The management of anxious depression in primary care

Patients with combinations of anxiety and depressive symptoms form the largest group in both community and primary care, yet many remain undetected by primary care physicians and relatively few are referred to mental health professionals. This review deals with 4 issues: (1) the natural history of undetected depression, showing that, although patients have a generally good outcome, there is considerable residual disability; (2) the best management for recognized cases, with evidence that patients with more severe depression benefit from antidepressant therapy and should be followed up more systematically; (3) the indications for specialist referral-suggesting that these are dependent on the skills available in the primary care team and the ease of access to mental health professionals; (4) possible roles for psychiatrists in the management of anxious depression in primary care, concluding that in the United Kingdom link workers could act as coordinators between the psychiatrist and the primary care team, thus improving the care of severely ill patients and improving access for those thought to need specialized care.