The burden of depression in primary care.
Authors: Linda Gask
Journal: World Psychiatry (2003)

Primary care is where the majority of people with mental health problems are treated. It is also the key point in the pathway to mental health care in which interventions for the detection and management of depression have been focused. The last few decades have witnessed the increasing awareness that depression is not only a common and treatable illness, but also a potentially disabling, chronic and sometimes even fatal condition (considering the mortality associated with both suicide and comorbid depression and physical illness such as coronary heart disease). Most people with depression, as David Goldberg indicates, are no longer only treated by psychiatrists, and fewer even become inpatients, but this has not so much to do with the trend towards deinstitutionalisation, but rather with the availability of effective medication than can be prescribed with confidence by a trained primary care physician.

Today, in developed countries, the majority of people with depression can be treated early and effectively in primary care, with drugs they can tolerate, in effective doses, by clinicians who feel confident that they understand what the effects and side effects of the treatment will be. Having antidepressants that can be taken on a long-term basis with minimal side effects has been a big step forward for people who suffer from depression. However, the newer drugs are much more expensive, and as yet are not widely available in the developing world for those who cannot pay for them. Furthermore, primary care physicians have still not come to understand that people with depression require proactive and perhaps even 'assertive' follow-up. People who are depressed may think that they do not deserve to take up the doctor's time or that it is not possible for doctors to listen to them or understand how they feel. The nature of the illness, and its impact on mental state, contributes further to ensuring that they do not obtain the treatment that they require. We may have spent many years trying to convince both the general public and primary care physicians that depression is an illness like any other, and even a 'physical' illness given that there is evidence of physical change in the brain. Yet, paradoxically these efforts to destigmatise depression also detract from a simple acknowledgment that depression affects not just the way we feel about ourselves and the world but also our need for help and treatment (1). People who are depressed don't always come back for more treatment and doctors don't necessarily tell them to.

Cynics might say that the discovery of depression in the latter part of the twentieth century had more to do with marketing of drugs by pharmaceutical companies than with public health, and I have some sympathy with this view. But there is no doubt, for those of us who see and treat people with depression every day, that these drugs are effective. And there is no doubt that depression is and will increasingly grow as a major contributor to the burden of disability in the world. Getting this message over to psychiatrists, particularly those in the UK, who, supported by government policy, confine their interest to people with 'severe and enduring' mental illness, is not always easy. I believe that the psychiatrist has a responsibility to take a public health perspective: to consider how his or her range of skills can most appropriately be utilised. This requires what Greg Simon (2) has described as taking a population view: stepping back and considering what his or her role must be to improve the quality of care provided in the system for all sufferers, as well as ensuring that those who are most severely ill, including many people with depression, get the care they need.

Mental health professional working in the level above primary care can provide support and supervision for those working in primary care to help ensure that not only do primary care workers feel supported, but also that they have back-up for when they feel out of their depth. In my experience as a trainer, it is essential to ensure that primary care staff understand pathways to more intensive care and support. Without this they may not feel confident to continue to use the new skills they have acquired. As doctors learn to explore patients' feelings, they uncover problems for which they feel unprepared. Training for primary care must go hand in hand with development of relationships between generalists and specialists. As psychiatrists, I believe we have a responsibility to take a leadership role in this task if we are serious about trying to help alleviate the increasing burden of depression.