Diagnosis of late life depression: the view from primary care

In the typical primary care practice, in which patients with a wide range of diseases and symptoms present with numerous needs, concerns, and requests, a chronic disease that lacks quantitative, biologically based diagnostic testing, such as depression, can present a daunting diagnostic challenge to even the best and most dedicated primary care physician. Depression does not compete well for patient and physician time and energy with other medical problems and medical co-morbidity in patients who seek care from their primary care physician. Primary care patients may be more comfortable with and accepting of depression being framed as a "normal" chronic disease rather than a psychiatric "brain" disease subject to cultural and generational stigmas, nihilism, and prejudice. Insurance parity in mental health care would make depression and other mental illness more legitimate in the eyes of patients, family members, employers, and physicians. Of particular value would be new and creative approaches to collaborative care, including telephone monitoring, nurse clinician outreach, and improved availability of psychiatric consultation in primary care, because elderly depressed patients often see the care of their depression as part of the integrated care of multiple chronic medical diseases, rather than a separate psychiatric problem to be referred for specialty care.