Skip to main content

Advertisement

SpringerLink
Log in

The Depression Treatment Cascade in Primary Care: A Public Health Perspective

  • Psychiatry in Primary Care (BN Gaynes, Section Editor)
  • Published:
Current Psychiatry Reports Aims and scope Submit manuscript

Abstract

Major depressive disorder (MDD) is common and costly. Primary care remains a major access point for depression treatment, yet the successful clinical resolution of depression in primary care is uncommon. The clinical response to depression suffers from a “treatment cascade”: the affected individual must access health care, be recognized clinically, initiate treatment, receive adequate treatment, and respond to treatment. Major gaps currently exist in primary care at each step along this treatment continuum. We estimate that 12.5% of primary care patients have had MDD in the past year; of those with MDD, 47% are recognized clinically, 24% receive any treatment, 9% receive adequate treatment, and 6% achieve remission. Simulations suggest that only by targeting multiple steps along the depression treatment continuum (e.g. routine screening combined with collaborative care models to support initiation and maintenance of evidence-based depression treatment) can overall remission rates for primary care patients be substantially improved.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289(23):3095–105.

    Article  PubMed  Google Scholar 

  2. World Health Organization. The global burden of disease: 2004 update. 2004; http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/index.html. Accessed 25 October 2010.

  3. Greenberg PE, Kessler RC, Birnbaum HG, et al. The economic burden of depression in the United States: how did it change between 1990 and 2000? J Clin Psychiatry. 2003;64(12):1465–75.

    Article  PubMed  Google Scholar 

  4. Birnbaum HG, Ben-Hamadi R, Greenberg PE, et al. Determinants of direct cost differences among US employees with major depressive disorders using antidepressants. Pharmacoeconomics. 2009;27(6):507–17.

    Article  PubMed  Google Scholar 

  5. Pincus H, Tanielian T, Marcus S, et al. Prescribing trends in psychotropic medications: primary care, psychiatry, and other medical specialities. JAMA. 1998;279(7):526–31.

    Article  PubMed  CAS  Google Scholar 

  6. Harman JS, Veazie PJ, Lyness JM. Primary care physician office visits for depression by older Americans. J Gen Intern Med. 2006;21(9):926–30.

    Article  PubMed  Google Scholar 

  7. Gaynes BN, Rush AJ, Trivedi M, et al. A direct comparison of presenting characteristics of depressed outpatients from primary vs. specialty care settings: preliminary findings from the STAR*D clinical trial. Gen Hosp Psychiatry. 2005;27(2):87–96.

    Article  PubMed  Google Scholar 

  8. Gaynes BN, Rush AJ, Trivedi MH, et al. Major depression symptoms in primary care and psychiatric care settings: a cross-sectional analysis. Ann Fam Med. 2007;5(2):126–34.

    Article  PubMed  Google Scholar 

  9. World Health Organization. The global burden of disease: 2004 update. 2004; http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/index.html.

  10. Gartlehner G, Hansen RA, Morgan LC, et al. Comparative benefits and harms of second-generation antidepressants for treating major depressive disorder: an updated meta-analysis. Ann Intern Med. 2011;155(11):772–85.

    PubMed  Google Scholar 

  11. • Katon WJ, Lin EH, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2011;363(27):2611–2620. This randomized controlled trial of a collaborative care treatment model for depression and chronic medical conditions demonstrated improvements in clinical indicators of cardiovascular disease and diabetes in the intervention arm relative to usual care.

    Article  Google Scholar 

  12. Trivedi MH, Rush AJ, Gaynes BN, et al. Maximizing the adequacy of medication treatment in controlled trials and clinical practice: STAR*D measurement-based care. Neuropsychopharmacology. 2007;32:2479–89.

    Article  PubMed  CAS  Google Scholar 

  13. Mugavero MJ. Guidelines for improving HIV treatment “adherence”: The big picture. 6th International Conference on HIV Treatment and Prevention Adherence. Miami, FL 2011.

  14. Hasin DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of major depressive disorder: results from the national epidemiologic survey on alcoholism and related conditions. Arch Gen Psychiatry. 2005;62(10):1097–106.

    Article  PubMed  Google Scholar 

  15. Vasiliadis HM, Lesage A, Adair C, et al. Do Canada and the United States differ in prevalence of depression and utilization of services? Psychiatr Serv. 2007;58(1):63–71.

    Article  PubMed  Google Scholar 

  16. • Mitchell AJ, Rao S, Vaze A. International comparison of clinicians' ability to identify depression in primary care: meta-analysis and meta-regression of predictors. Br J Gen Pract. ;61(583):e72-80. This meta-analysis compares the prevalence of depression in primary care practices across countries as well as primary care providers’ ability to identify depression.

    Article  PubMed  Google Scholar 

  17. Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet. 2009;374(9690):609–19.

    Article  PubMed  Google Scholar 

  18. Wang PS, Berglund P, Olfson M, et al. Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):603–13.

    Article  PubMed  Google Scholar 

  19. Wang PS, Lane M, Olfson M, et al. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):629–40.

    Article  PubMed  Google Scholar 

  20. American Psychiatric Association. Practice Guideline for the Treatment of Patients With Major Depressive Disorder. 3rd ed. Washington: American Psychiatric Association Press; 2010.

    Google Scholar 

  21. Agency for Health Care Policy and Research. Depression in Primary Care: Vol 2: Treatment of Major Depression. Rockville: US Dept of Health and Human Services; 1993.

    Google Scholar 

  22. Gaynes BN, Warden D, Trivedi MH, et al. What did STAR*D teach us? Results from a large-scale, practical, clinical trial for patients with depression. Psychiatr Serv. 2009;60(11):1439–45.

    Article  PubMed  Google Scholar 

  23. Rush AJ, Kraemer HC, Sackeim HA, et al. Report by the ACNP Task Force on response and remission in major depressive disorder. Neuropsychopharmacology. 2006;31(9):1841–53.

    Article  PubMed  Google Scholar 

  24. Carlin BP, Louis TA. Bayesian methods for data analysis. 3rd ed. Boca Raton: Chapman and Hall/CRC Press; 2009.

    Google Scholar 

  25. Katon WJ, Von Korff M, Lin EH, et al. The Pathways Study: a randomized trial of collaborative care in patients with diabetes and depression. Arch Gen Psychiatry. 2004;61(10):1042–9.

    Article  PubMed  Google Scholar 

  26. • Pyne JM, Fortney JC, Curran GM, et al. Effectiveness of collaborative care for depression in human immunodeficiency virus clinics. Arch Intern Med. 2011;171(1):23–31. This randomized controlled trial of a collaborative care treatment model for depression and HIV in VA facilities (the HITIDES intervention) demonstrated improvements in depression and HIV-related symptomatology but not HIV medication adherence.

    PubMed  Google Scholar 

  27. Katon WJ, Lin EH, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363(27):2611–20.

    Article  PubMed  CAS  Google Scholar 

  28. • O’Connor EA, Whitlock EP, Beil TL, Gaynes BN. Screening for depression in adult patients in primary care settings: a systematic evidence review. Ann Intern Med. 2009;151(11):793–803. This review argues in favor of routine screening for depression in primary care settings.

    PubMed  Google Scholar 

  29. Screening for depression in adults: U.S. preventive services task force recommendation statement. Ann Intern Med. 2009;151(11):784–792.

    Google Scholar 

  30. • Thombs BD, Coyne JC, Cuijpers P, et al. Rethinking recommendations for screening for depression in primary care. CMAJ. 2009;184(4):413–8.. This review identifies concerns with routine screening for depression in primary care. This review identifies concerns with routine screening for depression in primary care

  31. Rost K, Nutting P, Smith J, et al. Improving depression outcomes in community primary care practice: a randomized trial of the quEST intervention. Quality Enhancement by Strategic Teaming. J Gen Intern Med. 2001;16(3):143–9.

    Article  PubMed  CAS  Google Scholar 

  32. Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA. 2000;283(2):212–20.

    Article  PubMed  CAS  Google Scholar 

  33. Whooley MA, Stone B, Soghikian K. Randomized trial of case-finding for depression in elderly primary care patients. J Gen Intern Med. 2000;15(5):293–300.

    Article  PubMed  CAS  Google Scholar 

  34. Callahan CM, Hendrie HC, Dittus RS, et al. Improving treatment of late life depression in primary care: a randomized clinical trial. J Am Geriatr Soc. 1994;42(8):839–46.

    PubMed  CAS  Google Scholar 

  35. Bergus GR, Hartz AJ, Noyes Jr R, et al. The limited effect of screening for depressive symptoms with the PHQ-9 in rural family practices. J Rural Health Fall. 2005;21(4):303–9.

    Article  Google Scholar 

  36. Jarjoura D, Polen A, Baum E, et al. Effectiveness of screening and treatment for depression in ambulatory indigent patients. J Gen Intern Med. 2004;19(1):78–84.

    Article  PubMed  Google Scholar 

  37. Bosmans J, de Bruijne M, van Hout H, et al. Cost-effectiveness of a disease management program for major depression in elderly primary care patients. J Gen Intern Med. 2006;21(10):1020–6.

    Article  PubMed  Google Scholar 

  38. Rubenstein LZ, Alessi CA, Josephson KR, et al. A randomized trial of a screening, case finding, and referral system for older veterans in primary care. J Am Geriatr Soc. 2007;55(2):166–74.

    Article  PubMed  Google Scholar 

  39. Anderson IM. Selective serotonin reuptake inhibitors versus tricyclic antidepressants: a meta-analysis of efficacy and tolerability. J Affect Disord. 2000;58(1):19–36.

    Article  PubMed  CAS  Google Scholar 

  40. Arroll B, Macgillivray S, Ogston S, et al. Efficacy and tolerability of tricyclic antidepressants and SSRIs compared with placebo for treatment of depression in primary care: a meta-analysis. Ann Fam Med. 2005;3(5):449–56.

    Article  PubMed  Google Scholar 

  41. Beasley Jr CM, Nilsson ME, Koke SC, Gonzales JS. Efficacy, adverse events, and treatment discontinuations in fluoxetine clinical studies of major depression: a meta-analysis of the 20-mg/day dose. J Clin Psychiatry. 2000;61(10):722–8.

    Article  PubMed  CAS  Google Scholar 

  42. Gartlehner G, Hansen RA, Thieda P, et al. Comparative Effectiveness of Second-Generation Antidepressants in the Pharmacologic Treatment of Adult Depression. Rockville (MD)2007.

  43. MacGillivray S, Arroll B, Hatcher S, et al. Efficacy and tolerability of selective serotonin reuptake inhibitors compared with tricyclic antidepressants in depression treated in primary care: systematic review and meta-analysis. BMJ. 2003;326(7397):1014.

    Article  PubMed  CAS  Google Scholar 

  44. Mottram P, Wilson K, Strobl J. Antidepressants for depressed elderly. Cochrane Database Syst Rev. 2006(1):CD003491.

  45. Mulrow CD, Williams Jr JW, Chiquette E, et al. Efficacy of newer medications for treating depression in primary care patients. Am J Med. 2000;108(1):54–64.

    Article  PubMed  CAS  Google Scholar 

  46. Williams Jr JW, Mulrow CD, Chiquette E, et al. A systematic review of newer pharmacotherapies for depression in adults: evidence report summary. Ann Intern Med. 2000;132(9):743–56.

    PubMed  CAS  Google Scholar 

  47. Gilbody S, Bower P, Fletcher J, et al. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006;166(21):2314–21.

    Article  PubMed  Google Scholar 

  48. Mitchell AJ. Clinical utility of screening for clinical depression and bipolar disorder. Curr Opin Psychiatry. 2012;25(1):24–31.

    PubMed  Google Scholar 

  49. Williams Jr JW, Pignone M, Ramirez G, Perez Stellato C. Identifying depression in primary care: a literature synthesis of case-finding instruments. Gen Hosp Psychiatry. 2002;24(4):225–37.

    Article  PubMed  Google Scholar 

  50. Benedetti F, Lanotte M, Lopiano L, Colloca L. When words are painful: unraveling the mechanisms of the nocebo effect. Neuroscience. 2007;147(2):260–71.

    Article  PubMed  CAS  Google Scholar 

  51. Mora MS, Nestoriuc Y, Rief W. Lessons learned from placebo groups in antidepressant trials. Philos Trans R Soc Lond B Biol Sci. 2011;366(572):1879–88.

    Article  PubMed  Google Scholar 

  52. Bing EG, Burnam MA, Longshore D, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry. 2001;58(8):721–8.

    Article  PubMed  CAS  Google Scholar 

  53. Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001;24(6):1069–78.

    Article  PubMed  CAS  Google Scholar 

  54. Hedayati SS, Minhajuddin AT, Toto RD, et al. Prevalence of major depressive episode in CKD. Am J Kidney Dis. 2009;54(3):424–32.

    Article  PubMed  Google Scholar 

  55. Lippi G, Montagnana M, Favaloro EJ, Franchini M. Mental depression and cardiovascular disease: a multifaceted, bidirectional association. Semin Thromb Hemost. 2009;35(3):325–36.

    Article  PubMed  Google Scholar 

  56. Asch SM, Kilbourne AM, Gifford AL, et al. Underdiagnosis of depression in HIV: who are we missing? J Gen Intern Med. 2003;18(6):450–60.

    Article  PubMed  Google Scholar 

  57. Katon WJ, Simon G, Russo J, et al. Quality of depression care in a population-based sample of patients with diabetes and major depression. Med Care. 2004;42(12):1222–9.

    Article  PubMed  Google Scholar 

  58. Hedayati SS, Minhajuddin AT, Afshar M, et al. Association between major depressive episodes in patients with chronic kidney disease and initiation of dialysis, hospitalization, or death. JAMA. 2010;303(19):1946–53.

    Article  PubMed  CAS  Google Scholar 

  59. Mugavero M, Ostermann J, Whetten K, et al. Barriers to antiretroviral adherence: the importance of depression, abuse, and other traumatic events. AIDS Patient Care STDS. 2006;20(6):418–28.

    Article  PubMed  Google Scholar 

  60. Leserman J. Role of depression, stress, and trauma in HIV disease progression. Psychosom Med. 2008;70(5):539–45.

    Article  PubMed  Google Scholar 

  61. De Groot M, Anderson R, Freedland KE, et al. Association of depression and diabetes complications: a meta-analysis. Psychosom Med. 2001;63(4):619–30.

    PubMed  Google Scholar 

  62. Lustman PJ, Anderson RJ, Freedland KE, et al. Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes Care. 2000;23(7):934–42.

    Article  PubMed  CAS  Google Scholar 

  63. Bush DE, Ziegelstein RC, Patel UV, et al. Post-myocardial infarction depression. Evid Rep Technol Assess (Summ). 2005(123):1–8.

  64. Gaynes BN, Rush AJ, Trivedi MH, et al. Primary versus specialty care outcomes for depressed outpatients managed with measurement-based care: results from STAR*D. J Gen Intern Med. 2008;23(5):551–60.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

BWP and BNG’s contribution to this paper was supported by grant R01MH086362 of the National Institute of Mental Health and the National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA. BWP is an investigator with the Implementation Research Institute (IRI), at the George Warren Brown School of Social Work, Washington University in St Louis; through an award from the National Institute of Mental Health (R25 MH080916-01A2) and the Department of Veterans Affairs, Health Services Research & Development Service, Quality Enhancement Research Initiative (QUERI). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIMH or the NIH.

Disclosure

Dr. Pence has received research support from the National Institute of Mental Health (NIMH) and received honoraria and research support from the National Institutes of Health (NIH).

Dr. O’Donnell reported no potential conflicts of interest relevant to this article.

Dr. Gaynes has received research support from the Agency for Healthcare Research and Quality (AHRC), the NIMH, and the NIH; has served as a consultant for Bristol-Myers Squibb; and has received payment for development of educational presentations from MedScape.

Author information

Authors and Affiliations

  1. Department of Community and Family Medicine, Duke Global Health Institute, and Center for Health Policy and Inequalities Research, Duke University, 2812 Erwin Road, Box 90392, Durham, NC, 27705, USA

    Brian W. Pence & Julie K. O’Donnell

  2. Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA

    Julie K. O’Donnell

  3. Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, NC, 27599-7160, USA

    Bradley N. Gaynes

Authors
  1. Brian W. Pence
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Julie K. O’Donnell
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Bradley N. Gaynes
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Brian W. Pence.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Pence, B.W., O’Donnell, J.K. & Gaynes, B.N. The Depression Treatment Cascade in Primary Care: A Public Health Perspective. Curr Psychiatry Rep 14, 328–335 (2012). https://doi.org/10.1007/s11920-012-0274-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11920-012-0274-y

Keywords

Search

Navigation