For Depression, the Family Doctor May Be the First Choice

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To treat severe or complicated depression, turn to a mental health specialist; a psychiatrist or psychologist. Here's why.

For most of his life, John Smythe of Glen Rock, N.J., struggled with a hot temper during day and insomnia at night. He thought of these problems as family traits; his parents had them, too. But two years ago his internist told him that they were signs of clinical depression.

Dr. John Greden says, "Just as you wouldn't want a primary-care physician to do coronary bypass surgery, you wouldn't want one to treat severe or complicated depression."

"A chill went down my spine," recalled Mr. Smythe, 60, who runs a small business. "Depression to me was somebody walking around moping, sort of withdrawn. It never occurred to me that there could be other symptoms."

His internist, Dr. Rick Cohen of nearby Midland Park, prescribed an antidepressant. It did not take Mr. Smythe long to start feeling better. "I could stay rational without getting annoyed and slamming the phone down," he said. "It turned me around."

Mr. Smythe is in a lucky minority. Only about 40 percent of people in treatment for depression get adequate care, according to a survey of more than 9,000 Americans that was sponsored by the National Institute of Mental Health and released last week.

The study defined "adequate treatment for depression" as a course of at least 30 days on an antidepressant or a mood stabilizer, along with four visits to a doctor or at least eight 30-minute psychotherapy sessions with a mental health professional.

Dr. Ronald Kessler, a professor of health care policy at Harvard who was the lead author of the study, says a crucial problem is that general medical doctors tend to be the first line of defense against mental disorders as well as physical ones. Because they are not as well informed about depression as mental health specialists, he said, they are more likely to undertreat it — prescribing either too little medication or an inappropriate one, like an anti-anxiety drug.

These general practitioners, typically family doctors and internists, treat 70 percent of the people who seek help for depression, according to other research. And more of them are treating depression now than a decade ago, Dr. Kessler said, because the newer antidepressants - selective serotonin reuptake inhibitors - are safer and easier to prescribe than older drugs.

"The companies that make these drugs are providing more educational material to general medical doctors," he said.

Psychiatrists say the new findings should not be interpreted to mean that primary-care physicians are unqualified to treat depression.

"The notion that everybody with depression should be treated by a mental health professional is ridiculous," said Dr. John Greden, a psychiatrist who is director of the Depression Center at the University of Michigan.

Dr. Greden said many general practitioners could effectively treat people with mild to moderate depression. But he added that mental health professionals agreed that severe or intractable depression should be referred to a psychiatrist or a psychologist.

"Just as you wouldn't want a primary-care physician to do coronary bypass surgery, you wouldn't want one to treat severe or complicated depression," said Dr. Greden, who works with primary-care doctors in Michigan on ways to improve the diagnosis and treatment of depression.

But there are many obstacles to receiving adequate care from a general practitioner, even for mild or moderate depression, experts say. For one thing, Dr. Greden says, primary-care physicians do not receive enough training on how to recognize the condition.

"Most patients don't come in and say, `I feel sad or depressed,' " he said. "They emphasize complaints like fatigue or insomnia or other physical manifestations of depression."

So their doctors tend to treat the physical symptoms, Dr. Greden added, by prescribing sleeping pills for insomnia, for example, instead of looking for the underlying causes.

Another obstacle is that many general practitioners are uncomfortable talking about depression, said Dr. David Kupfer, chairman of psychiatry at the University of Pittsburgh Medical Center, who has studied trends in treating depression.

"If a patient talks about his sleep problems, the doctor won't ask about other possible depression symptoms," he said.

Yet another obstacle is time. Doctors in managed-care plans have a financial incentive to see as many patients as possible each day. Dr. Cohen, the internist, said the time pressure discouraged many of his colleagues from asking the necessary questions to find out whether patients are depressed.

"One colleague said to me, `I see so many patients a day, I don't want to open up a can of worms,' " he said.

When they do diagnose depression, primary-care doctors often fail to provide enough information on drugs' side effects, patients say. Yet unpleasant side effects from antidepressants llike anxiousness, weight gain and loss of sexual desire are among the main reasons that patients stop taking antidepressants.

"I've rarely heard any patient say, `My family doctor explained it all to me,' " said Howard Smith, director of operations for the Mood Disorders Support Group, an organization in New York City that operates support groups for people with depression and bipolar disorder.

Mr. Smith says the side effects can start within a day of two of beginning an antidepressant, but the benefits often take a few weeks to show up. "So patients call their doctors and complain that they feel sicker, and the doctors tell them to stop the medication or they prescribe something else," he said.

If doctors took the time to explain to their patients that the side effects were often temporary, he said, many more would continue treatment and have their depression effectively managed.

Dr. Cohen said most primary-care doctors did not know about the nuances of the many antidepressants — which ones are best for particular symptoms and what to do if the lowest dose does not work.

"Internists are grilled on how to use multiple medications for diabetes or hypertension and how to switch medications if the first one doesn't work," he said. "But there's not as much education geared to internists on dosing and switching antidepressants."

Further, research has shown that depression medication and psychotherapy together are more effective for treating depression than either approach alone.

If general practitioners lack the time and expertise to treat depression properly — and if they are not compensated enough for it under managed care — why do they provide most of the treatment for depression?

"Many of my patients want me to treat them because they trust me as their family doctor," said Dr. Jim Martin, a family physician in San Antonio. "Some of my patients don't want to see a specialist because of the stigma of depression."

But growing numbers of patients no longer have the choice, he added, because some managed-care plans have begun reducing or even eliminating coverage for general practitioners for treating depression.

Psychiatrists say it is unrealistic to think that mental health professionals can do the job themselves because there are not enough of them to treat the estimated 35 million Americans with depression, only about half of whom receive treatment now.

"Without primary-care physicians, we won't make a dent in treating more people with depression," Dr. Greden said.

His research shows that primary-care physicians improve their ability to diagnose and treat depression when they forge relationships with psychiatrists and psychologists, consulting with them about particular patients. Under this model, primary-care doctors do the medical treatment, but check with the specialists about drug choice and dosing and refer patients to them for talk therapy.

"If general practitioners don't have the wiggle room from managed care to spend more time with patients who are suffering from depression," Dr. Kupfer said, "society will pay a large price in suicides and in high levels of impairment."

Source: NY Times

You can find comprehensive information about depression and treatment for depression in the HealthyPlace.com Depression Center.

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