Depression in primary care: current and future challenges

To describe the current state of knowledge about detection and treatment of major depressive disorder (MDD) by family physicians (FPs), and to identify gaps in practice and current and future challenges.

We reviewed the recent literature on MDD (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, or International Classification of Diseases, Revision 10) in primary care, with an emphasis on systematic reviews and meta-analyses addressing prevalence, the impact of an aging population and of chronic disease on MDD rates in primary care, detection and treatment rates by FPs, adequacy of treatment, and interventions that could improve recognition and treatment.

About 10% of primary care patients are likely to meet criteria for MDD. The number of cases will increase as the baby boomer cohort ages and as the prevalence of chronic disease increases. The bidirectional relation between MDD and chronic disease is now firmly established. Detection and treatment rates in primary care remain low. Treatment quality is frequently inadequate in terms of follow-up and monitoring. Formal case management and collaborative care interventions are likely to provide some benefits.

Low detection rates and low treatment rates need to be addressed. Planned reassessment may improve detection rates when the FP is uncertain whether MDD is present, but further research is needed to determine why FPs frequently do not initiate treatment, even when MDD is detected. A caring, attentive FP who monitors depressed patients is likely to have considerable placebo effect. Greater focus on integrated, concurrent treatment for MDD and chronic physical diseases in the middle-aged and elderly is also required.