Competing Demands: Does Care for Depression Fit in Primary Care?

Major depression ranks fourth among diseases in its global impact on disability-adjusted life years, and it is projected to move up to second place by the year 2020.1 Much of the care for depression, perhaps the majority, is provided in the general medical sector rather than the mental health sector. Unfortunately, the care in either setting is too often suboptimal. In this issue, Katz et al. add to our understanding of the problems with care by comparing the rates of mental health care and the appropriateness of care between the United States and Canada.2 One of the most important differences between these systems is access to health care. In the United States, many individuals lack health insurance, and even those with coverage usually have greater constraints on mental health coverage than on coverage for physical problems. Canadians have universal health coverage that includes generous mental health benefits. The key findings of Katz et al.'s study were as follows: (1) although “appropriate management” for major depression was low in both countries, individuals living in the United States were 40% as likely to receive appropriate management as Canadians; (2) the lower rates of appropriate care in the United States were predominantly due to fewer visits in the general medical sector; (3) almost 40% of depressed persons did not perceive a need for services; and (4) more Americans perceived care as too expensive or were uncertain where to go for care. These findings add to the substantial literature documenting that care for major depression is not ideal. In theory, depression can be treated effectively. In practice, it often is not. Further, the results suggest that economic barriers are an important reason for low rates of appropriate care. In the United States, the Mental Health Parity Act requires employers to increase dollar limits for mental health coverage to those for medical care and thus may lower the economic barriers. However, the major difference between countries in the Katz et al. study was fewer primary care visits for mental health care in the United States. To improve mental health care in the United States, primary care coverage must be expanded. Greater insurance benefits are necessary but not sufficient. We must learn how to improve care for those who have access and seek care. Among those seeking care, only about one quarter in either country received appropriate care. Recognizing that primary care physicians provide the majority of mental health care, thoughtful groups have sponsored educational programs, such as the Depression Awareness Recognition and Treatment program and clinical guidelines targeted at improving primary care physicians' knowledge. Their exact impact is uncertain, but less than half of primary care physicians have seen the guidelines, and care remains suboptimal.3 The persistent deficits in care for depression have left some to wonder if primary care physicians should or can include treatment for depression as part of routine practice. After all, how many guidelines and how many issues can be squeezed into the average 13-minute patient visit?