The management of depression in primary care: Current state and a new team approach

Introduction

Although depression is among the most common disorders encountered in primary care, depressed patients are frequently treated ineffectively, in a manner inconsistent with current evidence. In the Ontario Health Survey of 333 individuals identified with major depression, 51% had received no treatment at all for their condition in the previous 12 months.[1] Of those patients who did receive treatment with antidepressant medications, it is likely that a minority would have been treated at an optimal level due to use of insufficient medication doses or too-short treatment periods. Current evidence indicates that only 30% to 40% of primary care patients diagnosed with major depressive disorder (MDD) receive antidepressant treatment at levels recommended by clinical practice guidelines.[2] Furthermore, fewer than 10% of depressed patients seen in primary care receive psychotherapies that have been established to be effective in treating depression.[3-5] This extraordinarily low rate is likely the result of numerous factors. Some of these are related to the organization and remuneration of health services that create barriers in access to existing psychotherapeutic services. However, even those patients who receive psychotherapy are unlikely to receive effective treatment. Despite robust evidence of the effectiveness of specific psychotherapies for depression (i.e., cognitive-behavioral therapy and interpersonal therapy), they are poorly disseminated. Many clinicians have been slow to adapt their counseling or psychotherapy treatments to conform to evidence, and instead adhere to personal preferences or to familiar approaches taught during their professional training.

Clearly, the burden of illness associated with depression is not being addressed optimally. In efforts to improve the current approach to depression, increased attention has been directed toward the management of depression in primary care, and an emphasis has been placed upon developing population-based systems of care for depression. This article aims to report on this shifting paradigm, highlighting some of the potential benefits of these system-level changes for the management of depression in primary care in British Columbia.

 The current state

An examination of health service utilization data shows the importance of primary care in mental health service delivery. The vast majority of BC residents are registered with the Medical Services Plan and see a general practitioner in the course of a year (Table 1, part A). An analysis of mental health utilization during the fiscal year 1997–98 using British Columbia’s linked health administrative databases (1997–98 is the latest year for which this linked data is currently available) has estimated that, of British Columbians aged 15 to 65 who received a diagnosis of a mental disorder, 82% received their only treatment from a general practitioner, that is, they received no additional treatment from a psychiatrist or from a mental health clinic (Table 1, part B).

Given these data, it is not surprising that general practitioners report spending a large proportion of their time diagnosing and treating people with emotional or psychiatric problems.[6] Yet many general practitioners feel unsupported in this role, and particular problems exist in the primary care/psychiatry interface. Researchers have identified a series of commonly encountered problems including strained relationships among general practitioners, psychiatrists, and community mental health teams; poor coordination between primary care and psychiatry services; communication problems; difficulty accessing timely consultation and treatment services; and a lack of mutual respect and support.[7]

Depression as a chronic disease and population-based care

It has been increasingly recognized that a large proportion of people who become depressed will develop either a chronic or recurrent course. Approximately 20% of treated patients with acute MDD will not recover in the first 2 years of their depressive episode8 and 12% of these will not recover within 5 years.[9] Overall, it has been estimated that 30% to 35% of all cases of depression develop a chronic course, despite chronic depression being relatively amenable to treatment.[10]

Disease management programs based on population-based care principles have now been developed for several chronic conditions such as asthma, hypertension, and diabetes. There is increasing evidence that such systems of care should also be adopted for depression, rather than the comparatively unsystematic or ad hoc approach that currently predominates. Population-based care aims to improve patient outcomes by restructuring service delivery and requires the development and implementation of a structured care strategy for all patients in a defined population with a recurrent or chronic illness.[5] Population-based programs tend to have several key components (see Table 2), one of the most important being the implementation of timely and appropriate measures to monitor patient outcomes and inform treatment decisions (see Anderson and colleagues in this issue). Although there is evidence for the efficacy of population-based strategies in the short-term treatment of depression[11] and in relapse prevention,[12] further research is still required concerning the long-term benefits of these strategies.

A new team approach

In recent years, most Canadian provinces have embarked upon reform of their mental health care systems. These provincial plans have a number of common goals, including more efficient use of scarce mental health resources, improved coordination of services, and increased collaboration between mental health care providers.[13] British Columbia’s Mental Health Plan (Ministry of Health and Ministry Responsible for Seniors, 1998) specifically identified a need for more collaboration between primary care and psychiatry, stating:

Because recruiting sufficient numbers of psychiatrists to rural communities is a challenge, providing adequate training and support to general practitioners is key to ensuring that effective diagnosis and treatment of mental illness is made available in all communities.

The success of these reforms rests in part upon the implementation of a “collaborative care” model in the management of mental disorders (see Isomura and colleagues in this issue). Collaborative mental health care (also known as shared mental health care) is a systematic approach to the management of mental disorders that integrates the patient, general practitioner, psychiatrist, and other care providers into the primary care setting to help provide effective, evidence-based treatment. The model enables the responsibilities of care to be apportioned according to the treatment needs of the patient at different points in time and according to the respective skills of the involved health care professionals. Collaborative care can have a number of benefits, including improved outcomes in patients with MDD. Further benefits may include better use of fiscal resources, optimal use of the time and skills of family physicians, psychiatrists and other providers, improvement in patient access to timely and appropriate psychiatric consultation, and enhanced morale on the part of the providers.

Evidence now exists to support the potential benefits of collaborative care at patient, physician, and system levels. However, a number of obstacles must be overcome before this body of evidence can be put into practice. These include physician time constraints, lack of remuneration for collaborative activities, lack of funding for non-physician staff and infrastructure support (including information management systems), and attitudinal barriers, which may include stereotyped views among professionals of the work of other disciplines and lack of respect for their roles.[14,15] The majority of the studies examining the outcomes of collaborative treatment of depression have been conducted in practice settings that differ substantially from those in Canada (such as health maintenance organizations in the United States and GP clinics in the United Kingdom). Consequently, further work is required to assess both the portability and success of collaborative mental health care models in the Canadian health care system.

 Conclusions

Despite the existence of evidence-based, efficacious treatments, the current treatment of depression appears to be less than optimal. There are several potential benefits to chronic disease and population-based management strategies for improving the treatment of depression in primary care settings in British Columbia. These methods of population-based disease management aim to develop new roles for psychiatrists and other health professionals and seek to enhance—not replace—the family physician’s role in treating depression. It will be essential to adapt collaborative care models and chronic disease management programs to fit the unique configuration and context of British Columbia’s system of health care services.

 Competing interests

Dr Michalak is supported by a Canadian Institutes of Health Research/Wyeth Ayerst Canada Postdoctoral Research Fellowship.

Table 1. Health service utilization data for British Columbians 1999–2000.

* BC Stats, 2001.
† Health Information Access Centre, 2001. Note that this report indicates that the 1999–2000 data was calculated after the clearing of the database of inactive and/or delinquent subscribers. Hence the 1999–2000 numbers are more accurate and are reported here, not earlier years. 
‡ Unpublished data abstracted by the Mental Health Evaluation & Community Consultation Unit (Mheccu).
§ Percent of the total population. 
|| Percent of the mental health claims.

Table 2. Key components of chronic disease management programs.

Erin E. Michalak, PhD, Elliot M. Goldner, MD, FRCPC, Wayne Jones, MA MSc, Heidi Oetter, MD, and Raymond W. Lam, MD, FRCPC