Recent epidemiological studies have found that most depressive disorders in children, adolescents, and adults are initially managed in primary care without a mental health referral. These patients often present with medically unexplained somatic symptoms and use two to three times the number of resources as nondepressed patients (eg, office visits, medication, laboratory tests and other procedures).1 There has been enormous interest in studying the interface between primary care and psychiatry in the past 10 years. This edition of Psychiatric Annals publishes informative articles that address primary care-psychiatric issues in light of recent depression research findings.
Five percent to nine percent of adults who see primary care providers suffer from depression.2 Because depression manifests itself in disguised maladies, up to half go undiagnosed and untreated. The cost associated with depression is staggering. In 1990, $31.6 billion was spent in indirect costs associated with disability and lost work days. An additional $12.4 billion was spent in direct treatment costs.3 General medical expenditures for depressed patients are often double the expenditures of non-depressed patients.4 For both economic and clinical reasons, the US Preventive Services Task Force recommends that primary care physicians screen all adult patients for depression.
Although a wide range of formal screening tools exists, practitioners often view the screening process as burdensome. Many readers will therefore be interested in the first article by Drs. Kurt Kroenke and Robert L. Spitzer, "The PHQ-9: A New Depression Diagnostic and Severity Measure." It describes a simple, self-administered depression rating scale as good as, and perhaps even better than, many more time-consuming, depression rating instruments. The PHQ-9 is based on DSMIV diagnostic criteria and has been validated in primary care and obstetrics and gynecological patient populations. A shorter version of the PHQ-9 (the PHQ-8) is useful in research settings and is also discussed in the article. An alternative two-item measure for depression screening, known as the PHQ-2, contains the first two items of the PHQ9 that inquire about depressed mood and anhedonia.
In the subsequent article, "Depression: A Common Illness Uncommonly Diagnosed," Dr. Joseph Lieberman describes several techniques busy practitioners can use in their office to further explore patients' psychodynamic and physical issues. He discusses the SOAPing, BATHEing, and SIG E CAPS mnemonics that many physicians have used both as an aid to the diagnosis of depression and to establish rapport with patients. Although these techniques were designed with primary care physicians in mind, psychiatrists will undoubtedly find them useful, especially psychiatrists involved in split treatment with non-medical psychotherapists, where the patient encounter is brief and medically oriented.
In the third article, "Depression and Chronic Medical Illness: Diabetes as a Model," Dr. Larry Culpepper illustrates how diabetes may be a model condition useful in understanding the complex relationships between depression and longterm physical illness. Although depression increases the risk of diabetes, and depression is two to three times more frequent in diabetics, diabetes does not itself appear to lead to the new lifetime onset of depression. Compared to those not depressed, depressed diabetics experience more symptoms of diabetes, have several fold worse treatment compliance, have worse glucose control, and elevated rates of complications. The conditions have an additive negative effect on quality of life. Management of depressed diabetic patients requires skillful attention to both conditions.
Given the importance of diagnosing and treating patients with combined medical and psychiatric disorders, Dr. David Brody poses a challenge to all of us. He asks, "How Can Psychiatry and Primary Care Work Together More Effectively to Manage Patients with Mental Disorders?" The title of Dr. Brody's article implies that psychiatrists and primary care physicians can improve the way they communicate. Models that integrate psychiatrists and other mental health specialists into the full spectrum of primary care medicine are especially conducive to collaboration and appear to result in the best outcomes for patients. Dr. Brody cautions, however, that until behavioral health care and general medical care have been reunited into one system of care, attempts to integrate the mind and body in most clinical settings will be difficult.
The daunting systems issues that thwart integration are addressed in the final article, "A Clinical Framework for Depression Treatment in Primary Care," by Dr. Amy Kilbourne et al. Appropriately designed information and delivery systems, fiscally aligned treatment incentives, and support from community organizations and other stakeholders are some of the key components necessary to make their model work. The model will be tested during the next several years through demonstration projects made possible through the Robert Wood Johnson Foundation. Ultimately, the paradigm must be relevant to "real world" practice so that depression care is available and consistent across diverse treatment settings. To effectively integrate psyche and soma, treatment aimed at both the mind and body must occur in a comprehensive system assuring accurate diagnosis, timely treatment, and careful follow-up of patients.
1. Simon G, Ormel J, Von Korff M, et al. Health care costs associated with depressive and anxiety disorders in primary care. Am J Psychiatry. 1995;152:352-357.
2. Wittchen HU, Holsboer F, Jacobi F. Met and unmet needs in the management of depressive disorder in the community and primary care: the size and breadth of the problem. J Clin Psychiatry. 2001;62(suppl 26):23-28.
3. Greenberg PE, Stiglin LE, Finkelstein SN, et al. The economic burden of depression in 1990. J Clin Psychiatry. 1993;54:405-418.
4. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA. 1995;273:1026-1031.