Recognition, management, and outcomes of depression in primary care

OBJECTIVE: To evaluate the recognition, management, and outcomes of depressed patients presenting in primary care. DESIGN: Epidemiologic survey with 12-month follow-up. SETTING: Primary care clinics of a staff-model health maintenance organization. PATIENTS AND MAIN OUTCOME MEASURES: Consecutive primary care attenders aged 18 to 65 years (n = 1952) were screened using the 12-item General Health Questionnaire (GHQ-12), and a stratified random sample (n = 373) completed a psychiatric assessment, including the Composite International Diagnostic Interview (CIDI), the 28-item GHQ, and a brief self-rated disability questionnaire (BDQ). Three-month follow-up assessment (n = 347) repeated the GHQ-28 and BDQ, and 12-month follow-up (n = 308) repeated the CIDI, GHQ-28, and BDQ. Use of psychotropic drugs and mental health services was assessed using computerized pharmacy and visit registration records. RESULTS: Structured interviews found 64 cases of current major depression (weighted prevalence, 6.6%) and 58 cases of current subthreshold depression (weighted prevalence, 8.8%). Of those with major depression, 64% (n = 41) were recognized as psychologically distressed by the primary care physician, 56% (n = 36) filled at least one antidepressant prescription during the next 3 months, and 39% (n = 25) made at least one specialty mental health visit. Compared with recognized cases, those with unrecognized major depression were less symptomatic at baseline (GHQ-28 score, 15.31 vs 11.07; P = .006) but showed a similar rate of improvement over 12 months (F test for difference in slopes, P = .93). CONCLUSIONS: While many depressed primary care patients may go unrecognized and untreated, this group appears to have milder and more self-limited depression. A narrow focus on increased recognition may not improve overall outcomes. Treatment resources might be best directed toward more intensive follow-up and relapse prevention among those now treated.