When treatment comes up short

Most people who seek treatment for depression turn to their primary care physicians -- and with good reason. They may find it easier to discuss such problems with a familiar doctor, and insurance is likely to pay for the visit. Often, however, the treatment doesn’t work, sometimes simply because of a lack of follow-up.

Researchers have found that even when people are treated for their depression by their primary care doctors, only 23% get better.

The study, published last week in the Archives of Internal Medicine, adds to a growing body of evidence that suggests many depressed people are not receiving the care they need.

The latest research involved 77 physicians and 573 patients. Although most patients were given what the study called “adequate care,” a recommendation to take antidepressant medication, three out of four still reported symptoms of depression six months later.

“A lot of these patients are getting what would qualify as quality care,” said principal investigator Ralph Swindle, a research psychologist at Eli Lilly & Co, maker of the popular antidepressant Prozac. “Not only did it not do the job, but we had 46% of patients who didn’t get well at all.”

The doctors in the study all prescribed an initial dose of the antidepressants Prozac, Zoloft or Paxil, but the study required no other specific steps for the next six months.

Although antidepressants fail to help many people with depression, most patients took doses that often proved to have some effect. The results suggest that the doctors failed to appropriately monitor their patients, Swindle said.

“It’s absolutely critical to follow up,” he said. “You need to know if a patient is not getting better in six weeks to three months.” If treatment is not making a difference after two months, it needs to be changed, he said.

Although depression has been identified by the World Health Organization as one of the leading causes of disability in the U.S. and worldwide, previous research has shown that appropriate diagnosis and quality care are lagging in the primary care setting. A lack of resources and time, reluctance on the part of primary care doctors to screen for depression and unfamiliarity with how to administer drugs for depression are some of the reasons, researchers say.

Diagnosis, alone, can be a difficult hurdle.

“Many people don’t know they have depression. They just know that they don’t feel well ... but much of depression presents through physical symptoms,” said Dr. Kenneth Wells, director of the Health Services Research Center at UCLA. Studies have suggested that doctors are aware of patients’ depression only half of the time.

Because many primary care doctors can spend only a limited time with their patients, those who have a specific problem -- back pain or severe headaches, for example -- are not likely to have depression diagnosed.

To make identifying depression easier for primary care doctors -- and for patients -- many mental health advocacy groups and mental health specialists have pushed for doctors to adopt short depression screenings. Designed to take only a few minutes, the screenings would be administered during a patient’s routine checkup.

“A depressed patient has aches and fatigue and doesn’t know they’re depressed,” said Dr. Lisa Rubenstein, an internist and professor at the L.A. Veterans Affairs hospital and UCLA. “It’s a funny thing. People don’t recognize it. But if you ask them, they can tell you.”

Still, once patients are screened, their doctors must determine what kind of depression they have and how to treat them. Patients then need the kind of follow-up that the recent study suggested was not happening.

“I don’t think most people realize the kind of active planning and awareness a primary care clinician has to put into a visit in order to get everything done,” Rubenstein said.

Studies have demonstrated that the optimum treatment would involve a nurse, a staff member or a counselor who could do the initial screening, a longer and more thorough assessment, patient education and frequent follow-up calls, she said. Unfortunately, she said, such care is expensive.

Wells said that health plans have varied, and often limited, options for mental health care. “Not all health plans cover mental health equally with physical health,” he said. “In primary care, the easier thing to do, if you will, is give medication.”

But handing out a prescription for depression is different from handing out a prescription for ulcers.

Better follow-up care for depression has the potential to improve overall health and productivity, Wells said.

“This is not a new point,” he said. “But we keep seeming to rediscover it because the problem has not improved at the ground level.”