Put Primary Care at Forefront of Treatment for Depression

With the broadest reach to patients, the primary care setting is well-suited for identifying and assessing depression.

The primary care setting is the most appropriate venue for the screening and early treatment of depression, according to the lead author of an article published recently in the New England Journal of Medicine.

Depression is one of the most common behavioral health disorders in the country, with the estimated lifetime risk of a major depressive episode set at about 30%. Suicide, which is associated with depression more than 50% of the time, has become more prevalent in recent years and is now the 10th leading cause of death for Americans.

"Primary care settings offer the broadest reach in terms of patients seeking care, and therefore are the optimal place to conduct screening for depression and suicide," Lawrence Park, MD, medical director of the Clinical Research Unit at the National Institute of Mental Health's Experimental Therapeutics and Pathophysiology Branch in Bethesda, Maryland, told HealthLeaders last week.

Although the primary care setting is well-suited to detect depression and suicidal ideation, there are challenges for clinicians to overcome, he said.

"One must be aware of not only depression, but all possible medical and mental health conditions. So, the primary care provider needs to be expert at detection and diagnosis across a broad range of diseases. Because depression is so common, we recommend the use of a brief screening tool for depression—and suicidal thoughts and behaviors—for all primary care patients."

If a patient presents signs of depression, primary care clinicians must weigh several options, Park said.

"When depression is suspected, primary care providers should conduct follow up assessment to determine the severity of the condition, safety evaluation, and consider interventions. Therapeutic interventions may include close monitoring of the patient's condition, initiation of psychotherapy and/or medications, referral to a mental healthcare provider, or hospitalization."

Primary care's depression niche

For treatment of depression, the primary care setting is only appropriate for patients with mild and moderate conditions, Park said.

"In primary care, there is a scarcity of healthcare resources. Primary care providers lack the time and support to comprehensively care for all aspects of the depressed patient. From our perspective, primary care is ideally placed to perform the critical screening function for depression and suicidal thoughts and behaviors. If quick and efficient screening is done on all patients, primary care providers can devote additional time for assessment to those with positive screens."

In cases of severe depression, interventions include the assistance of mental health specialists, time-consuming treatments such as psychotherapy, and higher levels of care such as emergency department evaluation, he said.

Avoiding primary care pitfalls

To provide optimal care for depressed patients, primary care physicians should have easy access to mental health resources, Park said.

"Many primary care settings have incorporated an embedded mental healthcare professional into their practices. Without adequate mental healthcare support, primary care providers may be reluctant, or unable, to conduct accurate screening and assessment of depression and suicidal thoughts and behaviors, or they may not be able to appropriately manage these conditions when they are identified."

Primary care clinicians also face a significant clinical challenge when managing depressed patients, he said.

"Primary care physicians should rule out underlying medical conditions that may cause or exacerbate depression, and they should distinguish between bipolar depression or major depressive disorder—unipolar depression—as both situations would have important therapeutic implications."