Part 1—Depression in primary care (Guest editorial)

The numbers associated with depression are staggering: 1.4 million people in Canada afflicted at any given time; over $3 billion in direct medical costs; 40 000 person-years lost from work and over $1 billion in economic costs; the second leading cause of long-term disability among workers, number one among white-collar workers; the fourth leading cause of global burden of disease, projected to be the second leading cause by 2020.[1,2]

The good news is that depression is a highly treatable condition. We have more proven treatments for depression than almost any other illness. From short-term psychotherapies to antidepressant medications to somatic treatments like electroconvulsive therapy and light therapy, we have an impressive array of treatment options for people with depression. We also have a series of professional clinical guidelines to help us make sense of these sometimes-bewildering options. The bad news is that, despite these effective treatments, the outcomes for patients with depression are still not optimal.[3,4]

Responding to the evidence that depression is a major public health problem due to its prevalence, distress, and disability, the British Columbia Ministry of Health has commissioned an innovative 3-year Provincial Depression Strategy. The goals are to reduce the morbidity, mortality, and economic impacts associated with depression. An Advisory Committee (including representatives from consumer, business, and labor groups) has been established to develop and articulate this strategy, which will comprise programs ranging from public awareness to improving treatment services to developing policies that will better integrate the system of care for people with depression. The programs developed with this strategy will incorporate principles such as evidence-based treatments, population-based programming, reflection of individual choice, and respect for the perspectives of rural and remote communities.

A major focus for the Provincial Depression Strategy will be to enhance primary care treatment of depression. This makes sense, given that, with the exception of hypertension, depression is more common in primary care than any other chronic medical condition and that most depressed patients are treated in primary care settings.

In keeping with that focus, the six articles in this double theme issue relate to depression in primary care. The first two papers describe the newer systems of care that have been shown to improve treatment outcomes for depression, including chronic disease management and collaborative, shared care. The third article describes how busy family physicians can select and use diagnostic and outcome measures. In next month’s BCMJ, the series continues with three more papers. The fourth paper of the series will feature tips on detecting depression in the young and old. Finally, the last two articles (Treatment--Part 1, Treatment--Part 2) summarize the recent Canadian clinical guidelines for treatment of depression. The guidelines are presented in a tabular and “user-friendly” format; detailed references and recommendations are available in the full guidelines.

We hope that all physicians, whatever their experience and comfort in treating depression, will find information that will be clinically useful in this series. By working together to enhance treatment, to empower patients and promote self-help, and to improve existing systems of care, we should be able to significantly reduce the burden of depression in British Columbia.

—Raymond W. Lam, MD, FRCPC,
Professor and Head, Division of Clinical Neuroscience, UBC, and Director, Mood Disorders Centre, UBC Hospital

—Heidi Oetter, MD,
Department of General Practice and Department of Psychiatry, Royal Columbian Hospital, 
New Westminster, BC

References

1. Parikh SV, Lam RW. Clinical guidelines for the treatment of depressive disorders. I. Definitions, prevalence, and health burden. Can J Psychiatry 2001;46 Suppl 1:13S-20S. PubMed Abstract 
2. Stephens T, Joubert N. The economic burden of mental health problems in Canada. In: Health Canada. Chronic Dis Can 2001;22(1):18-23. Ottawa, ON: Minister of Public Works and Government Services Canada, 2001. PubMed Abstract Full Text  
3. Higgins ES. The “usual care” of depression is not “good enough.” Arch Fam Med 1997;6:340-341. PubMed Citation 
4. Dawson R, Lavori PW, Coryell WH, et al. Course of treatment received by depressed patients. J Psychiatr Res 1999;
33:233-242. PubMed Abstract