Treatment of Depression by Mental Health Specialists and Primary Care PhysiciansTreatment of Depression by Mental Health Specialists and Primary Care Physicians

To the Editor: In their nationally representative US survey, Dr Kessler and colleagues reported that of individuals who reported depression, 64.3% seen in the specialty mental health sector had received adequate care, but that only 41.9% of individuals seen in primary care had received care at this level.¹ Although these percentages may seem to imply that the mental health sector provides better care for patients with depression,² there are significant differences between patients with depression who seek care from their primary physicians vs those who are treated by mental health specialists. Patients with depression seen in the specialty mental health sector receive more care and would not be there if they did not accept that they needed such care. They also are probably more likely to adhere to treatment. The situation in primary care is different, where patients with depression typically present with somatic symptoms such as fatigue, may not accept a diagnosis of depression if suggested, and may not be willing to obtain mental health treatment even if it is offered.

The authors suggested that increasing the adequacy of treatment for depression requires "redirection of patient help-seeking to sectors where guideline concordant care can be provided."¹ Other research, however, suggests that primary care physicians provide similar levels of guideline-concordant antidepressant prescriptions as do mental health specialists.³ The problem should not be conceived as one of quality of care in one sector vs another, but rather as a system problem in terms of overall adherence to evidence-based guidelines. The US Preventive Services Task Force has advised that patients with depression need systematic evidence-based follow-up care to benefit from treatment.⁴ A number of such cost-effective depression management programs have been developed in primary care.⁵

Finally, Kessler et al stated that "dissemination [of cost-effective depression management programs] has been hampered by the reluctance to implement them by primary care physicians."¹ While this may be true for some clinicians, more significant barriers to dissemination include costs of care to the patient, limited access to counseling, and limited availability of the supportive resources needed to provide evidence-based systematic management in primary care. We agree with Kessler and colleagues that proven strategies to enhance the quality of depression management are available and should be implemented widely. A centerpiece of many of these strategies is cooperation between specialty and primary care physicians. It is time to move beyond primary care bashing and on to collaboration across sectors.