Herbert C. Schulberg, PhD

Much has been learned about how to effectively treat depressive disorders, but we remain less certain about how to deliver these treatments in routine primary care practice. Clinical guidelines point the way; their implementation, however, requires system change. Key issues in improving health care system capacities for effective depression care include: (1) enhancing continuity of care; (2) activating and empowering patients; (3) matching interventions to patients, including stepped care strategies; (4) improving treatment follow through; (5) monitoring clinical course outcomes; and (6) revising the structure of care so guideline-based care is feasible in routine patient care. (J Fam Pract 2001; 50:535-537)

The public health significance of depression as a prevalent disorder in primary care practice is well established, and the value of diagnosing this disorder accurately and treating it effectively is amply documented.¹ However, the benefits of treatment that are evident in research projects remain elusive in routine ambulatory practice. The outcomes of usual care are still significantly worse than those of standardized interventions carefully monitored by investigators.² Even the benefits of the latter dissipate when the research program is completed.³ The critical issue, therefore, is how to transfer efficacious treatments of depression from research settings to routine primary care practice in a manner that will permit them to flourish. Recommendations about steps pertinent to these processes are presented in this paper.

Guideline-Based Treatment Algorithms

The treatment algorithms recommended in 1993⁴ and 2000⁵ by the American Psychiatric Association and in 1993 by the Depression Guideline Panel of the Agency for Health Care Policy and Research (AHCPR)¹ are landmarks in the quest for optimal management of depressive disorders. Despite initial concerns about the effectiveness of treatments transferred from the psychiatric to the primary care sector, the guideline recommendations have proven valid and durable.⁶ It is clear that antidepressant medications produce a 60% recovery rate when prescribed within proper dosages and for adequate duration. Depression-specific time-limited psychotherapies achieve similar outcomes, even with patients experiencing moderate to severe symptomatology.⁷ Two principles emerge from this body of work: (1) major depression should not be treated with anxiolytic medications alone or with long-term psychotherapy; and (2) patient preference for a particular guideline-based treatment should be considered when it is clinically and practically feasible.

Despite this scientific progress and the extensive efforts to disseminate the AHCPR depression guidelines, few would assert that such efforts have significantly influenced routine primary care of depression. Thus, guidelines are a necessary but not sufficient condition for improving the treatment of depression; they constitute a blueprint for building rather than completing a structure. Accordingly, attention has shifted to the manner in which general principles of effective clinical care can be customized to the structural, fiscal, and sociodemographic characteristics of a particular primary care practice. The study by Wells and colleagues⁸ illustrates efforts to disseminate guidelines in the context of local circumstances and suggests that administrative support for state of the art practice can positively influence patient outcomes.

Moving Beyond the Guidelines

The dissemination of existing guidelines surely is warranted, but it should be recognized that guideline standard treatments are imperfect. Antidepressant medications and depression-specific psychotherapies produce only 70% to 75% recovery rates even in treatment-completer analyses.¹ Thus, altered strategies, like those that follow, are needed to help the significant minority of depressed patients who fail to recover.

Continunity of Care

Although case identification attracted much attention during the 1980s, various studies have demonstrated that an improved case finding by itself does not improve depression outcomes.^7,8 Inadequate attention has been directed to the fuller continuum of care on which screening and assessment are the starting points. Case identification must be followed by timely and targeted feedback to the primary care physician; appropriate treatment must be provided the patient; the patient’s clinical course must be actively monitored; and the treatment should be modified when clinically indicated. Each component of this continuum must be refined if the quality of care is to improve.

Activating and Empowering Patients

It is vital that patients with depression be actively involved in their treatment, since overcoming helplessness and hopelessness is central to recovery.¹ Strategies for activating and empowering these patients range from the educational to the social. The former include increasingly effective materials about the nature and course of mood disorders that use state of the art technologies to capture and maintain the patient’s interest. Self-care programs have been developed that permit patients to monitor beliefs and behaviors linked to clinical depression. Social strategies for activating and empowering patients are also becoming more commonplace.

Matching Patient to Intervention

Uncomplicated cases of depression are effectively treated with presently available interventions, but we are less successful in treating patients whose particular clinical or demographic characteristics make their depression atypical. The resulting uncertainties have stimulated clinical trials of interventions for co-existing Axis I and II psychopathology, double depression, minor depression and dysthymia, and mood disorders that co-exist with physical illnesses. Treatments compatible with the specific needs and expectations of racial or ethnic minorities are also the focus of clinical trials.¹¹

Ambiguities also persist as to which patient subgroups require particular treatment decisions. For which patients is “watchful waiting” the appropriate treatment, and which patients require immediate referral to a mental health specialist? Also, patient subgroups requiring customized interventions are made up of high users of medical care¹² and nonresponders to initial treatments. Collaborative care in which primary care physicians and mental health specialists co-manage patients^13,14 and stepped care in which the intensity and content of treatment are guided by initial outcomes¹⁵ are emerging as effective approaches to depression care. Of particular interest with regard to stepped care is the relationship between the intensity of treatment and clinical outcome (ie, the marginal point at which optimal cost-effectiveness is achieved).

Treatment Follow-Through

Efficacious treatments are necessary to improve the care of depression, but it is equally vital that patients follow through with these treatments. Efforts such as psychoeducation, motivational strategies and family involvement may improve fuller patient participation. However, we still do not adequately understand the influence of such variables as socioeconomic status, race, and ethnicity on treatment participation. More specifically, do patients with particular characteristics enter treatment with implicit or explicit expectations at variance with the actual treatment process? Studies of the congruence between a patient’s illness model and the treatment offered by the physician are recommended.

Monitoring Clinical Course and Outcome

A depressive episode’s acute phase typically attracts much clinical scrutiny from primary care physicians and other providers. However, this scrutiny must extend well beyond the initial 6 to 12 weeks of acute-phase treatment, since mood disorders are often chronic in nature. As this growing awareness extends the duration for monitoring mood disorders, various clinical and practical decisions will be required since all too scarce resources are needed to longitudinally assess a patient’s depressed state and level of functioning. A specific schedule is needed, given that the time frame for improved social functioning exceeds that for symptom resolution. Also, decisions are required with regard to how the information needed for monitoring purposes will be obtained. In-person assessments are preferable but impractical when patients live at a distance from the health center, have limited mobility, or find it inconvenient to miss work. It is of interest, therefore, that relatively efficient telephone follow-up assessments yield reliable and valuable information.^16,17

Revising the Structure of Care

Although refined treatments can improve patient outcomes, more fundamental change in the structure of ambulatory medicine is needed if desired outcomes are to be regularly achieved.¹⁸ This perspective questions the present structure of primary care as it pertains to treating depression. For example, given the constraints imposed by the typical brief 10- to 15-minute physician-patient encounter, is the leadership of primary care willing to sanction structural changes more conducive to the treatment of depression? Can the leadership judge proper management of mood disorder an opportunity to improve the patient’s health rather than an additional task imposed on already overburdened physicians?

A central element in the needed structural change is the creation of fiscal and cultural incentives to match such disincentives as capitated coverage and mental health carve-outs. A second structural element potentially amenable to change is the role of nurses and social workers already functioning within primary care settings. Can they expand their job description to include responsibility for depressive disorders, as well as such conditions as hypertension, diabetes, and asthma, and perhaps even come to serve as chronic disease specialists?¹⁹ Various studies are analyzing the tasks to be performed routinely by nurses, such as monitoring a patient’s adherence to prescribed antidepressant medication regimens; assessing patients’ clinical status, providing feedback to primary care providers, ensuring that guideline-based services are provided, and conveying interest and concern to depressed patients who may feel helpless and even hopeless.²⁰

Conclusions

Modified treatment algorithms can enhance the effectiveness of available interventions, but questions about their compatibility with the present organizational structure of primary care practice ultimately must be confronted and resolved. The manner in which this occurs will determine whether research findings from the laboratory can be transferred to the ambulatory medical setting in ways that benefit the large numbers of depressed patients in primary care settings.

Much has been learned about how to effectively treat depressive disorders, but we remain less certain about how to deliver these treatments in routine primary care practice. Clinical guidelines point the way; their implementation, however, requires system change. Key issues in improving health care system capacities for effective depression care include: (1) enhancing continuity of care; (2) activating and empowering patients; (3) matching interventions to patients, including stepped care strategies; (4) improving treatment follow through; (5) monitoring clinical course outcomes; and (6) revising the structure of care so guideline-based care is feasible in routine patient care. (J Fam Pract 2001; 50:535-537)

The public health significance of depression as a prevalent disorder in primary care practice is well established, and the value of diagnosing this disorder accurately and treating it effectively is amply documented.¹ However, the benefits of treatment that are evident in research projects remain elusive in routine ambulatory practice. The outcomes of usual care are still significantly worse than those of standardized interventions carefully monitored by investigators.² Even the benefits of the latter dissipate when the research program is completed.³ The critical issue, therefore, is how to transfer efficacious treatments of depression from research settings to routine primary care practice in a manner that will permit them to flourish. Recommendations about steps pertinent to these processes are presented in this paper.

Guideline-Based Treatment Algorithms

The treatment algorithms recommended in 1993⁴ and 2000⁵ by the American Psychiatric Association and in 1993 by the Depression Guideline Panel of the Agency for Health Care Policy and Research (AHCPR)¹ are landmarks in the quest for optimal management of depressive disorders. Despite initial concerns about the effectiveness of treatments transferred from the psychiatric to the primary care sector, the guideline recommendations have proven valid and durable.⁶ It is clear that antidepressant medications produce a 60% recovery rate when prescribed within proper dosages and for adequate duration. Depression-specific time-limited psychotherapies achieve similar outcomes, even with patients experiencing moderate to severe symptomatology.⁷ Two principles emerge from this body of work: (1) major depression should not be treated with anxiolytic medications alone or with long-term psychotherapy; and (2) patient preference for a particular guideline-based treatment should be considered when it is clinically and practically feasible.

Despite this scientific progress and the extensive efforts to disseminate the AHCPR depression guidelines, few would assert that such efforts have significantly influenced routine primary care of depression. Thus, guidelines are a necessary but not sufficient condition for improving the treatment of depression; they constitute a blueprint for building rather than completing a structure. Accordingly, attention has shifted to the manner in which general principles of effective clinical care can be customized to the structural, fiscal, and sociodemographic characteristics of a particular primary care practice. The study by Wells and colleagues⁸ illustrates efforts to disseminate guidelines in the context of local circumstances and suggests that administrative support for state of the art practice can positively influence patient outcomes.

Moving Beyond the Guidelines

The dissemination of existing guidelines surely is warranted, but it should be recognized that guideline standard treatments are imperfect. Antidepressant medications and depression-specific psychotherapies produce only 70% to 75% recovery rates even in treatment-completer analyses.¹ Thus, altered strategies, like those that follow, are needed to help the significant minority of depressed patients who fail to recover.

Continunity of Care

Although case identification attracted much attention during the 1980s, various studies have demonstrated that an improved case finding by itself does not improve depression outcomes.^7,8 Inadequate attention has been directed to the fuller continuum of care on which screening and assessment are the starting points. Case identification must be followed by timely and targeted feedback to the primary care physician; appropriate treatment must be provided the patient; the patient’s clinical course must be actively monitored; and the treatment should be modified when clinically indicated. Each component of this continuum must be refined if the quality of care is to improve.

Activating and Empowering Patients

It is vital that patients with depression be actively involved in their treatment, since overcoming helplessness and hopelessness is central to recovery.¹ Strategies for activating and empowering these patients range from the educational to the social. The former include increasingly effective materials about the nature and course of mood disorders that use state of the art technologies to capture and maintain the patient’s interest. Self-care programs have been developed that permit patients to monitor beliefs and behaviors linked to clinical depression. Social strategies for activating and empowering patients are also becoming more commonplace.

Matching Patient to Intervention

Uncomplicated cases of depression are effectively treated with presently available interventions, but we are less successful in treating patients whose particular clinical or demographic characteristics make their depression atypical. The resulting uncertainties have stimulated clinical trials of interventions for co-existing Axis I and II psychopathology, double depression, minor depression and dysthymia, and mood disorders that co-exist with physical illnesses. Treatments compatible with the specific needs and expectations of racial or ethnic minorities are also the focus of clinical trials.¹¹

Ambiguities also persist as to which patient subgroups require particular treatment decisions. For which patients is “watchful waiting” the appropriate treatment, and which patients require immediate referral to a mental health specialist? Also, patient subgroups requiring customized interventions are made up of high users of medical care¹² and nonresponders to initial treatments. Collaborative care in which primary care physicians and mental health specialists co-manage patients^13,14 and stepped care in which the intensity and content of treatment are guided by initial outcomes¹⁵ are emerging as effective approaches to depression care. Of particular interest with regard to stepped care is the relationship between the intensity of treatment and clinical outcome (ie, the marginal point at which optimal cost-effectiveness is achieved).

Treatment Follow-Through

Efficacious treatments are necessary to improve the care of depression, but it is equally vital that patients follow through with these treatments. Efforts such as psychoeducation, motivational strategies and family involvement may improve fuller patient participation. However, we still do not adequately understand the influence of such variables as socioeconomic status, race, and ethnicity on treatment participation. More specifically, do patients with particular characteristics enter treatment with implicit or explicit expectations at variance with the actual treatment process? Studies of the congruence between a patient’s illness model and the treatment offered by the physician are recommended.

Monitoring Clinical Course and Outcome

A depressive episode’s acute phase typically attracts much clinical scrutiny from primary care physicians and other providers. However, this scrutiny must extend well beyond the initial 6 to 12 weeks of acute-phase treatment, since mood disorders are often chronic in nature. As this growing awareness extends the duration for monitoring mood disorders, various clinical and practical decisions will be required since all too scarce resources are needed to longitudinally assess a patient’s depressed state and level of functioning. A specific schedule is needed, given that the time frame for improved social functioning exceeds that for symptom resolution. Also, decisions are required with regard to how the information needed for monitoring purposes will be obtained. In-person assessments are preferable but impractical when patients live at a distance from the health center, have limited mobility, or find it inconvenient to miss work. It is of interest, therefore, that relatively efficient telephone follow-up assessments yield reliable and valuable information.^16,17

Revising the Structure of Care

Although refined treatments can improve patient outcomes, more fundamental change in the structure of ambulatory medicine is needed if desired outcomes are to be regularly achieved.¹⁸ This perspective questions the present structure of primary care as it pertains to treating depression. For example, given the constraints imposed by the typical brief 10- to 15-minute physician-patient encounter, is the leadership of primary care willing to sanction structural changes more conducive to the treatment of depression? Can the leadership judge proper management of mood disorder an opportunity to improve the patient’s health rather than an additional task imposed on already overburdened physicians?

A central element in the needed structural change is the creation of fiscal and cultural incentives to match such disincentives as capitated coverage and mental health carve-outs. A second structural element potentially amenable to change is the role of nurses and social workers already functioning within primary care settings. Can they expand their job description to include responsibility for depressive disorders, as well as such conditions as hypertension, diabetes, and asthma, and perhaps even come to serve as chronic disease specialists?¹⁹ Various studies are analyzing the tasks to be performed routinely by nurses, such as monitoring a patient’s adherence to prescribed antidepressant medication regimens; assessing patients’ clinical status, providing feedback to primary care providers, ensuring that guideline-based services are provided, and conveying interest and concern to depressed patients who may feel helpless and even hopeless.²⁰

Conclusions

Modified treatment algorithms can enhance the effectiveness of available interventions, but questions about their compatibility with the present organizational structure of primary care practice ultimately must be confronted and resolved. The manner in which this occurs will determine whether research findings from the laboratory can be transferred to the ambulatory medical setting in ways that benefit the large numbers of depressed patients in primary care settings.

Much has been learned about how to effectively treat depressive disorders, but we remain less certain about how to deliver these treatments in routine primary care practice. Clinical guidelines point the way; their implementation, however, requires system change. Key issues in improving health care system capacities for effective depression care include: (1) enhancing continuity of care; (2) activating and empowering patients; (3) matching interventions to patients, including stepped care strategies; (4) improving treatment follow through; (5) monitoring clinical course outcomes; and (6) revising the structure of care so guideline-based care is feasible in routine patient care. (J Fam Pract 2001; 50:535-537)

The public health significance of depression as a prevalent disorder in primary care practice is well established, and the value of diagnosing this disorder accurately and treating it effectively is amply documented.¹ However, the benefits of treatment that are evident in research projects remain elusive in routine ambulatory practice. The outcomes of usual care are still significantly worse than those of standardized interventions carefully monitored by investigators.² Even the benefits of the latter dissipate when the research program is completed.³ The critical issue, therefore, is how to transfer efficacious treatments of depression from research settings to routine primary care practice in a manner that will permit them to flourish. Recommendations about steps pertinent to these processes are presented in this paper.

Guideline-Based Treatment Algorithms

The treatment algorithms recommended in 1993⁴ and 2000⁵ by the American Psychiatric Association and in 1993 by the Depression Guideline Panel of the Agency for Health Care Policy and Research (AHCPR)¹ are landmarks in the quest for optimal management of depressive disorders. Despite initial concerns about the effectiveness of treatments transferred from the psychiatric to the primary care sector, the guideline recommendations have proven valid and durable.⁶ It is clear that antidepressant medications produce a 60% recovery rate when prescribed within proper dosages and for adequate duration. Depression-specific time-limited psychotherapies achieve similar outcomes, even with patients experiencing moderate to severe symptomatology.⁷ Two principles emerge from this body of work: (1) major depression should not be treated with anxiolytic medications alone or with long-term psychotherapy; and (2) patient preference for a particular guideline-based treatment should be considered when it is clinically and practically feasible.

Despite this scientific progress and the extensive efforts to disseminate the AHCPR depression guidelines, few would assert that such efforts have significantly influenced routine primary care of depression. Thus, guidelines are a necessary but not sufficient condition for improving the treatment of depression; they constitute a blueprint for building rather than completing a structure. Accordingly, attention has shifted to the manner in which general principles of effective clinical care can be customized to the structural, fiscal, and sociodemographic characteristics of a particular primary care practice. The study by Wells and colleagues⁸ illustrates efforts to disseminate guidelines in the context of local circumstances and suggests that administrative support for state of the art practice can positively influence patient outcomes.

Moving Beyond the Guidelines

The dissemination of existing guidelines surely is warranted, but it should be recognized that guideline standard treatments are imperfect. Antidepressant medications and depression-specific psychotherapies produce only 70% to 75% recovery rates even in treatment-completer analyses.¹ Thus, altered strategies, like those that follow, are needed to help the significant minority of depressed patients who fail to recover.

Continunity of Care

Although case identification attracted much attention during the 1980s, various studies have demonstrated that an improved case finding by itself does not improve depression outcomes.^7,8 Inadequate attention has been directed to the fuller continuum of care on which screening and assessment are the starting points. Case identification must be followed by timely and targeted feedback to the primary care physician; appropriate treatment must be provided the patient; the patient’s clinical course must be actively monitored; and the treatment should be modified when clinically indicated. Each component of this continuum must be refined if the quality of care is to improve.

Activating and Empowering Patients

It is vital that patients with depression be actively involved in their treatment, since overcoming helplessness and hopelessness is central to recovery.¹ Strategies for activating and empowering these patients range from the educational to the social. The former include increasingly effective materials about the nature and course of mood disorders that use state of the art technologies to capture and maintain the patient’s interest. Self-care programs have been developed that permit patients to monitor beliefs and behaviors linked to clinical depression. Social strategies for activating and empowering patients are also becoming more commonplace.

Matching Patient to Intervention

Uncomplicated cases of depression are effectively treated with presently available interventions, but we are less successful in treating patients whose particular clinical or demographic characteristics make their depression atypical. The resulting uncertainties have stimulated clinical trials of interventions for co-existing Axis I and II psychopathology, double depression, minor depression and dysthymia, and mood disorders that co-exist with physical illnesses. Treatments compatible with the specific needs and expectations of racial or ethnic minorities are also the focus of clinical trials.¹¹

Ambiguities also persist as to which patient subgroups require particular treatment decisions. For which patients is “watchful waiting” the appropriate treatment, and which patients require immediate referral to a mental health specialist? Also, patient subgroups requiring customized interventions are made up of high users of medical care¹² and nonresponders to initial treatments. Collaborative care in which primary care physicians and mental health specialists co-manage patients^13,14 and stepped care in which the intensity and content of treatment are guided by initial outcomes¹⁵ are emerging as effective approaches to depression care. Of particular interest with regard to stepped care is the relationship between the intensity of treatment and clinical outcome (ie, the marginal point at which optimal cost-effectiveness is achieved).

Treatment Follow-Through

Efficacious treatments are necessary to improve the care of depression, but it is equally vital that patients follow through with these treatments. Efforts such as psychoeducation, motivational strategies and family involvement may improve fuller patient participation. However, we still do not adequately understand the influence of such variables as socioeconomic status, race, and ethnicity on treatment participation. More specifically, do patients with particular characteristics enter treatment with implicit or explicit expectations at variance with the actual treatment process? Studies of the congruence between a patient’s illness model and the treatment offered by the physician are recommended.

Monitoring Clinical Course and Outcome

A depressive episode’s acute phase typically attracts much clinical scrutiny from primary care physicians and other providers. However, this scrutiny must extend well beyond the initial 6 to 12 weeks of acute-phase treatment, since mood disorders are often chronic in nature. As this growing awareness extends the duration for monitoring mood disorders, various clinical and practical decisions will be required since all too scarce resources are needed to longitudinally assess a patient’s depressed state and level of functioning. A specific schedule is needed, given that the time frame for improved social functioning exceeds that for symptom resolution. Also, decisions are required with regard to how the information needed for monitoring purposes will be obtained. In-person assessments are preferable but impractical when patients live at a distance from the health center, have limited mobility, or find it inconvenient to miss work. It is of interest, therefore, that relatively efficient telephone follow-up assessments yield reliable and valuable information.^16,17

Revising the Structure of Care

Although refined treatments can improve patient outcomes, more fundamental change in the structure of ambulatory medicine is needed if desired outcomes are to be regularly achieved.¹⁸ This perspective questions the present structure of primary care as it pertains to treating depression. For example, given the constraints imposed by the typical brief 10- to 15-minute physician-patient encounter, is the leadership of primary care willing to sanction structural changes more conducive to the treatment of depression? Can the leadership judge proper management of mood disorder an opportunity to improve the patient’s health rather than an additional task imposed on already overburdened physicians?

A central element in the needed structural change is the creation of fiscal and cultural incentives to match such disincentives as capitated coverage and mental health carve-outs. A second structural element potentially amenable to change is the role of nurses and social workers already functioning within primary care settings. Can they expand their job description to include responsibility for depressive disorders, as well as such conditions as hypertension, diabetes, and asthma, and perhaps even come to serve as chronic disease specialists?¹⁹ Various studies are analyzing the tasks to be performed routinely by nurses, such as monitoring a patient’s adherence to prescribed antidepressant medication regimens; assessing patients’ clinical status, providing feedback to primary care providers, ensuring that guideline-based services are provided, and conveying interest and concern to depressed patients who may feel helpless and even hopeless.²⁰

Conclusions

Modified treatment algorithms can enhance the effectiveness of available interventions, but questions about their compatibility with the present organizational structure of primary care practice ultimately must be confronted and resolved. The manner in which this occurs will determine whether research findings from the laboratory can be transferred to the ambulatory medical setting in ways that benefit the large numbers of depressed patients in primary care settings.