May 6, 2004 — Primary care depression treatment fails half the time, a new study shows.

If you’re suffering from depression in the U.S., chances are the only treatment you’ll get is from your primary care doctor. Half the time, that’s not enough, report Cathy Sherbourne, PhD, and colleagues at RAND Corp.

The data come from a study in which the researchers tested ways to improve primary care doctors’ depression treatment. By teaching them better use of psychiatric medication — and by lowering the cost of referral to psychotherapy — they did improve. But overall, primary care wasn’t enough for many people suffering from depression.

“In a diverse sample of depressed patients in managed primary care practices who received two courses of at least minimally appropriate treatment for their depression, almost half remain depressed,” Sherbourne and colleagues report. Their findings appear in the March/April issue of General Hospital Psychiatry.

Appropriate Depression Treatment Rare

Sherbourne’s team looked at the records of 1,248 depressed patients. Of these, only 542 people got what the researchers considered “minimally appropriate care.” They defined this as four or more specialty counseling visits in a six-month period, and/or at least two months of properly dosed antidepressants.

Those who got this minimal care usually got a lot more. They averaged not just four, but 12.5 therapy visits in six months. Those who didn’t get minimal care usually got a lot less. They averaged 0.4 therapy visits in six months.

But this minimal care wasn’t enough. Nearly half the patients who got such care — for at least two of three six-month periods — were still depressed 18 months later.

Those who didn’t respond to depression treatment tended to be those who were most depressed and most suicidal. They also tended to have more psychiatric symptoms — especially anxiety. And they were more likely to stop taking their medication before their doctors told them to.

It’s important to note the current guidelines call for continuing depression treatment for at least four to nine months after depression symptoms resolve. This is done to help prevent a relapse.

Unemployment Linked to Depression

Those who didn’t respond to depression treatment also tended to have another thing in common: They were out of work.

It’s likely that being depressed makes it hard to hold down a job. But it might work the other way, too. Having a job may help keep depression at bay.

“Work itself may be ‘therapeutic,'” Sherbourne and colleagues note. “One might evaluate whether employment rehabilitation coupled with more traditional medical therapies will increase the rate of recovery in such patients.”

Needed: Change in Depression Treatment System

Most people with depression have few options other than to see their primary care doctor. So what can be done?

There’s strong evidence that people suffering “treatment-resistant” depression need both medication and psychotherapy.

Sherbourne and colleagues conclude that it will take “either marked changes in the delivery infrastructure to make both treatments available, or grater integration of primary care with mental health specialty practices to facilitate combined treatments.”