Harvard Mental Health Letter

Improving care for depression

New approaches to managing a chronic illness

Patients with depression are much more likely to receive effective treatment today than in the 1990s, but the results often fall short of what most patients want and deserve — full relief. The length of depressive episodes and the risk of recurrence have changed too little. Most people who seek help for depression rely exclusively on primary care medicine — family doctors, who are generalists. They are usually the gatekeepers even for patients who eventually use specialized mental health services for psychotherapy or antidepressant prescriptions. So non-psychiatric physicians, mental health professionals, insurers, and HMOs have been looking for ways to improve the detection, diagnosis, and treatment of depression in primary care.

Surveys suggest that there is plenty of room for improvement. A third to a half of depressed patients who see a primary care physician are not accurately diagnosed, and even when depression is identified, it is often inadequately treated. Patients do not get a sufficient dose of antidepressants for a sufficient time, do not return for follow-up visits often enough, and usually receive no psychotherapy at all.

Physicians often lack the time, training, and experience needed to persuade patients to keep appointments and continue taking antidepressant drugs. Nearly 50% of depressed patients in primary care stop taking their medication within three months, and 60%–70% stop within six months, the usual recommended minimum time. They quit because of side effects, or because they feel a little better and think they no longer need the drug. And since they are not seeing a doctor regularly, there is no one with whom to discuss their options for controlling the side effects or choosing alternative treatments. In one review of employer data, only 20% of depressed patients had as many as three contacts with a clinician in the first three months after the diagnosis. A survey found that only about 20% of people who report depression have had any counseling or psychotherapy in the past year. Blacks, Hispanics, and the poor — who on average have less access to health care than whites and the well-heeled — are especially likely to miss out on treatment or quit at an early stage.

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