Integrating depression treatment into primary care for common medical illnesses.

Integrating psychiatric and psychological treatments into the bedrock of medical management for common chronic illnesses can increase access and enhance patient outcomes in general medical settings. As Sir David Goldberg highlighted in the introductory paper for this forum - primary care physicians (PCPs) have been shouldering an increasing burden of care for mental disorders over the last few decades. Yet, additional demands for PCP services are not limited to mental disorders. Primary care physicians are increasingly compelled to provide a higher volume of and more complex services to patients with common medical illnesses such as diabetes, heart disease, and arthritis. Care of patients with depression, the most common mental disorder in primary care, can help illustrate challenges and potentially efficient next steps to better serve patients who seek care in this interface of medicine and psychiatry. Sir David Goldberg and colleagues helped launch the research discipline on common mental disorders in general medical settings over 25 years ago (1). Depression's toll on personal suffering, disability, medical and societal costs has been documented eloquently around the world (2,3). Recent research on older adults with depression in the US describes a population with many medical co-morbidities, significant disability and largely unmet mental health needs (4). Depression is more prevalent in patients with chronic medical diseases. Moreover, comorbid depression is associated with worse medical outcomes (e.g. diabetic complications, mortality following myocardial infarctions) (5). Unfortunately, a quality chasm separates depression care available in usual primary care from treatment guidelines for efficacious management of depression (6). Primary care physicians face competing demands such as comprehensive services for an increasing number of disorders, acute care, follow-up of chronic illnesses, and a mandate to be more productive and economical in their daily practices. It would be a wonder, if optimal depression care were routinely provided in general medical settings. A chronic disease model was developed to guide re-organization of health care services for patients with chronic diseases, and to improve their well-being (7). Recent randomized trials to improve the quality of depression treatment in primary care demonstrated that patients who received interventions organized according to this chronic care model showed superior clinical and functional outcomes compared to their counterparts in usual care (4,8). In a study on late life depression, care manager collaborated with a primary care physician and/or psychiatric consultant to provide antidepressant pharmacotherapy or brief structured problem-solving treatment, patient activation and follow-up of clinical progress and treatment adherence (4). Care management interventions embedded in a chronic care framework have also improved outcomes of patients with diabetes, asthma, heart disease, and even reduced costs in some studies (9). Current trends such as escalating medical needs of aging populations, and skyrocketing costs of hi-tech medicine can only magnify the pressures on PCPs to provide readily accessible, efficient and efficacious medical and psychiatric services in general ambulatory care settings. Care management for depression, though proven efficacious, cannot be delivered in isolation from treatment of comorbid medical illnesses. In the US, competing demands for medical services, and tightening fiscal constraints have forced large numbers of health plans to refer patients with mental disorders out of primary care into 'carveout' behavioral health services. A biopsychosocial approach, embedded into core medical services, may provide a viable way for better serving the psychological and physical health needs of patients.