Depression and its Management in Primary Care

Murray and Lopez1 estimated that, in 1990, unipolar major depression accounted for 13% of all years lived with disability, making it the leading cause of disability in developed regions of the world. They also estimated that, in the established market economies, only 35% of people with unipolar major depression were actually treated, even though treatment can reduce the disability by 50%.2 Primary care services have an essential role if the best public health outcome is to be achieved (that is, the best possible reduction in morbidity as a result of improved awareness, detection, diagnosis, and treatment) because this goal far exceeds what is feasible for existing secondary and specialist level services. Thus the questions raised in this In Review section by Busker et al3 and Kates and Mach4-how to define the responsibilities of primary care and construct the best interface between primary care and specialist services, what primary care should be able to manage, and what are the best methods for managing depression-are critical to improving both the system of care and patient outcomes. Primary health care is under considerable stress in Canada, as in other countries,5 owing to the overall low numbers of physicians and to particular problems regarding recruitment into primary care. Overall, Canada has 2.1 doctors per 1000 population. The figure is 3.5 per 1000 in the Euro area, 2.7 per 1000 in the United States, and 2.0 per 1000 in the United Kingdom. Clearly, Canada's ratio of physicians to population is considerably lower than the ratio in most Western European countries and in the United States, although higher than that in the United Kingdom.6 A further concern is that the level of expertise and the complexity of the work required in primary care has reached the stage where it may be beyond what can reasonably be expected from most individuals. This shortfall may be partly attributed to the short-sighted physician recruitment policies adopted in Canada a decade ago, which led to cutbacks in medical school enrolment; it may also be attributed to payment systems that financially disadvantage those who choose to work and provide services in teams of health care providers. Across the country, the problem is now being in addressed by various schemes to encourage and support primary care reform. About 30% of the population have symptoms of a mental disorder over a 1 -year period, and over 80% of the population see a family physician. A mental disorder is detected in about 14% of the population each year; about 3.4% will see a psychiatrist, 3% a psychologist, and fewer than 0.5% will be admitted to hospital. Less than one-half of those who have symptoms of a mental disorder within a given year actually get treatment.7 Bilsker et al3 show that the physician-treated prevalence of depression in British Columbia increased from 7.7% in 1991-1992 to 9.5% in 2000-2001. Consistently, however, more than 95% were seen by family physicians, and in the last year, only 7.5% were seen by psychiatrists. (Busker and colleagues are to be congratulated on accessing the British Columbia billing database, which that province has sensibly made available to researchers. …

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