Diagnosing and Treating Depression in the Primary Care Setting:
It Can Be a Depressing Experience for the Primary Care Physician
Epidemiological and clinical research over the past two decades
has shown depression to be a common and highly debilitating
condition. Depression can exact high costs in terms of work
productivity, the success of personal relationships and general
satisfaction with life.
For the family physician in a primary care setting, however,
the depressed patient poses enormous challenges of diagnosis
and treatment. A growing body of research, to which Michael
Klinkman, associate professor of family medicine, Thomas Schwenk,
professor of family medicine and chair of the Department of
Family Medicine, and James Coyne, formerly a member of the family
medicine faculty at Michigan and now at the University of Pennsylvania,
have contributed significantly, suggests a developing awareness
of the shortcomings of the “top-down,” diagnosisdriven
approach to mental health care in the complex world of primary
care, but the absence, as yet, of a clearly articulated “bottom-up”
approach that will provide a more accurate view of mental health
problems as they exist in primary care. Classic psychiatric
instruments for screening depressed patients don’t seem
to work very well in the primary care setting, but the question
of what will work is still unanswered.
In several recent articles, Schwenk, Klinkman and Coyne discuss
the results of a study they undertook involving 425 adult patients
in the family practice setting. The study suggests that there
are significant differences in the past history, severity and
impairment of depressed patients in the primary care setting
and those in a psychiatric setting, that primary care physicians
are nevertheless pretty good at identifying patients who are
overtly psychologically distressed, but that they miss significant
numbers of depressed patients who are different from the overtly
depressed patients in psychiatric settings who provided the
basis of their medical training.
Depression, they say, is an important diagnosis but often an
elusive one, and for the primary care physician, diagnosis and
treatment of the depressed patient can be downright daunting.
Depression in different patients doesn’t always look the
same or act the same: some patients get depressed only when
they’re under stress, others are depressed much of the
time. In some ways, Klinkman and his colleagues have found,
depression in the primary care setting can look and feel a lot
like asthma and diabetes in the sense that they are all chronic
conditions requiring not only good diagnosis and treatment,
but patient energy and attention as well. “You can tell
asthma patients, ‘You’re breathing at only half your
capacity,’ and suggest they use their inhalers, but some
of them will elect not to use the inhalers even if their breathing
is greatly reduced. It just isn’t their highest priority,”
Klinkman says.
And there are other reasons depressed patients may not respond.
Not all patients view depression as a legitimate medical problem;
they may think mood disorders are inappropriate for a doctor’s
attention. Some physicians may be less or more likely to identify
depression in a patient depending on the patient’s gender,
age and ethnic derivation. Many physicians feel they just don’t
have time to explore psychosocial issues, no matter what the
patient’s level of depression or gender, age or ethnic
background. Even when the primary care physician does correctly
identify the depressed patient, the diagnosis may not necessarily
lead to an improved outcome for the patient, since depression
is not easily treated.
The complexity of their findings has led Klinkman and his colleagues
to come to at least three major conclusions:
- A “snapshot” diagnosis doesn’t work with
the depressed patient in the primary care setting; one has
to take into account the passage of time, how the patient
performs over weeks and months and years, not for a few minutes
in a clinical setting.
- Blaming the physician because the depressed patient doesn’t
improve is missing the big picture; much is still not known
about how best to approach depression in the primary care
setting and the attitudes and value systems of patients must
also be taken into account.
- How and when the primary care physician should intervene
is a matter of priorities, of communication and decision-making.
Having the physician engage in a onetime, stand-alone consultation
with a psychiatrist as well as having the patient engage in
brief, diagnostic consultations with a psychiatrist may be
beneficial. (Such consultations, Klinkman suggests, can be
as important for the relief they provide the physician in
sharing the caregiving burden as for the information they
provide.)
“We think we know what doesn’t work very well,”
Klinkman says. “Our next challenge is to find out what
does work.”
For more information, see the following articles:
- “Depression in Primary Care...More Like Asthma than
Appendicitis: The Michigan Depression Project, Canadian Journal
of Psychiatry, November, 1997
- “Depression in the Family Physician’s Office:
What the Psychiatrist Needs to Know,” Journal of Clinical
Psychiatry supplement, September, 1998
- “False Positives, False Negatives, and the Validity
of the Diagnosis of Major Depression in Primary Care,”
Archives of Family Medicine, September/October 1998
You may reach Michael Klinkman at mklinkma@umich.edu
You may reach Thomas Schwenk at tschwenk@umich.edu
 
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