Americans Are Depressed. Should They Get Help at Their Primary Care Doctor's Office?

In some ways, depression has gone mainstream. Considering the countless TV and magazine ads touting the latest feel-good medications, celebrities divulging their postpartum struggles, and even studies on the benefits of the kind of ruminative thinking associated with depression, it seems possible--even probable--that the stigma once assigned to this tricky mental illness could eventually shrink away. But until it does and everyone is eager to sign up for therapy, Americans need accessible treatment.

More affordable and convenient treatment options for depression would seem the next logical step, but according to the 2009 National Survey on Drug Use and Health, 60 percent of antidepressants are already being prescribed at a very opportune place: the office of their GP or primary care physicians. It seems like a wonderful idea: treat Americans where they already are. But do these initiative provide a quick-fix that undercuts the value of intensive, long-term psychotherapy, and doesn't solve the underlying factors that cause depression? A recent New York Times story described the reduction of therapy, and its replacement by pill-dispensing:

The switch from talk therapy to medications has swept psychiatric practices and hospitals, leaving many older psychiatrists feeling unhappy and inadequate... Psychiatric hospitals that once offered patients months of talk therapy now discharge them within days with only pills.

Given this changing landscape, integrated care--in which a therapist and physician coordinate shorter-term care for depressed patients--could be as a stop-gap measure that combines medication with counseling. Or it could be a harbinger of doom for old-fashioned talk therapy with its ethos of hard work and life-long commitment to ending depression.

Shift Towards Primary Care

It’s true that this shift toward primary care treatment for depression began taking hold in the late 1980s, with the boom in prescriptions of SSRIs (selective seratonin re-uptake inhibiters), like Prozac. However, it wasn’t until the late 1990s that a group of scientists undertook a closer evaluation of primary care physicians’ recognition and treatment of depression. That group, called the MacArthur Initiative, hoped to strengthen links between primary care physicians and behavioral health providers, such as psychologists and clinical social workers.  

Although they receive some psychology training, many primary care doctors feel unprepared to treat patients with mental health problems because of the time required and the lack of evaluation and screening tools at their disposal, the MacArthur Initiative found. Diagnosis of depression is further complicated by the ambiguity of symptoms--depressed patients often complain of physical symptoms, such as pain or fatigue, that can be mistaken for other illnesses. 

Partly as a result of these roadblocks, the 2009 NSDUH revealed that, among the approximately 1 in 13 Americans aged 18 or older who experienced a major depressive episode in 2008, one-third did not receive any treatment. In addition, prior studies of depressed patients who were treated in a primary care setting revealed that a significant portion didn't find their treatment to be adequate, reporting problems like insufficient dosages or treatment that didn't last long enough.

As such studies were considered and the MacArthur Initiative progressed, doctors arrived at a potential solution: the Three Component Model (3CM). This model comprises a primary care physician, a care manager and a mental health professional (typically psychologists, clinical social workers or master’s level psychology graduates) who work together to develop a patient’s course of treatment. 3CM has been implemented in multiple primary care offices across the United States; Maine Health, Colorado Intermountain Healthcare, and Dr. Wayne Katon’s “Shared Care” in Washington State are particularly successful and ambitious integrated care programs. Additionally, the model has facilitated nearly half a million diagnoses of post traumatic stress disorder among returning soldiers from Iraq and Afghanistan, according to MacArthur Initiative co-chair Allen J. Dietrich of Dartmouth University.