Emotional Disorders in Primary Care - CiteSeerX

Journal of Consulting and Clinical Psychology 2002, Vol. 70, No. 3, 798 – 809

Copyright 2002 by the American Psychological Association, Inc. 0022-006X/02/$5.00 DOI: 10.1037//0022-006X.70.3.798

Emotional Disorders in Primary Care James C. Coyne and Richard Thompson

Michael S. Klinkman and Donald E. Nease Jr.

University of Pennsylvania Health System

University of Michigan

Individuals with emotional disorders are more likely to use primary medical care than specialty mental health services, but these disorders are likely to be undetected or inadequately treated. Recognition of the importance of primary medical care for the treatment of mental disorder has resulted in pressing new research priorities. One set of issues concerns the adequacy of existing nosological systems for conceptualizing emotional disorder in primary care and identifying need for treatment. Another concerns the difficulties translating efficacious treatment into effective strategies that can be integrated into the competing demands of primary medical care. Psychologists have played only a limited role in defining and addressing emerging questions. Irreversible changes in mental health services have created the need for the development of a psychosocial perspective for what would otherwise be defined as narrowly biomedical issues.

Beginning in the 1970s, a number of important developments rapidly advanced our understanding of the nature of emotional disorders outside of mental health settings. First, there were increasing refinements in diagnostic criteria as seen in the Research Diagnostic Criteria (RDC; Spitzer, Endicott, & Robins, 1978), followed by the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980), a revised DSM-III (DSM-III-R; American Psychiatric Association, 1987), and a successor (DSM-IV; American Psychiatric Association, 1994). Second, interview schedules including the Schedule for Affective Disorders and Schizophrenia (SADS; Endicott & Spitzer, 1978), the Diagnostic Interview Schedule (DIS; Robins, Helzer, Croughan, & Ratcliff, 1981), the Structured Clinical Interview for DSM-III (SCID; Spitzer & Williams, 1985), and the Composite International Diagnostic Interview (CIDI; World Health Organization, 1990) incorporated these refined diagnostic criteria into readily applicable assessment tools. No longer were researchers forced to choose between defining emotional disorder in terms of patients in mental health treatment or relying on some arbitrary cutpoints on frustratingly nonspecific self-report scales. It also became possible to begin to make cautious comparisons of emotional disorders across populations (Henderson, 1998). Third, using these refined research diagnostic criteria, a number of ambitious research projects examined the nature, prevalence, and correlates of emotional disorder in the community. The most notable of these projects were the Epidemiologic Catchment Area (ECA) study (Regier, Myers, & Kramer, 1985; Robins et al., 1981), the National Co-Morbidity Survey (NCS; R. C. Kessler et al., 1994), and the Depression Research in European Society (DEPRES) study (Lepine, Gastpar, Mendlewicz, & Tylee, 1997). Such projects added to a wealth of accumulating data indicating that emotional disorders were highly prevalent in the community and personally and socially impairing. In addition to prevalence rates, the ECA study yielded estimates of the proportion of individuals with each disorder who received treatment and of the type of treatment services received. It was

There are dramatic shifts occurring in the settings in which emotional disorders are treated, how they are treated, and by whom. The present discussion must be placed in the context of these sweeping changes to fully appreciate the significance of emotional disorders in primary care. Pressing new research priorities are being defined by policymakers who need an empirical foundation for the key decisions they face. Yet with relatively few exceptions (Arean & Miranda, 1996; Coyne & Schwenk, 1995; Munoz, Hollon, McGrath, Rehm, & VandenBos, 1994; Schulberg & Rush, 1994), psychologists have taken almost no role in defining the relevant research questions, generating the requisite findings, and posing empirically based solutions to the problem of emotional disorders in primary care, where such disorders are increasingly most likely to be treated. Aside from psychologists not looking after their self-interests, they have failed to articulate a perspective that could serve as a needed balance to what have come to be a narrowly defined set of biomedical issues. The absence of a clearly articulated psychosocial perspective is to the detriment of all concerned and, most importantly, to those who must pay for, deliver, or receive treatment for emotional disorders in primary care. Like Rip Van Winkle, psychologists have slept through a revolution, and as they awaken, they must grasp how their world has changed.

James C. Coyne and Richard Thompson, Department of Psychiatry, University of Pennsylvania Health System; Michael S. Klinkman and Donald E. Nease Jr., Department of Family Medicine, University of Michigan. This work was supported by Center Grant MH 52129 – 06 and National Institute of Mental Health Grant RO1MH43796. The opinions expressed herein are the sole responsibility of the authors, but the contributions of the following people were very much appreciated: Patricia A. Arean, Joseph J. Gallo, Ashraf Kagee, Linda Kruus, Ira R. Katz, Steven C. Palmer, Melissa W. Racioppo, and Joel Streim. Correspondence concerning this article should be addressed to James C. Coyne, Department of Psychiatry, University of Pennsylvania Health System, 11 Gates, 3400 Spruce Street, Philadelphia, Pennsylvania 191044283. E-mail: [email protected] 798

SPECIAL ISSUE: PRIMARY CARE

found that most persons with emotional disorders did not get treatment and that only a minority of the treatment received came from specialized mental health services (Regier et al., 1993; Shapiro et al., 1984). The de facto mental health system in the United States was found to consist not only of formal mental health services but of general medical care, social services, and various self-help efforts (Regier et al., 1993). Most people in the community with an emotional disorder visited a general medical provider in the course of a year, and more persons with emotional disorders were treated in this sector than by mental health professionals. Yet most emotional disorders in people visiting a general medical provider were undetected and untreated (Regier et al., 1993). Similar results were obtained in the NCS (R. C. Kessler et al., 1999) and DEPRES study (Lepine et al., 1997). Furthermore, even when detected, emotional disorders were found likely to be inadequately treated or not treated at all (Katon, Von Korff, Lin, Bush, & Ormel, 1992; Schulberg et al., 1997). However, these findings may have become outdated in the face of accelerating trends that place even more emphasis on primary care as the site in which emotional disorders are treated. Both the lay public and primary care physicians are more likely to accept newer antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), venlafaxine, and nefazodone, than the antidepressants previously available. Patients are increasingly more likely to seek and receive an antidepressant from a primary care physician than from a psychiatrist. From 1991 to 1997, the annual number of antidepressant prescriptions written by primary care providers in the United States increased from nearly 25 million antidepressant prescriptions to over 50 million, compared with an increase from 15 to 33 million for psychiatrists (Hirschfeld, 1998). Although the depressed elderly are presumed to be less likely to be treated than younger depressed patients, a recent populationbased study in Ontario, Canada, found large and growing rates of antidepressant prescriptions for the elderly, with over 17% of the oldest women in the province receiving antidepressants in 1997 (Mamdani, Herrmann, & Austin, 1999). In a similar manner, 14.3% of elderly White individuals (but only 5.0% of African Americans) in the Piedmont region of North Carolina were found to be receiving an antidepressant (Blazer, Hybels, Simonsick, & Hanlon, 2000). In France, between 5% and 7% of the general population and 17% of the elderly were found to be chronic users of anxiolytics and hypnotics (Pelissolo, Boyer, Lepine, & Bisserbe, 1996). These high rates of prescription cannot be presumed to represent adequate treatment. Indeed, we will review literature below suggesting that under conditions of routine care, primary care patients do not obtain the anticipated benefits when treated with antidepressants. However, these figures do suggest that the assumption that most depression in primary care will go untreated needs to be reexamined with contemporary data. Furthermore, these rates of treatment exceed the presumed prevalence of depression among the elderly and raise the issue of specificity of treatment with antidepressants: Patients may be receiving treatment who do not meet criteria for a condition for which the efficacy of treatment with antidepressants has been established. A considerable gap may still exist between the large number of depressed patients being seen by general medical providers and the smaller number obtaining effective treatment. The growing body of research refining and evaluating solutions to these problems includes investigations of integrating mental health profession-

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als—including psychologists—into primary care, as well as facilitating referral to them. However, other trends make it unlikely that a reliance on mental health professionals will prove to be the major means of improving the outcome of emotional disorders in primary care. The cost of stationing mental health professionals in primary care settings could prove prohibitive, and a recent review of the impact of on-site mental health professionals found disappointingly modest effects on consultation, referral, and treatment in primary care (Bower & Sibbald, 2000). Changes brought on by health care system reform have further decreased the availability of specialty mental health care to primary care patients and have more generally restricted the intensity of treatment offered by mental health professionals (Rosenheck, Druss, Stolar, Leslie, & Sledge, 1999). These trends are likely to continue, and future reforms and innovations in the treatment of emotional disorder in primary care will undoubtedly rely heavily on what primary care providers can accomplish, with and without the assistance of practice nurses and master’s level professionals. These profound changes should be of interest, if not disconcerting, to psychologists, but they are rarely acknowledged in the mainstream outlets for clinical psychological research. Like Rip Van Winkle awakening after the American Revolution and proclaiming “God Save the King!” clinician–scientists may find the value of their contributions questioned if they attempt to go about their usual research as if these changes have not occurred. For instance, conventional comparisons between patients with major depression and controls must now be qualified by a recognition that depressed patients in primary care and other settings may differ in significant ways from the more frequently studied but smaller number of depressed patients in specialty mental health settings and particularly from the even more select group being enrolled in clinical trials in these specialized settings (Blacker & Clare, 1987; Schwenk, Coyne, & Fechner-Bates, 1996). We need to better understand the social processes that determine the preferences depressed individuals exercise in presenting or seeking care in a particular setting. In a similar manner, psychotherapeutic interventions for depression may be judged by their ability to be deliverable by less-trained professionals in the midst of the competing demands of primary care (Mynors-Wallis, 1996). Therefore, one could argue that little relevance to primary care can be claimed for demonstrations showing that the highly trained professionals can efficaciously deliver an intensive treatment to carefully selected depressed patients in a tertiary psychiatric setting. The characteristics and treatment needs of depressed patients identified during routine visits to primary care may be quite different than those of patients self-selecting for treatment in specialty mental health settings.

Nature of Emotional Disorders in Primary Care The bulk of studies on emotional disorder in primary care have focused on major depression not only because the disorder is highly prevalent and a source of considerable impairment but also because a full range of treatments are available for which efficacy has been established (Depression Guidelines Panel, 1993). Psychological distress, however, is even more prevalent and readily assessed with self-report screening instruments. Indeed, early studies of the performance of primary care providers in managing depression often relied exclusively on self-report measures to

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define depression. Yet it was subsequently recognized that most patients who have elevated scores on screening instruments do not meet criteria for a depressive disorder and that, by themselves, such instruments provide distorted estimates of the need for treatment and the performance of providers. Still, attention has remained focused on how screening for psychological distress might still serve as a tool in improving the detection and outcome of depression. It was also noted that a considerable pool of patients had significant depressive symptoms but did not meet criteria for major depression. This raised questions about the adequacy of conventional DSM-IV criteria for use in primary care, an issue that has yet to be satisfactorily resolved. In particular, concerns remain about whether minor depression should be given greater recognition as a diagnostic entity and therefore as a suitable target for detection and treatment. More recently, attention has been turned to anxiety disorders. This is justified not only by arguments about their prevalence and associated impairment but also by findings that newer antidepressants are efficacious for anxiety disorders.

Psychological Distress A variety of self-report measures of distress have been used with primary care populations, including the Center for Epidemiologic Studies Depression scale (CES-D; Radloff, 1977), the Hopkins Symptom Checklist (HSCL; Derogatis, Lipman, Rickels, Uhlenuth, & Covi, 1974), the Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983), the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erlbaugh, 1961), and the General Health Questionnaire (GHQ; Goldberg & Hillier, 1979), as well as the Beck Depression Inventory, Primary Care edition (BDI-PC; Beck, Guth, Steer, & Ball, 1997), a measure specifically designed for use in primary care settings. With adjustments in cutpoints, such instruments are equivalent in providing moderate efficiency in first-stage screening for depression (see Coyne, Thompson, Palmer, Kagee, & Maunsell, 2000, for a review). In general, these instruments have relatively high sensitivity but limited specificity (Mulrow et al., 1995). They may identify a pool of patients who may have depression, but they do not provide a reliable diagnosis. Consistent with other studies (e.g., Coulehan, Schulberg, Block, Janosky, & Arena, 1990), Fechner-Bates, Coyne, and Schwenk (1994) found that the CES-D had a sensitivity of 79.5% and a specificity of 71.1% but a modest positive predictive value of 28.5%, using a SCID-based diagnosis of major depression as the comparison. Practically speaking, the CES-D identified more than one in three patients as needing further evaluation, but less than one third of these were actually depressed, and 1 in 5 depressed patients would have been missed if a physician had relied exclusively on the screening to detect depression. Efforts to improve the performance of the CES-D and similar instruments by raising cutpoints, by modifying scoring, or by eliminating poor-performing items inevitably involve some trade-off between sensitivity and specificity (Santor & Coyne, 1997). There are inherent limitations to self-report instruments as indicators of major depression. What else do elevated scores on measures of distress indicate? Fechner-Bates et al. (1994) found that taking into account any DSM-III-R diagnosis of a depressive disorder only marginally improved the performance of the CES-D as a screening instrument and that most adjustment disorders were missed. It is readily possible for patients to score in the distressed range without a

single depressive symptom, and less than half of distressed patients have had 2 weeks of mood disturbance (Coyne & Schwenk, 1997). Our experience with screening for distress in elderly primary care patients is that over 40% of positively screening patients will not be distressed 2 weeks later (J. Streim, personal communication, March 6, 2000). Yet can nondepressed patients who screen positive, but who do not meet criteria for major depression, be viewed as an at-risk population? With cases of major depression excluded, an elevated score on the CES-D is so inefficient in identifying patients at risk for subsequent depression (Munoz et al., 1995) that an effect for any preventive intervention cannot be demonstrated without a prohibitively large sample (see Coyne et al., 2000, for an extended analysis of this problem). Undoubtedly, much of the self-reported distress assessed in primary care samples reflects psychosocial problems, physical symptoms including pain, and unhappiness, which are not appropriately construed as emotional disorders (Coyne & Kagee, 2000).

Major Depression The first wave of primary care office-based studies found that major depression was highly prevalent among primary care patients but was often undetected and untreated by primary care physicians. Estimates of prevalence ranged from 4.8% to 13% (Barrett, Barrett, Oxman, & Gerber, 1988; Coyne, Fechner-Bates, & Schwenk, 1994; Katon, 1987; L. G. Kessler, Cleary, & Burke, 1985; Schulberg et al., 1985), and even the lowest estimate may still make major depression the most common condition in primary care, perhaps exceeding hypertension (Katon & Schulberg, 1992). Studies that use results of semistructured interviews as the criterion for diagnosis and formally solicit diagnoses from the primary care physicians find as many as 50%–70% of patients with a current major depression are missed (Coyne, Schwenk, & FechnerBates, 1995; Gerber et al., 1989; Perez-Stable, Miranda, Munoz, & Ying, 1990; Von Korff et al., 1987). Taken together, this body of research has been widely interpreted as upholding the view that undetected depression among primary care patients is a major public health problem. However, interpretation of such prevalence data is more complex. Many depressed patients have few or no symptoms beyond what is needed to meet criteria for a diagnosis and are not substantially impaired (Coyne et al., 1994). The cases missed by physicians are disproportionately milder cases (Coyne et al., 1995). Furthermore, the symptoms of many depressed primary care patients, and particularly the symptoms of those patients who are not detected as having depression by their physicians, are in a range of severity in which antidepressants have not been shown to have a decided advantage over placebos (Elkin et al., 1989; Paykel, Hollyman, Freeling, & Sedgwick, 1988). Furthermore, patients’ willingness to accept an antidepressant is a strong predictor of whether they will be detected (Rost et al., 2000), suggesting a role for patient preference in the process of detection. In addition, patients with less severe depression are also less likely to accept treatment (Grembowski, Martin, & Patrick, 2001). On the other hand, primary care patients who present with mild major depression and remain undetected may suffer later exacerbation of symptoms when they no longer are in contact with their physician (Rost, Zhang, Fortney, Smith, & Coyne, 1998).


Minor Depression Estimates of the rates of minor and intermittent depression insufficient to meet criteria for current major depression range from 2% to 9% among primary care patients (Barrett et al., 1988; Hoeper, Nycz, Cleary, Regier, & Goldberg, 1979; Ormel, Van Den Brink, Koeter, & Giel, 1990), but there is ambiguity as to the clinical significance of these conditions. It has been suggested that minor depression represents a source of considerable impairment and a risk for major depression such that early intervention could reduce unnecessary suffering and disability (Broadhead, Blazer, George, & Tse, 1990; Horwarth, Johnson, Klerman & Weissman, 1992; Wells et al., 1989). However, controlled studies of intervention for minor depression in primary care have produced quite modest and even null effects, in part due to the improvement in symptoms among these patients regardless of intervention (Barrett et al., 1999; Katon et al., 1995; Williams et al., 2000). In general, although minor depression may entail severe functional impairment (Callahan et al., 1994), few treatments have been shown to be effective with this disorder (Coyne et al., 1995). There appears to be an emerging paradox concerning depressive symptoms and conditions that are not sufficient to meet full criteria for major depression. Namely, although such conditions are less severe than major depression, it may be more difficult to demonstrate that they benefit from treatment (Callahan, 2001). However, the clinical significance of minor depression may vary according to whether such symptomatology reflects a general vulnerability to major depression (Coyne & Katz, 2001). Given the recurrent nature of major depression, prior depression is an excellent marker for this vulnerability (Coyne, Pepper, & Flynn, 1999). Yet, in contrast to the DSM-IV, which makes past major depression an exclusion criteria, studies of minor depression typically do not take history of depression into account. Individuals with a history of major depression actually spend more time with subsyndromal depressive symptoms than in full episodes of major depression (Judd et al., 1998b). However, most individuals experiencing mild symptoms do not progress to a full episode of depression, with only 9%–21% of women and 4%–13% of men becoming clinically depressed in their lifetime (R. C. Kessler et al., 1994). The finding that subsyndromal symptoms in recovered depressed persons are an important predictor of rapid relapse (Judd et al., 1998a) adds to the weight of evidence that both recent and more distant history of depression should be routinely assessed and taken into account in the interpretation of depressive symptoms.

Anxiety Disorders Although anxiety disorders are believed to be the most common psychiatric disorder in primary care (Sherbourne, Jackson, Meredith, Camp, & Wells, 1996), they have only begun to be given attention other than as a comorbidity of depression. Panic disorder and general anxiety disorder can be highly impairing, but the common phobias, which contribute to the high prevalence of anxiety disorders, are not (Nisenson, Pepper, Schwenk, & Coyne, 1998). Although comorbid anxiety disorders facilitate the detection of depression, there has been a concern in the past that this contributed to the inappropriate treatment of depression with benzodiazepines (Depression Guidelines Panel, 1993). However, newer antidepressants, including the SSRIs, can also be effective

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for anxiety disorders, potentially reducing this problem (Uhlenhuth, Balter, Ban, & Yang, 1999). The availability of these newer antidepressants will give rise to simplified treatment algorithms that do not require primary care providers to make complex diagnostic distinctions or treatment choices. The apparent efficiency of such algorithms may make it more difficult for consumers and nonphysician mental health professionals to argue for the necessity of offering psychosocial interventions in primary care as alternatives to these algorithms.

Mixed Anxiety–Depression Katon and Roy-Byrne (1991) have provided a comprehensive review concerning evidence for a mixed anxiety– depressive disorder among primary care patients. The DSM-IV includes such a condition, requiring 1-month mood disorder and other affective symptoms, but only as a set of criteria for further study rather than an accepted diagnosis. Such mixed states are highly prevalent (Barrett et al., 1988). There is evidence that primary care providers take into account both anxious and depressive symptoms in deciding caseness for major depression (Nisenson et al., 1998) and that a substantial proportion of patients receiving antidepressants have mixed anxiety and depressive symptoms without meeting full criteria for major depression (Sireling, Paykel, Freeling, Rao, & Patel, 1985). Some anxious– depressed patients suffer substantial impairment and may be at risk for subsequently full criteria major depression. However, other such patients are not impaired and recover without formal treatment. Nease, Volk, and Cass (1999) used cluster analysis to examine mood and anxiety symptoms in primary care patients and found that patients clustered into four groups, all of which displayed some mixture of mood and anxiety symptoms at varying levels of severity, rather than into groups of mostly pure mood, mostly pure anxiety, and mixed mood and anxiety symptoms. Patients with mood and anxiety disorders were distributed throughout all the groups, suggesting that coexisting mood and anxiety symptoms are the rule rather than the exception. Katon and Roy-Byrne suggested that further research is needed to resolve the apparent heterogeneity of mixed anxiety– depressive disorder and its relation to major depression. They note that the bulk of available studies are limited by the absence of data concerning lifetime psychiatric disorder or a longitudinal perspective.

Controversy Over Diagnostic Criteria The controversy over the adequacy of psychiatric diagnostic criteria for primary care patients (Barrett et al., 1988; Nease et al., 1999) is rather different from the disputes familiar to psychologists concerning the suitability of self-reported distress as an equivalent to diagnosis (Coyne, 1994; Vredenburg, Flett, & Krames, 1993). The key issues in primary care are how to best identify patients who are both significantly impaired by emotional distress and likely to benefit from specific treatments while minimizing unnecessary treatment. The prevailing view has emphasized treatment of any patients who currently meet diagnostic criteria. However, this approach leaves out a number of intermediate steps that are important in primary care: namely, assessment and interpretation of the severity of current symptoms in light of prior history, as well as the negotiation toward the patient’s acceptance of the diagnosis and treatment plan. In other words, determining whether patients

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currently fit into traditional diagnostic categories is only one step in identifying those who will accept and benefit from treatment. Primary care providers must make diagnostic judgments in a context in which most patients are suffering some physical and emotional discomfort, and therefore, the risk of a lowered threshold for diagnosis is that a large number of patients will be inappropriately labeled as having an emotional disorder. Many depressed patients have only the minimum number of symptoms required for a diagnosis, meaning that interpretation of one or two symptoms makes the difference between an accurate diagnosis or a false positive or a false negative diagnosis. Symptoms may not be numerous or severe enough to warrant a formal diagnosis at an index visit, yet these symptoms may intensify when the patients are no longer in contact with their physician (Rost et al., 1998). A history of prior depression can be crucial in interpreting current presentation. Issues in assessing anxiety disorders are more complex, in that it is more difficult to reliably establish a prior history, and the revised criteria presented in the DSM-IV may not be clinically valid (Bienvenu, Nestadt, & Eaton, 1998). Although intended to distinguish generalized anxiety from normal worrying, the increase in the required duration of symptoms from 1 month to 6 months may not be an acceptable means of drawing this distinction in primary care. Finally, unlike patients seeking treatment in specialized mental health settings, patients identified as having emotional disorders in primary care may not be ready to accept and benefit from treatment (Rost et al., 2000; T. L. Thompson, Mitchell, & House, 1989). These factors may help to explain evidence that primary care providers often reject formal psychiatric nosology and instead rely on their own assessment of current symptoms and their knowledge of the patient (Klinkman, Coyne, Gallo, & Schwenk, 1998; Valenstein et al., 1997). Primary care providers are widely criticized for missing major depression (Depression Guidelines Panel, 1993). Yet when compared with formal diagnostic criteria, they make more false positive diagnoses than false negatives (Klinkman et al., 1998). Many false positive patients have a mix of affective symptoms and a history of depression, and it is not clear that the primary care providers’ judgments are clinically invalid. A diagnostic system that was more clinically useful and acceptable in primary care would better accommodate the number and severity of a full range of affective symptoms and, importantly, incorporate more of a temporal perspective. Prior history would be given weight in interpreting ambiguous presentations of symptoms, but some diagnoses would still be best resolved only with extended observation or “watchful waiting” (Freedman, 1989).

Improving the Outcome of Depression in Primary Care Dominant View: Screen, Detect, Medicate, and Observe Improvement As we have noted, most efforts to improve the outcome of emotional disorders in primary care have centered on depression. Identification of depression as highly prevalent, but largely untreated in primary care, was the impetus for development (by the U.S. Public Health Service Agency for Health Care Policy and Research [AHCPR]) of practice guidelines for the management of depression (Depression Guidelines Panel, 1993). These guidelines advocated front-loading strategies to improve the outcome of depression: increased case finding with routine screening as a key

means of facilitating physician detection of depression. Although they acknowledged the efficacy of psychotherapy for mild and moderate depression, they put greater emphasis on medication as the first line of treatment (Munoz et al., 1994). Initial clinical trials confirmed that screening led to increased detection and treatment of major depression (Magruder-Habib, Zung, & Feussner, 1990; Rand, Badger, & Coggins, 1988; Shapiro et al., 1987). Yet enthusiasm for the routine screening for depression (Depression Guidelines Panel, 1993) has been dampened by repeated findings that screening and feedback to providers do not improve the outcome or adequacy of treatment of depressed patients in primary care (Callahan et al., 1994; Dowrick & Buchan, 1995; Moore, Silimperi, & Bobula, 1978; Reifler, Kessler, Bernhard, Leon, & Martin, 1996; Scott & Freeman, 1992; Shapiro et al., 1987). To be of benefit, screening must be integrated with additional enhancements of routine care, and even then, the benefits are not assured (Callahan et al., 1994). Moreover, potential drawbacks of routine screening include the risk of encouraging providers to overdiagnose and treat patients who are distressed but not depressed (Klinkman, Coyne, Gallo, & Schwenk, 1997) and the commitment of considerable resources to interview assessments of patients who are not found to be depressed. Screening for distress is clearly not a panacea for the problem of depression in primary care (see Coyne et al., 2000, for a review). A recent meta-analysis failed to find that routine screening improved the outcome of depression in general medical care (Gilbody, House, & Sheldon, 2001), and a cost-effectiveness analysis concluded that screening was justified under only highly restricted conditions (Valenstein, Vijan, Zeber, Boehm, & Buttar, 2001). However, both of the analyses may still have been overly optimistic in their conclusions, because they made unrealistic assumptions about rates of treatment in the absence of screening and about the effectiveness of treatment under conditions of routine care (Coyne, Palmer, & Thompson, 2001). One important limitation on the effectiveness of routine screening as a means of improving the outcome of depression is that it depends on the effectiveness of initiating treatment of patients who are found to be depressed. Ormel et al. (1990) reported that although detection of depression was associated with fewer patients meeting diagnostic criteria for depression at 1 year, treatment of depression was not associated. Brugha, Bebbington, MacCarthy, Sturt, and Wykes (1992) noted equivalent outcomes for major depressive disorder patients not receiving antidepressant treatment and for those receiving treatment. A number of studies in both North America and Europe found either modest short-term benefits for detection and treatment or, more consistently, none at all (Coyne, Klinkman, Gallo, & Schwenk, 1997; Pini, Perkonnig, Tansella, Wittchen, & Psich, 1999; Rost et al., 1998; Simon et al., 1999; Tiemens, Ormel, & Simon, 1996). Indeed, Schulberg et al. (1996) found that the improvement rates of depressed patients provided antidepressant treatment by primary care physicians was only 48%, which is lower than the rates of improvement often found with placebos administered in the context of randomized clinical trials in specialty mental health settings.

Next Wave of Physician- and Practice-Centered Strategies for Improving Outcome Renewed efforts to improve the outcome of depression in primary care tend to presume that the difficulty lies with primary care


physicians. Physician-centered interventions have included a variety of educational strategies, feedback and supervision, and academic detailing. In a review of the literature from 1966 –1998 for all emotional disorders in primary care, Kroenke, Taylor-Vaisey, Dietrich, and Oxman (2000) reported changes in diagnosis and treatment for the majority of interventions but improvement in patient symptomatology for only 4 of 11 studies, with some of this improvement short-lived. For instance, Katon et al. (1995) examined the effect of a collaborative management protocol including training, conferences, and a review of each case by a psychiatrist. Although considered a successful trial, the intervention improved outcomes for only those patients with major depressive disorder who required adjustment of their medication regimen during the intervention period. Lin et al. (1997) later found that none of the short-term improvements in depression treatment persisted after the collaborative care intervention ended. Several newer primary care interventions have also failed to improve outcomes. In a particularly ambitious study, Goldberg et al. (1998) randomized 15 practices with 95 practitioners and 1,177 depressed patients to either academic detailing, continuous quality improvement, or routine care but were unable to demonstrate improvement in patient outcomes for the active intervention groups. Katon and colleagues (Katon et al., 1999) have now reported a stepped collaborative care trial, which provided collaborative care intervention for only those patients whose depressive episodes had not resolved at 6 – 8 weeks. They found improved outcomes at 3 and 6 months, although differences in outcomes were of marginal statistical significance at the 6-month measure. Tiemens et al. (1999) implemented a 20-hr training program for primary care physicians on detection, diagnosis, and treatment, finding an initial improvement in short-term outcomes for depressed patients but no effect by 1 year. C. Thompson et al. (2000) carried out a randomized, controlled trial of a practice-based educational intervention based on clinical practice guidelines in 60 primary care practices in the United Kingdom and found no effect on either recognition or clinical outcome. Results from recent studies examining both practice-level interventions and outcomes monitoring are just now becoming available. These studies show minimal short-term improvements in selected patient outcomes when compared with routine care (Rollman et al., 1999; Sherbourne et al., 1999), but even these minimal improvements may not be maintained (Lin et al., 1997, 1999) and are unlikely to result in improved quality of life or daily functioning (Revicki, Simon, Chan, Katon, & Heiligenstein, 1998; Simon et al., 1998). Trials with multiple outcome assessments showed narrowing of differences between intervention and control arms over time (Hunkeler, 1999). An important but often overlooked finding in this generation of clinical trials is that routine or usual care arms often show short-term improvements in outcome measures approaching that of intervention arms. It is clear that not all patients require intensive intervention, and better identification of those who do could provide a means of better allocating resources.

Whither Psychotherapy in Primary Care? The AHCPR Depression Guidelines are widely interpreted as emphasizing medication, and most efforts to improve the outcome of depression in primary care have a similar bias. Collaborative mental health care has generally come to mean psychiatrists or

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nurse specialists providing enhanced management of medication. Some ongoing multisite trials for which results are not yet available prescribe psychotherapy as a second line of treatment for patients who refuse medication or who are inadequately responsive to it (Schulberg et al., 2001; Unu¨ tzer et al., 2001). All of this reflects the profound medicalization of the issue of emotional disorders in primary care. On the other hand, data demonstrating the effectiveness of psychotherapy provided to depressed primary care patients within the constraints of that setting are quite limited. Schulberg et al. (1996) showed in intent-to-treat analyses that interpersonal psychotherapy (IPT) was equivalent to enhanced management of antidepressants, and both were superior to routine care, despite that only 42% of the patients receiving IPT and 33% receiving antidepressants completed the trial. Secondary analyses showed that this effect also held for severely as well as mildly and moderately depressed patients (Schulberg, Pilkonis, & Houck, 1998). Two studies have failed to show a benefit for cognitive therapy over routine care by primary care physicians (Scott & Freeman, 1992; Teasdale, Fennell, Hibbert, & Amies, 1984), but another study showed a benefit (Ross & Scott, 1985). Reviewing the outcome studies available through 2000, Schulberg, Raue, and Rollman (in press) concluded that, overall, manualized psychotherapies were superior to routine care for depressed primary care patients. Yet there remains the practical issue of skilled therapists willing to adhere to manualized treatment being readily available in primary care. Both IPT and cognitive therapy require highly skilled therapists, and their efficacy may depend on the degree to which therapists adhere to the manualized treatment manuals (Frank, Kupfer, Wagner, McEachran, & Cornes, 1991). Mynors-Wallis and colleagues (Mynors-Wallis, 1996; Mynors-Wallis, Davies, Gray, Barbour, & Gath, 1997; Mynors-Wallis & Gath, 1997; Mynors-Wallis, Gath, Day, & Baker, 2000) have tested a problemsolving treatment (PST) for depression that is specifically designed to be feasible for clinicians who are not highly trained in providing therapy. The most recent trial using PST randomized patients to one of four treatment groups: PST administered by a nurse, PST administered by a general practitioner, antidepressant medication, or combination treatment with PST and medication (MynorsWallis et al., 2000). No differences in outcomes were seen at 6, 12, or 52 weeks, although all groups showed significant levels of improvement. The authors concluded that their results demonstrate the effectiveness of PST at levels equal to that of antidepressants, although it is unclear whether the study was sufficiently powered to detect differences between the groups. What effectiveness can be expected for routinely referring depressed primary care patients to psychotherapists? Phrased in this way, effectiveness depends not only on the efficacy of treatment but on uptake—patients accepting the referral and adequately completing the course of treatment. Psychotherapy may appeal to the substantial numbers of primary care patients who reject antidepressants (Rost et al., 2000). Schulberg et al. (1996) and others have demonstrated that treatment effects are found even when depressed primary care patients with substantial physical comorbidity are not excluded from a clinical trial. Yet, however encouraging such data may be, policymakers may remain unconvinced of the benefits of referral of depressed primary care patients until effectiveness can demonstrated under conditions of routine care. Aside from issues of patient uptake, there are unanswered ques-

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tions about psychotherapists’ performance outside of clinical trials in which treatment fidelity is monitored and enforced. Practicing clinicians tend to express reservations about adherence to manualized treatment as being too rigid (Addis & Krasnow, 2000). Moreover, some data are not reassuring that concern the effectiveness of routinely provided psychotherapy. Lambert, Hansen, and Finch (2001) examined effectiveness data for over 10,000 patients receiving psychotherapy in a health maintenance organization. At least 21 sessions were required for 50% of the patients to show clinically significant improvement, and it was estimated that at least 40 sessions and sometimes the addition of medication would be required for 75% of patients to show clinically significant improvement. Effectiveness of psychotherapy in this study was undoubtedly limited by the nonspecificity of the treatment provided, as well as the nonspecificity of the conditions being treated. Lambert et al. (2001) noted that a substantial percentage (10%– 20%) of the patients were already highly functioning and therefore could not be expected to show substantial gains from treatment. These data are thus not decisive, even if they suggest that routine psychotherapy may require more sessions to be effective than many patients and third party payers are willing to accept. However, it is likely that policymakers will require compelling effectiveness data as well as efficacy data if they are to be convinced of the benefits of referring depressed patients to psychotherapy. Such demonstrations should be seen as an important research agenda.

Competing Demands on Primary Care as a Treatment Setting for Emotional Disorder There is a certain Willie Suttonism to the focus on emotional disorders in primary care.1 A large number of individuals with emotional disorders are to be found there, and many of them will not have consulted a mental health professional. Primary care providers are prepared to dispense medications that have proven efficacious in clinical trials. Yet the results obtained with this treatment do not match what is obtained in clinical trials, and a variety of interventions to improve patient outcomes have not had marked success. In light of this, greater attention needs to be given to some of the difficulties posed by primary care as a treatment setting. During routine clinical encounters, primary care physicians deal with multiple health problems and multiple priorities encompassing multiple domains, biomedical as well as social and emotional. This complex balancing act must take place over 12–15 min under usual circumstances (6 min in the United Kingdom), setting limits on what can be accomplished and placing negotiation at the center of every primary care encounter (Klinkman, 1997). The various practice- and physician-centered efforts to improve the outcome of emotional disorders have minimized the role of the patients in this negotiation. The assumption seems to be that they are passive, open to discussion of their problems in terms of emotional disorder, and willing to accept treatment with an emphasis on medication. Yet visits to primary care start with patients’ declaration of the reason for the encounter (for example, “My back hurts,” or “I need you to check my cholesterol”), which sets the agenda for the encounter (Lamberts, Meads, & Wood, 1985), and patient responses to clinician questions can encourage, discourage, or deflect subsequent inquiry about symptoms and complaints. As we have noted, depressed patients’ interest in antidepressants is a

strong predictor of whether their emotional disorder will be detected (Rost et al., 1998), and this is consistent with other evidence indicating the importance of patient preference (Dew, Dunn, Bromet, & Schulberg, 1988; Olfson, 1991). A close examination of recent primary care-based interventions may illustrate the degree to which patient preferences shape treatment. Katon and colleagues (Katon et al., 2001) recently reported a relapse prevention program with primary care patients diagnosed with recurrent depression. Although the trial specifically targeted patients who had already been diagnosed and had accepted treatment in the past, the results of recruitment efforts were sobering. Only a little more than half (53.6%) of patients eligible for the study were successfully enrolled, and most of the failure to enroll was due to patient refusal or dropout before enrollment; in fact, by the conclusion of the study, more patients had refused or dropped out than those originally enrolled (Katon et al., 2001). In a lessselect sample of patients, one would expect an even lower level of uptake. A recent trial by Wells and colleagues (Wells et al., 2000) illustrated this. In investigating a quality improvement program, they screened a large number of primary care patients. Of the patients who were screened and eligible to participate, only 35% were enrolled; the rest refused or dropped out before the beginning of the trial (Wells et al., 2000). Most intervention trials report similar levels of uptake, despite aggressive recruiting and the provision of free medication or psychotherapy. These problems are likely to be magnified outside of traditional intervention trials, when these barriers to treatment are not addressed. Klinkman’s (1997) model of competing demands of psychosocial care depicts detection and treatment of emotional disorder as dependent on the interactive effects of patient, clinician, and practice ecosystem factors, balanced over time in a setting of shifting clinical priorities and competing demands for the time and attention of both clinician and patient. Hohmann’s (1999) contextual model for clinical mental-health-effectiveness research similarly portrays treatment outcomes as a direct result of a complex therapeutic process, as influenced by characteristics of caregiver and client, their respective personal and professional networks, and larger organizational and personal cultures. The two models are strikingly similar: both emphasize the central role of the patient as well as the provider, both postulate multiple influences on the behavior and decisions of the central actors, and both place treatment in the context of an organizational environment. Greater understanding of the variables and psychosocial processes identified by these models as relevant to the treatment of emotional disorders in primary care is crucial to improving the outcome of this care.

Emotional Disorders in Primary Care: Missed Opportunity or New Frontier? Our discussions should convey the significance of emotional disorders in primary care and how current understanding is dom1

William Francis Sutton Jr., also known as Willie Sutton and Willie the Actor, was a celebrated American bank robber and prison escapee. The title of his autobiography, Where the Money Was (written with Edward Linn; Sutton & Linn, 1976) echoed his allegedly often repeated reason for robbing banks: “Because that’s where the money is.”


inated by a biomedical perspective, to which psychologists have as yet contributed little. We can point to the largely disappointing results of efforts to improve the outcome of emotional disorders in primary care and call for a greater role for psychologists. However, it may be unrealistic to expect that primary care will be deemphasized as a key context for the treatment of emotional disorders or to expect a wholesale integration into primary care of psychologists providing conventional psychotherapy. Nonetheless, there are key ways in which psychologists can have a crucial role in redefining a research agenda for emotional disorders in primary care, and in doing so, they can identify a place for the discipline’s unique expertise. There are a number of pressing needs: 1. Develop a nosological system for emotional disorders in primary care that takes into account that many patients will not present with clearly defined symptom patterns. Such a system would undoubtedly require a temporal perspective to explicate patients’ presentation and will need to be validated in terms of its ability to predict benefit from treatment. 2. Address accelerating rates of the prescription of psychotropic medication, particularly among the elderly. Efforts to increase the detection and treatment of emotional disorder need to be tempered with greater attention to when medication is inappropriate and when it can be terminated. Reduction in the inappropriate prescription of antidepressants and anxiolytics should be identified as an important mental health outcome. 3. Explicate the relevant patient variables and social processes affecting problem definition, acceptability of treatments, and preferred providers and settings. This would involve attention to the trade-offs and commitment of resources patients are willing to accept and an underlying conceptualization of patients as decisionmaking consumers, not simply passive recipients of treatment. 4. Explore the relationship between symptom relief and the associated personal and social problems patients seek to have addressed in primary care. This involves attention not only to functional outcomes but to the interpersonal circumstances that give rise to emotional disorder and leave patients vulnerable to relapse. Indeed, the potential for this role in relapse prevention is validated by a recent meta-analysis of cognitive– behavioral treatment outcomes (Gloaguen, Cottraux, Cucherat, & Blackburn, 1998). The value of psychotherapeutic intervention should be defined in part by a rehabilitative function not served by medication alone. 5. Explicate the relevant provider and practice variables that affect how treatments are delivered. The lack of acceptance of psychiatric nosology by primary care providers, the ineffectiveness of screening-based feedback in improving outcomes, and the disappointing effects of educational strategies and practice guidelines on provider behavior all point to the need for a better understanding of providers. 6. Develop brief, structured psychological treatments compatible with the competing demands and staffing of primary care. Just as SSRIs allow simplified treatment algorithms for treating emotional disorders, it should be possible to develop algorithms for psychological treatments that exploit common elements or mechanisms. For instance, there has been lively debate as to whether similarities between behavioral activation for depression and exposure for anxiety might allow for simplified strategies for treating anxiety and depression (Arean & Coyne, 2000).

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7. Identify what bundling of skills and services might make integration of psychologists into primary care more cost-effective and acceptable. For instance, roles in the diagnosis and treatment of emotional disorder might be supplemented with activities such as health promotion and pain management. The opportunities related to health psychology and behavioral medicine in primary care may be complementary to those related to a role in the management of emotional disorders.

References Addis, M. E., & Krasnow, A. D. (2000). A national survey of practicing psychologists’ attitudes toward psychotherapy treatment manuals. Journal of Consulting and Clinical Psychology, 68, 331–339. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Arean, P. A., & Coyne, J. C. (2000). [Are behavioral activation and exposure the same? A survey of clinician-researchers]. Unpublished raw data. Arean, P. A., & Miranda, J. (1996). Do primary care patients accept psychological treatments? General Hospital Psychiatry, 18, 22–27. Barrett, J. E., Barrett, J. A., Oxman, T. E., & Gerber, P. D. (1988). The prevalence of psychiatric disorders in a primary care practice. Archives of General Psychiatry, 45, 1100 –1106. Barrett, J. E., Williams, J. W., Oxman, T. E., Katon, W., Frank, E., Hegel, M. T., et al. (1999). The treatment effectiveness project: A comparison of the effectiveness of paroxetine, problem-solving therapy, and placebo in the treatment of minor depression and dysthymia in primary care patients. Background and research plan. General Hospital Psychiatry, 21, 260 –273. Beck, A. T., Guth, D., Steer, R. A., & Ball, R. (1997). Screening for major depression disorders in medical inpatients with the Beck Depression Inventory for Primary Care. Behavior Research and Therapy, 35, 785– 791. Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561–571. Bienvenu, J., Nestadt, G., & Eaton, W. W. (1998). Characterizing generalized anxiety: Temporal and symptomatic thresholds. Journal of Nervous and Mental Disease, 186, 51–56. Blacker, C., & Clare, A. (1987). Depressive disorder in primary care. British Journal of Psychiatry, 150, 737–751. Blazer, D. G., Hybels, C. F., Simonsick, E. M., & Hanlon, J. T. (2000). Marked differences in antidepressant use by race in an elderly community sample: 1986 –1996. American Journal of Psychiatry, 157, 1089 – 1094. Bower, P., & Sibbald, B. (2000). Systematic review of the effect of on-site mental health professionals on the clinical behaviour of general practitioners. British Medical Journal, 320, 614 – 617. Broadhead, W. E., Blazer, D. G., George, L. K., & Tse, C. K. (1990). Depression, disability days, and days lost from work in a prospective epidemiologic survey. Journal of the American Medical Association, 264, 2524 –2528. Brugha, T., Bebbington, P. E., MacCarthy, B., Sturt, E., & Wykes, T. (1992). Antidepressants may not assist recovery in practice: A naturalistic prospective survey. Acta Psychiatrica Scandinavica, 86, 5–11. Callahan, C. M. (2001). Quality improvement research on late life depression in primary care. Medical Care, 39, 772–784. Callahan, C. M., Hendrie, H. C., Dittus, R. S., Brater, D. C., Hui, S. L., & Tierney, W. M. (1994). Improving treatment of late life depression in

806


primary care: A randomized clinical trial. Journal of the American Geriatric Society, 42, 839 – 846. Coulehan, J. L., Schulberg, H. C., Block, M. R., Janosky, J. E., & Arena, V. C. (1990). Depressive symptomatology and medical co-morbidity in a primary care clinic. International Journal of Psychiatry in Medicine, 20, 335–347. Coyne, J. C. (1994). Self-reported distress: Analog or ersatz depression? Psychological Bulletin, 116, 29 – 45. Coyne, J. C., Fechner-Bates, S., & Schwenk, T. L. (1994). The prevalence, nature and co-morbidity of depressive disorders in primary care. General Hospital Psychiatry, 16, 267–276. Coyne, J. C., & Kagee, A. (2000). Disability associated with psychiatric comorbidity and health status in Bosnian refugees living in Croatia [Commentary]. Journal of the American Medical Association, 283, 55. Coyne, J. C., & Katz, I. R. (2001). Improving the primary care treatment of late life depression: Progress and opportunities. Medical Care, 39, 756 –759. Coyne, J. C., Klinkman, M. S., Gallo, S. M., & Schwenk, T. L. (1997). Short-term outcomes of detected and undetected depressed primary care patients and depressed psychiatric outpatients. General Hospital Psychiatry, 19, 333–343. Coyne, J. C., Palmer, S. C., & Thompson, R. (2001). Routine screening entails additional pitfalls. British Medical Journal, 323, 167. Coyne, J. C., Pepper, C. M., & Flynn, H. A. (1999). Significance of prior episodes of depression in two populations. Journal of Consulting and Clinical Psychology, 67, 76 – 81. Coyne, J. C., & Schwenk, T. L. (1995). AHCPR depression guidelines: Countering misconceptions with more misconceptions? American Psychologist, 50, 452– 453. Coyne, J. C., & Schwenk, T. L. (1997). The relationship of distress to mood disturbance in primary care and psychiatric populations. Journal of Consulting and Clinical Psychology, 65, 161–168. Coyne, J. C., Schwenk, T. L., & Fechner-Bates, S. (1995). Nondetection of depression by primary care physicians reconsidered. General Hospital Psychiatry, 17, 3–12. Coyne, J. C., Thompson, R., Palmer, S. C., Kagee, A., & Maunsell, E. (2000). Should we screen for depression? Caveats and potential pitfalls. Applied and Preventive Psychology, 9, 101–121. Depression Guidelines Panel. (1993). Depression in primary care (AHCPR Publication No. 93– 0551). Rockville, MD: U. S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. Derogatis, L. R., Lipman, R. S., Rickels, K., Uhlenuth, E. H., & Covi, L. (1974). The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory. Behavioral Science, 19, 1–15. Derogatis, L. R, & Melisaratos, N. (1983). The Brief Symptom Inventory: An introductory report. Psychological Medicine, 13, 595– 605. Dew, M. A., Dunn, L. O., Bromet, E. J., & Schulberg, H. C. (1988). Factors affecting help-seeking during depression in a community sample. Journal of Affective Disorders, 14, 223–234. Dowrick, C., & Buchan, I. (1995). Twelve month outcome of depression in general practice: Does detection or disclosure make a difference? British Medical Journal, 311, 1274 –1276. Elkin, I., Shea, M. T., Watkins, J. T., Imber, S. D., Sotsky, S. M., Collins, J. F., et al. (1989). National Institute of Mental Health treatment of depression collaborative research program: General effectiveness of treatments. Archives of General Psychiatry, 46, 971–982. Endicott, J., & Spitzer, R. L. (1978). A diagnostic interview: The schedule for affective disorders and schizophrenia. Archives of General Psychiatry, 35, 837– 844. Fechner-Bates, S., Coyne, J. C., & Schwenk, T. L. (1994). The relationship of self-reported distress to psychopathology. Journal of Consulting and Clinical Psychology, 62, 550 –559. Frank, E., Kupfer, D., Wagner, E., McEachran, A., & Cornes, C. (1991).

Efficacy of interpersonal psychotherapy as a maintenance treatment of recurrent depression: Contributing factors. Archives of General Psychiatry, 48, 1053–1059. Freedman, D. X. (1989). Editorial note: Especially for the media. Archives of General Psychiatry, 46, 983–984. Gerber, P. D., Barrett, J., Barrett, J., Manheimer, E., Whiting, R., & Smith, R. (1989). Recognition of depression by internists in primary care: A comparison of internist and “gold standard” psychiatric assessments. Journal of General Internal Medicine, 4, 7–13. Gilbody, S. M., House, A. O., & Sheldon, T. A. (2001). Routinely administered questionnaires for depression and anxiety: Systematic review. British Medical Journal, 322, 406 – 409. Gloaguen, V., Cottraux, J., Cucherat, M., & Blackburn, I. M. (1998). A meta-analysis of the effects of cognitive therapy in depressed patients. Journal of Affective Disorders, 49, 59 –72. Goldberg, D., & Hillier, V. (1979). A scaled version of the General Health Questionnaire. Psychology Medicine, 9, 139 –145. Goldberg, H. I., Wagner, E. H., Fihn, S. D., Martin, D. P., Horowitz, C. R., Christensen, D. B., et al. (1998). A randomized controlled trial of CQI teams and academic detailing: Can they alter compliance with guidelines? Journal of Quality Improvement, 24, 130 –142. Grembowski, D., Martin, D., & Patrick, D. (2001). Managed care, access to mental health specialists, and outcomes among primary care patients with depressive symptoms. Manuscript submitted for publication. Henderson, A. S. (1998). New methods in psychiatric epidemiology. Psychiatry & Clinical Neurosciences, 52, S261–S264. Hirschfeld, R. M. A. (1998). American health care systems and depression: The past, present, and the future. Journal of Clinical Psychiatry, 59, 5–10. Hoeper, E. W., Nycz, G. R., Cleary, P. D., Regier, D. A., & Goldberg, I. D. (1979). Estimated prevalence of RDC mental disorder in primary medical care. International Journal of Mental Health, 8, 6 –15. Hohmann, A. (1999). A contextual model for clinical mental health effectiveness research. Mental Health Services Research, 1, 83–92. Horwarth, E., Johnson, J., Klerman, G. L., & Weissman, M. M. (1992). Depressive symptoms as relative and attributable risk factors for firstonset major depression. Archives of General Psychiatry, 49, 817– 823. Hunkeler, E. (1999, February). Efficacy and cost of nurse telephone follow-up to improve depression treatment in primary care. Paper presented at the Improving Care for Depression in Organized Health Care Systems conference, Seattle, WA. Judd, L. L., Akiskal, H. S., Maser, J. D., Zeller, P. J., Endicott, J., Coryell, W., et al. (1998a). Major depressive disorder: A prospective study of residual subthreshold depressive symptoms as predictors of rapid relapse. Journal of Affective Disorders, 50, 97–108. Judd, L. L., Akiskal, H. S., Maser, J. D., Zeller, P. J., Endicott, J., Coryell, W., et al. (1998b). A prospective 12-year study of subsyndromal and syndromal depressive symptoms in unipolar major depressive disorders. Archives of General Psychiatry, 55, 694 –700. Katon W. (1987). Epidemiology of depression in medical care. International Journal of Psychiatric Medicine, 17, 93–112. Katon, W., & Roy-Byrne, P. P. (1991). Mixed anxiety and depression. Journal of Abnormal Psychology, 100, 337–345. Katon, W., Rutter, C., Ludman, E. J., Von Korff, M., Lin, E., Simon, G., et al. (2001). A randomized trial of relapse prevention of depression in primary care. Archives of General Psychiatry, 58, 241–247. Katon, W., & Schulberg, H. (1992). Epidemiology of depression in primary care. General Hospital Psychiatry, 14, 237–247. Katon, W., Von Korff, M., Lin, E., Bush, T., & Ormel, J. (1992). Adequacy and duration of antidepressant treatment in primary care. Medical Care, 30, 67–76. Katon, W., Von Korff, M., Lin, E., Simon, G. E., Walker, E., Unutzer, J., et al. (1999). Stepped collaborative care for primary care patients with

SPECIAL ISSUE: PRIMARY CARE persistent symptoms of depression: A randomized trial. Archives of General Psychiatry, 56, 1109 –1115. Katon, W., Von Korff, M., Lin, E., Walker, E., Simon, G. E., Bush, T., et al. (1995). Collaborative management to achieve treatment guidelines: Impact on depression in primary care. Journal of the American Medical Association, 273, 1026 –1031. Kessler, L. G., Cleary, P. D., & Burke, J. D. (1985). Psychiatric disorders in primary care. Archives of General Psychiatry, 42, 583–587. Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., et al. (1994). Lifetime and 12-month prevalence of DSMIII-R psychiatric disorders in the United States. Archives of General Psychiatry, 51, 8 –19. Kessler, R. C., Zhao, S. Y., Katz, S. J., Kouzis, A. C., Frank, R. G., Edlund, M., & Leaf, P. (1999). Past-year use of outpatient services for psychiatric problems in the national comorbidity survey. American Journal of Psychiatry, 156, 115–123. Klinkman, M. S. (1997). Competing demands in psychosocial care: A model for the identification and treatment of depressive disorders in primary care. General Hospital Psychiatry, 19, 98 –111. Klinkman, M. S., Coyne, J. C., Gallo, S. M., & Schwenk, T. L. (1997). Can case-finding instruments be used to improve physician detection of depression in primary care? Archives of Family Medicine, 6, 567–573. Klinkman, M. S., Coyne, J. C., Gallo, S. M., & Schwenk, T. L. (1998). False positives, false negatives, and the validity of the diagnosis of major depression in primary care. Archives of Family Medicine, 7, 451– 461. Kroenke, K., Taylor-Vaisey, A., Dietrich, A. J., & Oxman, T. E. (2000). Interventions to improve provider diagnosis and treatment of mental disorders in primary care: A critical review of the literature. Psychosomatics, 41, 39 –52. Lambert, M. J., Hansen, N. B., & Finch, A. E. (2001). Patient-focused research using patient outcome data to enhance treatment effects. Journal of Consulting and Clinical Psychology, 69, 159 –172. Lamberts, H., Meads, S., & Wood, M. (1985). Results of the international field trial with the Reason for Encounter Classification. Sozial- und Praventivmedizin, 30, 80 – 87. Lepine, J. P., Gastpar, M., Mendlewicz, J., & Tylee, A. (1997). Depression in the community: The first pan-European study DEPRES (Depression Research in European Society). International Clinical Psychopharmacology, 12, 19 –29. Lin, E. H., Katon, W. J., Simon, G. E., Von Korff, M., Bush, T. M., Rutter, C. M., et al. (1997). Achieving guidelines for the treatment of depression in primary care: Is physician education enough? Medical Care, 35, 831– 842. Lin, E. H. B., Simon, G. E., Katon, W. J., Russo, J. E., Von Korff, M., Bush, T. M., et al. (1999). Can enhanced acute-phase treatment of depression improve long-term outcomes? A report of randomized trials in primary care. American Journal of Psychiatry, 156, 643– 645. Magruder-Habib, K., Zung, W. W. K., & Feussner, J. R. (1990). Improving physician’s recognition and treatment of depression in general medical care. Medical Care, 28, 239 –250. Mamdani, M., Herrmann, N., & Austin P. (1999). Prevalence of antidepressant use among older people: Population-based observations. Journal of the American Geriatrics Society, 47, 1350 –1353. Moore, J. T., Silimperi, D. R., & Bobula, J. A. (1978). Recognition of depression by family medicine residents: The impact of screening. Journal of Family Practice, 7, 509 –513. Mulrow, C. D., Williams, J. W., Gerety, M. B., Ramirez, G., Montiel, O. M., & Kerber, C. (1995). Case-finding instruments for depression in primary care settings. Annals of Internal Medicine, 122, 913–921. Munoz, R. F., Hollon, S. D., McGrath, E., Rehm, L. P., & VandenBos, G. R. (1994). On the AHCPR depression in primary care guidelines: Further considerations for practitioners. American Psychologist, 49, 42– 61. Munoz, R. F., Ying, Y. W., Bernal, G., Perez-Stable, E. J., Sorensen, J. L.,

807

Hargreaves, W. A., et al. (1995). Prevention of depression with primary care patients: A randomized controlled trial. American Journal of Community Psychology, 23, 199 –222. Mynors-Wallis, L. (1996). Problem-solving treatment: Evidence for effectiveness and feasibility in primary care. International Journal of Psychiatry in Medicine, 26, 249 –262. Mynors-Wallis, L., Davies, I., Gray, A., Barbour, F., & Gath, D. (1997). A randomised controlled trial and cost analysis of problem-solving treatment for emotional disorders given by community nurses in primary care. British Journal of Psychiatry, 170, 113–119. Mynors-Wallis, L., & Gath, D. (1997). Predictors of treatment outcome for major depression in primary care. Psychological Medicine, 27, 731–736. Mynors-Wallis, L. M., Gath, D. H., Day, A., & Baker, F. (2000). Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care. British Medical Journal, 320, 26 –30. Nease, D. E., Jr., Volk, R. J., & Cass, A. R. (1999). Investigation of a severity-based classification of mood and anxiety symptoms in primary care patients. Journal of the American Board of Family Practice, 12, 21–31. Nisenson, L. G., Pepper, C. M., Schwenk, T. L., & Coyne, J. C. (1998). The nature and prevalence of anxiety disorders in primary care. General Hospital Psychiatry, 20, 21–28. Olfson, M. (1991). Primary care patients who refuse specialized mental health services. Archives of Internal Medicine, 151, 129 –132. Ormel, J., Van Den Brink, W., Koeter, M. W. J., & Giel, R. (1990). Recognition, management and outcome of psychological disorders in primary care: A naturalistic follow-up study. Psychological Medicine, 20, 909 –923. Paykel, E. S., Hollyman, J. A., Freeling, P., & Sedgwick, P. (1988). Predictors of therapeutic benefit from amitriptyline in mild depression: A general practice placebo-controlled trial. Journal of Affective Disorders, 14, 83–95. Pelissolo, A., Boyer, P., Lepine, J. P., & Bisserbe, J. C. (1996). Epidemiology of anxiolytics and hypnotics use in France and in the world. Encephale-Revue de Psychiatrie Clinique Biologique et Therapeutique, 22, 187–196. Perez-Stable, E. J., Miranda, J., Munoz, R. F., & Ying, Y. W. (1990). Depression in medical outpatients: Underrecognition and misdiagnosis. Archives of Internal Medicine, 150, 1083–1088. Pini, S., Perkonnig, A., Tansella, M., Wittchen, H. U., & Psich, D. (1999). Prevalence and 12-month outcome of threshold and subthreshold mental disorders in primary care. Journal of Affective Disorders, 56, 37– 48. Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385– 401. Rand, E. H., Badger, L. W., & Coggins, D. R. (1988). Toward a resolution of contradictions. Utility of feedback from the GHQ. General Hospital Psychiatry, 10, 189 –196. Regier, D. A., Myers, J. K., & Kramer, M. (1985). The NIMH Epidemiological Catchment Area Program: Historical context, major objectives, and study population characteristics. Archives of General Psychiatry, 41, 934 –941. Regier, D. A., Narrow, W. E., Rae, D. S., Manderscheid, R. W., Locke, B. Z., & Goodwin, F. K. (1993). The de facto US mental and addictive disorders service system. Archives of General Psychiatry, 50, 85–94. Reifler, D. R., Kessler, H. S., Bernhard, E. J., Leon, A. C., & Martin, G. J. (1996). Impact of screening for mental health concerns on health service utilization and functional status in primary care patients. Archives of Internal Medicine, 156, 2593–2599. Revicki, D. A., Simon, G. E., Chan, K., Katon, W., & Heiligenstein, J. (1998). Depression, health-related quality of life, and medical cost outcomes of receiving recommended levels of antidepressant treatment. Journal of Family Practice, 47, 446 – 452.

808


Robins, L. N., Helzer, J. E., Croughan, R., & Ratcliff, K. S. (1981). National Institute of Mental Health Diagnostic Interview Schedule: Its history, characteristics, and validity. Archives of General Psychiatry, 38, 837– 844. Rollman, B. L., Hanusa, B. H., Gilbert, T., Lowe, H., Kapoor, W. N., & Schulberg, H. C. (1999, July). Improving the quality of treatment for depression in primary care using computerized decision support. Paper presented at the 13th International Conference on Mental Health Problems in the General Health Care Sector, Washington, DC. Rosenheck, R. A., Druss, B., Stolar, M., Leslie, D., & Sledge, W. (1999). Effect of declining mental health service use on employees of a large corporation. Health Affairs, 18, 193–203. Ross, M., & Scott, M. (1985). An evaluation of the effectiveness of individual and group cognitive therapy in the treatment of depressed patients in an inner city health center. Journal of the Royal College of General Practice, 35, 239 –242. Rost, K., Nutting, P., Smith, J., Coyne, J. C., Cooper-Patrick, L., & Rubenstein, L. (2000). The role of competing demands in the treatment provided primary care patients with major depression. Archives of Family Medicine, 9, 150 –154. Rost, K., Zhang, M., Fortney, J., Smith, J., & Coyne, J. C. (1998). Persistently poor outcomes of undetected major depression in primary care: Implications for intervention. General Hospital Psychiatry, 20, 12–20. Santor, D., & Coyne, J. C. (1997). Shortening the CES-D to improve its ability to detect cases of depression. Psychological Assessment, 9, 233– 243. Schulberg, H. C., Block, M. R., Madonia, M. J., Scott, C. P., Lave, J. R., Rodriguez, E., & Coulehan, J. L. (1997). The “usual care” of major depression in primary care practice. Archives of Family Medicine, 6, 334 –339. Schulberg, H. C., Block, M. R., Madonia, M. J., Scott, C. P., Rodriguez, E., Imber, S. D., et al. (1996). Treating major depression in primary care practice: Eight-month clinical outcomes. Archives of General Psychiatry, 53, 913–919. Schulberg, H. C., Bryce, C., Chism, K., Mulsant, B. H., Rollman, B., Bruce, M., et al. (2001). Managing late-life depression in primary care practice: A case study of the health specialist’s roles. International Journal of Geriatric Psychiatry, 16, 577–584. Schulberg, H. C., Pilkonis, P. A., & Houck, P. (1998). The severity of major depression and choice of treatment in primary care practice. Journal of Consulting and Clinical Psychology, 66, 932–938. Schulberg, H. C., Raue, P., & Rollman, B. (in press). The effectiveness of psychotherapy in treating depressive disorders in primary care practice: Clinical and cost perspectives. General Hospital Psychiatry. Schulberg, H. C., & Rush, A. J. (1994). Clinical practice guidelines for managing major depression in primary care practice: Implications for psychologists. American Psychologist, 49, 34 – 41. Schulberg, H. C., Saul, M., McClelland, M., Ganguli, M., Christy, W., & Frank, R. (1985). Assessing depression in primary medical and psychiatric practices. Archives of General Psychiatry, 42, 1164 –1170. Schwenk, T. L., Coyne, J. C., & Fechner-Bates, S. (1996). Differences between detected and undetected depressed patients in primary care and depressed psychiatric patients. General Hospital Psychiatry, 18, 407– 415. Scott, A. I., & Freeman, C. P. (1992). Edinburgh primary care depression study: Treatment outcome, patient satisfaction, and cost after 16 weeks. British Medical Journal, 304, 883– 887. Shapiro, S., German, P., Skinner, E., Von Korff, M., Turner, R. W., Klein, L. E., et al. (1987). An experiment to change detection and management of mental morbidity in primary care. Medical Care, 25, 327–339. Shapiro, S., Skinner, E. A., Kessler, L. G., Von Korff, M., German, P. S., Tischler, G. L., et al. (1984). Utilization of health and mental health

services: Three epidemiologic catchment sites. Archives of General Psychiatry, 41, 971–978. Sherbourne, C. D., Jackson, C. A., Meredith, L. S., Camp, P., & Wells, K. B. (1996). Prevalence of comorbid anxiety disorders in primary care outpatients. Archives of Family Medicine, 5, 27–34. Sherbourne, C. D., Miranda, J., Rubenstein, L. V., Unutzer, J., Schoenbaum, M., Duan, N., & Wells, K. B. (1999, July). Intervention effects on one-year health-related quality of life outcomes due to quality improvement interventions with enhanced resources for medication or counseling. Paper presented at 13th International Conference on Mental Health Problems in the General Health Sector, Washington, DC. Simon, G. E., Goldberg, D., Tiemens, B. G., & Ustun, T. B. (1999). Outcomes of recognized and unrecognized depression in an international primary care study. General Hospital Psychiatry, 21, 97–105. Simon, G. E., Katon, W., Rutter, C., Von Korff, M., Lin, E., Robinson, P., et al. (1998). Impact of improved depression treatment in primary care on daily functioning and disability. Psychological Medicine, 28, 693– 701. Sireling, L. I., Paykel, E. S., Freeling, P., Rao, B. M. & Patel, S. P. (1985). Case thresholds and diagnosis. British Journal of Psychiatry, 147, 113– 119. Spitzer, R. L., Endicott, J., & Robins, E. (1978). Research Diagnostic Criteria: Rationale and reliability. Archives of General Psychiatry, 35, 773–782. Spitzer, R. L., & Williams, R. B. J. (1985). Structured Clinical Interview for DSM-III (SCID). New York: Biometrics Research Department, New York State Psychiatric Institute. Sutton, W., & Linn, E. (1976). Where the money was: Memoirs of a bank robber. New York: Viking Press. Teasdale, J. D., Fennell, M. J., Hibbert, G. A., & Amies, P. L. (1984). Cognitive therapy for major depressive disorder in primary care. British Journal of Psychiatry, 144, 400 – 406. Thompson, C., Kinmonth, A. L., Stevens, L., Peveler, R. C., Stevens, A., Ostler, K. J., et al. (2000). Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial. Lancet, 355, 185–191. Thompson, T. L., Mitchell, W. D., & House, R. M. (1989). Geriatric psychiatry patients’ care by primary care physicians. Psychosomatics, 30, 65–72. Tiemens, B. G., Ormel, J., Jenner, J. A., van der Meer, K., Van Os, T. W., van den Brink, R. H., et al. (1999). Training primary-care physicians to recognize, diagnose and manage depression: Does it improve patient outcomes? Psychological Medicine, 29, 833– 845. Tiemens, B. G., Ormel, J., & Simon, G. E. (1996). Occurrence, recognition, and outcome of psychological disorders in primary care. American Journal of Psychiatry, 153, 636 – 644. Uhlenhuth, E. H., Balter, M. B., Ban, T. A., & Yang, K. (1999). International study of expert judgment on therapeutic use of benzodiazepines and other psychotherapeutic medications: VI. Trends in recommendations for the pharmacotherapy of anxiety disorders, 1992–1997. Depression and Anxiety, 9, 107–116. Unu¨ tzer, J., Katon, W., Williams, J. W., Jr., Callahan, C. M., Harpole, L., Hunkeler, E. M., et al. (2001). Improving primary care for depression in late life: The design of a multi-center randomized trial. Medical Care, 39, 785–799. Valenstein, M., Dalack, G., Blow, F., Figueroa, S., Standiford, C., & Douglass, A. (1997). Screening for psychiatric illness with a combined screening and diagnostic instrument. Journal of General Internal Medicine, 12, 679 – 685. Valenstein, M., Vijan, S., Zeber, J. E., Boehm, K., & Buttar, A. (2001). Utility of screening for depression in primary care. Annals of Internal Medicine, 134, 345–360. Von Korff, M., Shapiro, S., Burke, J. D., Teitlebaum, M., Skinner, E. A.,

SPECIAL ISSUE: PRIMARY CARE & German, P. (1987). Anxiety and depression in a primary care clinic: Comparison of diagnostic interview schedule, general health questionnaire, and practitioner assessments. Archives of General Psychiatry, 44, 152–156. Vredenburg, K., Flett, G. L., & Krames, L. (1993). Analog versus clinical depression: A clinical re-appraisal. Psychological Bulletin, 113, 327– 344. Wells, K. B., Sherbourne, C., Schoenbaum, M., Duan, N., Meredith, L., Unu¨ tzer, J., et al. (2000). Impact of disseminating quality improvement programs for depression in managed primary care: A randomized controlled trial. Journal of the American Medical Association, 283, 212– 220. Wells, K. B., Stewart, A., Hays, R. D., Burnam, M. A., Rogers, W., Daniel,

809

M., et al. (1989). The functioning and well-being of depressed patients: Results from the medical outcomes study. Journal of the American Medical Association, 262, 914 –919. Williams, J. W., Jr., Barrett, J., Oxman, T., Frank, E., Katon, W., Sullivan, M., et al. (2000). Treatment of dysthymia and minor depression in primary care: A randomized controlled trial in older adults. Journal of the American Medical Association, 284, 1519 –1526. World Health Organization. (1990). Composite International Diagnostic Interview (CIDI) [Version 1. 0]. Geneva, Switzerland: Author.

Received January 17, 2001 Revision received October 7, 2001 Accepted October 7, 2001 䡲