge base among primary care physicians has reported that, while important factual gaps remain between psychiatrists and primary care physicians, most primary care practitioners gain real professional satisfaction from treating depression.2 Primary care practitioners are often in the best position to institute and follow up on depression treatment for their patients, given the continuity in provider-patient relationships. In some cases, referral from the primary care practitioner to a mental health specialist is warranted. The study by Hartley et al,3 which appears in this issue of the ARCHIVES, helps to better define factors involving this process.
The diversity among the surveyed practicing primary care practitioners in this Maine-based study was considerable, in disciplines and in practice characteristics. Respondents reported seeing a wide range of numbers of patients with depression, although they did not document a diagnosis of depression in 35% of the cases. Documentation is important because all depressions are not created equal. There are causative, therapeutic, and prognostic differences among dysthymia, adjustment disorder with depressed mood, major depression, and major depression with psychotic features. It should also cross the practitioner's mind to document if the depression is secondary to another medical condition, if it is due to substance abuse, or if it is a manifestation of a bipolar disorder. Nevertheless, it is reassuring that 65% of providers reported using some form of screening and that an impressive 82% saw their patients with depression on at least a bimonthly basis.
A higher use of mental health specialist referrals was reported by those practitioners who practiced in areas with a lower density of such consultants. This information was in contrast to the authors' original hypothesis that rural providers would make fewer referrals based on their relative isolation. While the authors suggest that this may have been due to variation in the severity of the disease—more severely ill patients with depression going directly to mental health providers in areas of higher density of such providers—rural and urban primary care practitioners may also have been seeing differing severities of depression. Depression treated by primary care practitioners is seen differently than what is seen in mental health settings.4 Despite these minor variations in practice or geographic characteristics, the authors report that the primary care practitioner's own sense of confidence in treating depression—provider characteristics—affected mental health specialist referrals for depression the most.
One issue missing from the survey data that may be of great relevance to the primary care practitioner's depression treatment decision-making process is mental health "referral" vs "consultation." While physicians reported that 51% of their patients with depression were not "referred" for their depression treatment, almost 83% of all respondents said the unavailability of "consultants" hindered their own ability to treat depression. Consultation implies an interaction between the mental health specialist provider and the primary care practitioner, whereas referral implies a transfer of care. Although having the primary care practitioner based at a location with a mental health resource did not affect referrals, we do not know what effect informal consultations might have had on the depression treatment patterns of these providers. The role of depressive symptoms themselves—decreased energy, apathy, and feelings of helplessness, hopelessness, shame, and guilt—may also contribute to the referral patterns of the primary care practitioners. Poor patient motivation to arrange or follow through with the mental health consultant in addition to the primary care practitioner may, by default, leave the primary care practitioner as the sole clinician treating depression.
This study should be of interest to educators. The authors are correct in stressing that planners of continuing medical education for depression should address factors identified by the study that hinder the ability to treat, such as the perceived lack of time and patient unwillingness to engage in treatment.
The study should also be of interest to mental health system providers. The authors cite patient perspectives of an unwillingness to access mental health providers and consider this a problem of inadequate patient education. While perhaps true, the mental health care system needs constructive feedback about how to become more effective and efficient in serving both patients with depression and their regional primary care practitioners. As the authors suggest, telephone consultation between primary care practitioners and a mental health consultant might help address issues of mental health specialist geographic maldistribution and help primary care practitioners treat depression. A larger issue identified was the excessive waiting times to access mental health depression services, which more than 90% of primary care practitioner respondents identified as being either somewhat or a good deal responsible for affecting depression referral decisions.
Ultimately, the goal of primary care practitioners and mental health specialists is to help as many of the untreated sufferers of depression as possible. To best capitalize on depression treatment by these primary care practitioners, the knowledge and resulting confidence in providing depression treatment must be further developed and strengthened across all disciplines. An educational dialogue between primary care practitioners and mental health providers can aid in this mission. To most effectively get those patients who need specialist-provided depression treatment into treatment, the clinical dialogue between primary care practitioners and mental health providers should be fostered and improved for better mutual understanding and patient care.
John M. Heath, MD;
Steven B. Hollander, MD
University of Medicine and Dentistry of New Jersey
Robert Wood Johnson Medical School
New Brunswick
REFERENCES
1. Schurman R, Kramer P, Mitchell J. The hidden mental health network. Arch Gen Psychiatry. 1985;42:89-94.
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2. Shao WA, Williams JW, Lee S, Badgett RG, Aaronson B, Cornell JE. Knowledge and attitudes about depression among non-generalists and generalists. J Fam Pract. 1997;44:161-169.
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3. Hartley D, Korsen N, Bird D, Agger M. Management of patients with depression by rural primary care practitioners. Arch Fam Med. 1998;7:139-145.
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4. Williamson PS, Yates WR. The initial presentation of depression in family practice and psychiatric outpatients. Arch Gen Psychiatry. 1989;11:188-193.
RELATED ARTICLE
Management of Patients With Depression by Rural Primary Care Practitioners
David Hartley, Neil Korsen, Donna Bird, and Marc Agger
Arch Fam Med. 1998;7(2):139-145.
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