Successfully treating depression requires an appreciation of the condition's impact on multiple levels of an individual's life. Similarly, improving primary care depression treatment requires an appreciation of the multiple levels at which the health care system needs to be retooled. The articles by Kroenke, Cooper, and Lin in this issue of the Journal of General Internal Medicine highlight thoughtful perspectives on three of these levels.
Improving primary care depression treatment requires increasing the systematic recognition of patients with the condition and monitoring their progress over time. Kroenke et al., in their article, “The PHQ-9: Validity of a Brief Depression Severity Measure” describe a finely tuned 10-item self-administered survey that primary care clinicians can use to accomplish both goals.1 Scored dichotomously, the survey efficiently identifies patients with current probable disorder. Scored continuously, the survey provides a reliable and valid measure of severity, which practices are currently using to monitor patient response to treatment. Given heterogeneous patient populations, it is encouraging that the survey works comparably in traditional primary care and obstetrician/gynecology patients, men and women, young and old. Also encouraging is PHQ-9's high internal consistency (∝ coefficients approaching 0.90), making it one of the few outcomes instruments in any field to convincingly measure severity on an individual (rather than a group) level. While the authors report excellent test-retest reliability of individual items, it would be useful to know whether at-risk patients are more likely to report suicidal ideation on a written instrument than to a primary care clinician they trust before adopting a self-administered survey approach with severely depressed patients. It would also be useful to know whether the instrument works comparably in disadvantaged and nondisadvantaged patient populations.
Improving primary care depression treatment also requires the primary care clinician to introduce the diagnosis and treatment recommendations in a manner compatible with the patient's belief system. The field has known for over a decade that this is a particular challenge for African-American patients, who report significantly lower rates of help-seeking for the disorder. The field's somewhat discouraging progress to date in better understanding the cultural barriers to help-seeking in this population has received an important ‘assist’ from Cooper's article “How Important is Intrinsic Spirituality in Depression Care? A Comparison of White and African-American Primary Care Patients.” In this article, Cooper et al. provide evidence that African Americans hold comparable views regarding depression care in virtually every domain except one. African Americans rate spirituality, particularly active internal efforts to challenge the associated guilt and hopelessness, as a more important aspect of care than do whites.2 The evidence that depressed African Americans often elect not to raise the problem during their primary care visit suggests that they perceive that the spiritual intervention their culture endorses competes with, rather than complements, the pharmacological treatment primary care physicians most often offer. The authors offer creative strategies that primary care physicians can use to communicate to their African-American patients that spiritual and pharmacological interventions are at a minimum complementary and at best, synergistic, with important implications for practicing clinicians as well as researchers.
Finally, efforts to define best practice will make a negligible contribution to improved outcomes if clinicians do not provide best practice to heterogeneous patients in heterogeneously structured primary care settings.Lin et al.'s article “Does Physician Education on Depression Management Improve Treatment in Primary Care?” underscores the challenges associated with that goal in staff model HMOs, the organization many experts feel is potentially most amenable to depression quality enhancement efforts.3 Lin et al. report that while expertly crafted training interventions encourage primary care clinicians to provide better depression care to selected research subjects, the training was not successful in persuading clinicians to provide high quality depression care to all depressed patients they treated. The ‘take home’ message from the body of literature to date in this area demonstrates that in addition to training, health plans need to provide depression care managers and other supportive services shown to improve outcomes to the primary care team, if they intend to manage most depression in the primary care sector. The field needs to decide whether it is possible to define a ‘minimum package’ that should be delivered to depressed primary care patients over time or whether outcomes improve proportionately with the complexity of the intervention. If it is possible to define a ‘minimum package,’ primary care administrators can potentially save considerable resources by choosing NOT to implement less-intensive interventions (e.g., annual screening) likely to have little or no effect on outcomes. If outcomes improve proportionately with intervention complexity, then policymakers will face hard decisions about what level of outcomes they want to ensure when health plans elect to treat many patients for this impairing disorder in the primary care setting.
The complexity of the clinical and organizational problems these papers raise is offset by the potential contribution that successful efforts to improve primary care depression management can make to the individual, to the family, to the work place, and to society at large. —Kathryn Rost, PhD, and Jeff Smith, BS, PhD(c)University of Colorado Health Science Center, Denver, Colo.