Illustrating Local Community Initiative in Mental Health Reform: The Management and Treatment of Depression by Primary Care Physicians

Abstract

RIMARY CARE PHYSICIANS care for patients with mental health problems on a daily basis. Patients with psychiatric disorders (depression, anxiety, mixed disorders) are common in primary care settings with a prevalence of about 25 percent. 1 The prevalence of major depressive disorders for lifetime was recently reported at 16.2 percent and for 12-months was 6.6 percent. 2 Depression results in significant difficulty with home and job performances in the majority of patients. Multiple studies continue to demonstrate that primary care providers in outpatient settings underrecognize and undertreat patients with depression. 4 3 2 During my residency in the late 1970s, little emphasis was placed on mental health training for primary care physicians. It was expected that patients with these disorders would be cared for by the mental health profession, either by private psychiatrists, psychologists, clinical social workers, or the public mental health sector. This distinct separation generally continued into the 1980s, but in the 1990s patients increasingly had difficulty accessing mental health providers due to a reduction in behavioral mental health benefits and increased disarray of the public mental health system. 5 Thus, these patients complained about their poor mental health to primary care providers and requested care directed by/provided by their primary care physicians. What a challenge for primary care providers! In 1995 the local health coalition in Buncombe County, NC (population 200,000) known as HealthPartners, conducted a comprehensive community assessment that identified the county’s health care assets and needs. Only 29 percent of Buncombe County adults, who in the past year said that they had a major depressive episode, had ever accessed or tried to access mental health treatment. Low-income uninsured people were more likely to be depressed (40 percent) as compared to higher income, insured people (18 percent). 6 Based on this information and increasing concerns from physicians and patients, HealthPartners identified funds to design and implement a primary care-based depression program located at the Buncombe County Health Center, part of the county health department caring for 70 percent of our low-income uninsured. The program’s design was based on data supporting the benefit of screening and feedback to providers; integrated treatment guidelines; care managers who work with physicians to monitor care; and a supervising psychiatrist. 7 8 4