CanJPsychiatry 2013;58(8):442448

In Review

Depression in Primary Care: Current and Future Challenges

Marilyn A Craven, MD, PhD, CCFP1; Roger Bland, MB, FRCPsych, FRCPC2
1

Associate Clinical Professor, Department of Psychiatry and Behavioural Neurociences, McMaster University, Hamilton, Ontario.
Correspondence: Department of Psychiatry and Behavioural Neurosciences, McMaster University, 50 Charlton Avenue East, Hamilton, ON L8N 4A6;
cravenm@mcmaster.ca.

Professor Emeritus, Department of Psychiatry, Walter Mackenzie Centre, University of Alberta, Edmonton, Alberta.

Key Words: major depressive

disorder, primary health
care, epidemiology, chronic
disease, recognition,
treatment, treatment adequacy,
collaborative care, disease
management
Received August 2012, revised,
and accepted January 2013.

Objectives: 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.
Methods: 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.
Results: 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.
Conclusions: 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.
WWW

La dpression dans les soins de premire ligne : enjeux actuels et

futurs
Objectifs : Dcrire ltat actuel des connaissances sur la dtection et le traitement du trouble
dpressif majeur (TDM) par les mdecins de famille (MF), et identifier les carts dans la
pratique et les enjeux actuels et futurs.
Mthodes : Nous avons revu la littrature rcente sur le TDM (Manuel diagnostique et
statistique des troubles mentaux, 4e dition, ou Classification internationale des maladies,
10e rvision) dans les soins de premire ligne, en mettant laccent sur les revues
systmatiques et les mta-analyses traitant de la prvalence, de leffet dune population
vieillissante et de la maladie chronique sur les taux de TDM dans les soins de premire ligne,
des taux de dtection et de traitement par les MF, du caractre adquat du traitement, et des
interventions aptes amliorer la reconnaissance et le traitement.
Rsultats : Environ 10 % des patients en soins de premire ligne sont susceptibles de
satisfaire aux critres du TDM. Le nombre de cas augmentera mesure que vieillira
la cohorte de la gnration du baby-boom et que crotra la prvalence des maladies
chroniques. La relation bidirectionnelle entre le TDM et la maladie chronique est dornavant
fermement tablie. Les taux de dtection et de traitement dans les soins de premire ligne
demeurent faibles. La qualit des traitements est souvent inadquate en ce qui a trait au
suivi et la surveillance. La prise en charge officielle de cas et les interventions de soins en
collaboration sont susceptibles doffrir certains avantages.
Conclusions : Il faut remdier aux faibles taux de dtection et de traitement. Une
rvaluation planifie peut amliorer les taux de dtection lorsque le MF nest pas certain
de la prsence dun TDM, mais il faut plus de recherche pour dterminer pourquoi souvent,
les MF ne commencent pas de traitement, mme si le TDM est dtect. Un MF bienveillant
442 W La Revue canadienne de psychiatrie, vol 58, no 8, aot 2013

www.LaRCP.ca

Depression in Primary Care: Current and Future Challenges

et attentif qui surveille des patients dprims est susceptible davoir un effet placebo
considrable. Il faut galement insister davantage sur le traitement intgr, concurrent
du TDM et des maladies physiques chroniques chez les personnes dge moyen ou
avanc.

ajor depressive disorder is a highly prevalent disorder

and a serious public health problem. The WHO reports
that unipolar depressive disorder has now surpassed traffic
accidents, cerebrovascular disease, and ischemic heart
disease in disability-adjusted life years in both middle- and
high-income countries.1

Methodologically rigorous studies of the 12-month

prevalence of MDD in large, general adult populations have
been conducted in recent years.28 These find prevalence
rates of MDD ranging from 4.1% to 8.1%. Canadian rates
based on the Canadian Community Health Survey: Mental
Health and Well-Being,9 the National Population Health
Survey,8 and the so-called Edmonton Survey4 have ranged
between 4.5% and 4.8%. Translated into absolute numbers,
during the course of a single year, 1 360 000 Canadians will
meet DSM-IV criteria for MDD.

How Common Is MDD in Primary Care?

Online eTable 1 shows the results of 12 recent international

studies of point prevalence rates for MDD in primary
care.1021 Most of these studies used a 2-stage sampling
procedure leading to a DSM-IV or ICD-10 diagnosis
of MDD. Most are limited to adult patients, and exclude
adolescents and the very elderly. The largest of these
studies, the WHO Collaborative Study of Psychological
Problems in General Health Care, included 26 000 patients
in 15 centres, worldwide, and found a point prevalence rate
of 10.4% for ICD-10 depression.17 The remaining studies,
summarized in online eTable 1,1021 report prevalence rates
for MDD in primary care ranging from 3.2% to 27.2%, with
8 of the 11 studies clustering between 8% and 14%. The
median for these studies is 10.4% and the mean 11%. A
meta-analysis by Mitchell et al22 gave a rather higher figure
of 19.5% from a pooled sample of 50 000 patients.
Abbreviations
AD antidepressant
CANMAT Canadian Network for Mood and Anxiety Treatments
DSM

Diagnostic and Statistical Manual of Mental Disorders

FP

family physician

GP

general practitioner

HADS

Hospital Anxiety and Depression Scale

ICD

International Classification of Diseases

MDD

major depressive disorder

PHQ-9

Patient Health Questionnaire

RCT

randomized controlled trial

SMD

standardized mean difference

WHO

World Health Organization

www.TheCJP.ca

Highlights

Difficulty in assessing the severity of depressive

symptoms may be a significant contributor to the
underrecognition of MDD in primary care. However,
even when MDD is recognized, it is frequently not
treated. More qualitative research is needed to
understand this disconnect.

The association between chronic disease and MDD will

play an increased role with an aging population.

New models of care that facilitate integration of

treatment approaches for comorbid depression and
chronic physical disease are needed.

Encouraging FPs to increase the monitoring and

reassessment of patients with MDD is likely to improve
treatment adherence and patient outcomes.

What Effect Will the Baby Boomer Cohort

Have on Depression Rates in Primary Care?

As the baby boomer cohort begins to enter old age,

primary care physicians will be facing large increases in
the proportion of elderly patients in their practices, based
solely on demographic changes. In 2009, the proportion of
the population age 65 and over was 14% and will increase
to between 23% to 25% by 2036 according to estimates
by Statistics Canada.23 This represents an approximate
doubling of the proportion of the elderly in the population
and, by extension, in primary care practices.
How many of these elderly people will suffer from
depression? Population prevalence studies of MDD
generally show lower rates in the elderly than in younger
age groups.3,5,6,24 For example, in a Canadian population
study,9 the lifetime prevalence of MDD increased from
8.8% in those aged from 15 to 25 years to 12.2% in those
aged from 26 to 45, remained stable at 12.4% in those 46 to
64 years, and then declined to 6.4% after age 65. However,
these lower rates may not consider the large number of
elderly who live in institutions. An earlier Edmonton study
using DSM-III Diagnostic Interview Schedule criteria
found a significantly lower 6-month prevalence of MDD
in community residents, compared with people who were
living in institutions for the elderly.4
A second problem is that prevalence rates vary greatly,
both geographically and depending on the instrument used
to detect depression. Riedel-Heller etal25 reviewed 28
European studies of the prevalence of depression in old age.
They divided them into studies that collected information
with symptom scales and produced a dimensional
diagnosis, and those that employed a categorical approach
leading to a DSM or ICD diagnosis of MDD. Prevalence
rates varied greatly between studies, and depending on
the type of instrument. In the studies using categorical
The Canadian Journal of Psychiatry, Vol 58, No 8, August 2013 W 443

In Review

criteria, point prevalence ranged from 3% to 27%; in the

studies using scales designed to detect clinically significant
depressive symptoms, point prevalence ranged from 7% to
58%. A recent systematic review and meta-analysis of the
prevalence of depression in people aged 75 and older26 found
a similar pattern: in studies using categorical instruments,
the pooled point prevalence of MDD was 7.2%. In studies
using dimensional criteria, the pooled point prevalence of
clinically significant depressive symptoms was 17.1%. Nine
European centres using the dimensional Geriatric Mental
StatusAGECAT system in a very large sample showed a
prevalence of 12.3% for depression judged suitable for
intervention.27, p 312 Snowdon28 concludes in his review
of this subject that depression, especially subsyndromal
depression, is common in the elderly. He also comments
that symptom patterns in the depressed elderly, often
associated with physical ill health and mental disabilities,
may not correspond with those required for a categorical
diagnosis of DSM MDD, even though the distress is evident
and resultant impairment and functional disabilities may be
severe.
The implications for primary care physicians are fairly clear.
The baby boomer cohort will create a large increase in the
number of elderly in primary care; MDD and subsyndromal
depression are likely to be more prevalent than previously
thought; and optimal detection and management will require
a heightened index of suspicion on the part of the FP.

What Is the Connection Between Depression

and Chronic Disease?

Many of these elderly people will also have chronic

diseases. Moussavi et al29 analyzed World Heath Survey
data from more than 245 000 people in 60 countries to
examine the association between chronic diseases and
MDD. The prevalence of ICD-10 MDD was 3- to 7-times
greater in people with any of the 4 following chronic
diseases: asthma, angina, arthritis, and diabetes. For
the 7.1% of respondents with 2 or more of these chronic
physical conditions, depression prevalence reached 23%.
After adjusting for socioeconomic factors and health
conditions, the authors found that depression produced the
largest decrement in health status, compared with all the
other chronic conditions studied.
Clarke and Currie30 also reviewed the relation between
depression, anxiety, and chronic physical diseases and found
similar results: the prevalence of depression was markedly
and consistently higher in people with heart disease, stroke,
diabetes, cancer, rheumatoid arthritis, and osteoporosis
than in the general population, and was associated with
increased disease severity and health resource use.3134 It is
likely that shared underlying biological mechanisms, such
as inflammatory processes, are etiological factors in both
depression and chronic physical illnesses.31,33,35,36
Thus depression is both more common in people with
chronic disease, and significantly worsens their overall
health status. This bidirectional relation between depression
and chronic disease has important clinical implications
444 W La Revue canadienne de psychiatrie, vol 58, no 8, aot 2013

for FPs, who are primarily responsible for these patients,

but it also makes a case for greater communication and
collaboration between FPs, medical specialists, and mental
health providers. As Clarke and Currie30 point out, linear
care is unlikely to be effective or efficient; mental and
physical disorders should be addressed simultaneously,
and future research should focus on developing effective
integrated disease management systems for depression in
patients with physical illness.

What Proportion of Depressed Patients Are

Identified in Primary Care?

FPs recognition of major depressive episodes in their

patients has been repeatedly studied and found to be low.
Mitchell et al22 conducted an extensive review of the
literature on recognition, including only studies that assessed
the unassisted diagnostic ability of GPs to identify MDD
according to DSM or ICD criteria. In a pooled sample size
of over 50 000 patients, the prevalence of MDD was 19.5%.
GP and (or) FPs diagnostic sensitivity across the 41 studies
included was 47.3%. In studies reporting both sensitivity
and specificity, the overall sensitivity of detection by GPs
was 50.1%, and the specificity was 81.3%. Slightly poorer
rates of depression detection were reported in another metaanalysis, conducted by Cepoiu et al37: these authors found
a detection sensitivity of 36.4% and specificity of 83.7%.
However, the authors included studies with other physician
groups, and some of the studies included were based on
chart review, which has been shown to be less sensitive.
Mitchell et als review22 suggests that much of the underidentification of patients with MDD is due to errors of
judgment about the severity of symptoms; that is, the
physician recognizes depressive symptoms but judges
them to be clinically insignificant. Improving assessment
of symptom severity may be a key factor in training future
FPs and improving the skills of practising FPs. In the
United Kingdom, incentives have been implemented to
encourage the use of severity measures in patients thought
to be depressed by GPs. Kendrick et al38 found that 80%
of the patients who were thought to be depressed by the
GP and who completed the 9-item PHQ-9 or the HADS,
subsequently received prescriptions for ADs and 20%
were referred to specialist services. The more severe the
depression score, the more likely there was treatment. Two
noteworthy and unexplained exceptions to this high rate
of treatment were patients over 65 years and patients with
comorbid physical illnesses.

What Proportion of Depressed Primary Care

Patients Are Treated?

Online eTable 2 summarizes data from 4 international

studies with large primary care study populations, a 2-stage
screening and diagnostic process, and data on whether
treatment took place.12,15,17,21,3941 They show considerable
geographic variation.15 However, note that in all of the
studies in online eTable 2, treatment occurred in less than
60% of patients diagnosed with MDD.
www.LaRCP.ca

Depression in Primary Care: Current and Future Challenges

The Longitudinal Investigation of Depression Outcomes

study15 is particularly interesting because it involved
feedback of screening measure results to primary care
physicians. For all patients who met DSM-IV criteria for
current MDD, the treating primary care physician received
a letter advising him or her that the research interview
indicated a probable diagnosis of depression,15, p 16271628
but no specific treatments were recommended. In 5 of
the 6 sites, less than 25% of these patients received any
potentially effective15, p 1628 treatment. Thus, even when
physicians were informed of the presence of a depressive
disorder in their patients, the majority were not treated.
These results are consistent with earlier studies,4245 which
have found that just providing physicians with the results
of depression screening does not in itself ensure treatment.
We are aware of only one study that attempted to study
prospectively the reasons for FPs inaction. Kendrick et al13
screened 694 UK primary care patients for depression
using the HADS. All participants completed questionnaires
on patient-related factors that have been suggested as
possible influences on whether GPs initiate treatment. After
each consultation, the GP completed a brief questionnaire
indicating whether the patient was depressed, the severity,
and the action taken for patients deemed to be depressed.
As in other studies, GP accuracy of diagnosis was low: GP
sensitivity, compared with the HADS depression subscale
(commonly referred to as HAD-D), was 33% and specificity
was 86%. Even in the 101 patients identified as depressed
by the GPs themselves, GPs did not discuss depression with
57 of them. GP offers of AD treatment were more likely
with greater perceived severity of depression and with GP
perception that the patient had a positive attitude toward
ADs. GPs accurately assessed many of their patients as
having negative attitudes about the addictiveness of ADs,
but often mistakenly assumed that their patients thought
ADs were not very effective. There was no significant
correlation between GPs treatment decisions and the
presence or absence of adverse life events, or a previous
history of AD use. Although this study13 suffers from low
numbers, it addresses an important gap in research and
models a useful approach to improving our understanding
of what actually drives GP treatment decisions.

What Proportion of Depressed Primary Care

Patients Receive Adequate Care?

Definitions of adequacy have been based primarily on MDD

treatment guidelines produced by various professional and
quality assurance organizations. Online eTable 3 summarizes
data from 9 primary care studies that report adequacy of
care for MDD.5,15,4652 Note that, with the exception of the
study by Vedavanum et al,51 which found very high rates of
treatment being offered, only about one-half of patients in
these studies were deemed to have received adequate care,
whether pharmacological or psychological. In many cases,
follow-up was the element of care that was inadequate.
CANMAT clinical guidelines for the management of MDD
in adults53 recommend that patients being treated for MDD
www.TheCJP.ca

be monitored every 1 to 2 weeks initially, with a decrease

in frequency to every 2 to 4 weeks depending on severity
and response. A recent study by Chen et al46 found that
only 47% of primary care patients with MDD completed
90 days of treatment with an AD, and that completers
were significantly more likely than noncompleters to have
received guideline-concordant, follow-up visits (38.1% and
24.5%, respectively, P < 0.001). Thus treatment adherence,
a major factor in determining patient outcomes, appears to
be associated with more adequate follow-up.
Adequate follow-up is also important to detect patients who
are not responding well. CANMAT guidelines53 recommend
that patients who show less than 20% improvement in scores
on a depression rating scale after 2 weeks of AD use should
have a change in treatment (for example, dose increase).
The recently published Clinical Outcomes in MEasurementbased Treatment (commonly referred to as COMET) trial54
provides information on the extent to which this happens.
In this primary care-based study, most patients continued
their initial AD therapy without modification throughout
the study period, and feedback of PHQ-9 scores during the
treatment period did not significantly affect the likelihood
of treatment adjustment in either nonresponders or partial
responders. As with depression screening scores, which
do not appear to affect physician treatment decisions (see
above), the reasons for this are unclear.
Finally, follow-up is likely to be therapeutic. Posternack
and Zimmerman55 reviewed 41 double-blind RCTs testing
putative new ADs against placebo in patients with MDD
and found that an extra visit at week 3 was associated with
a 0.86 further reduction in the Hamilton Rating Scale for
Depression score, and that an extra visit at week 5 was
associated with a 0.67 further reduction. The authors
conclude that,
after accounting for spontaneous improvement, the
placebo response in trials of antidepressants stems
largely from the attention and care received during
the course of the clinical trial.55, p 290
In other words, a caring and attentive FP is likely to be
highly therapeutichardly a surprise, but worth exploiting
in a systematic fashion.

What Interventions Improve the Detection

and Management of Depression in Primary
Care?

Considerable research has focused on methods to improve

the detection and management of MDD in primary care.
We found 8 systematic reviews and meta-analyses of RCT
studies that have been conducted since 2000.5663 Like
the individual studies that they analyze, the rigour and
sophistication of the reviews has tended to increase with
time. However, the studies included in the reviews continue
to have serious deficits (see Gunn et al61 for a good review of
the shortcomings of this research). With this caveat in mind,
the following conclusions should be considered tentative.
The Canadian Journal of Psychiatry, Vol 58, No 8, August 2013 W 445

In Review

Screening

A Cochrane review published in 2005 and edited in 2009

concluded that
routinely administered case finding/screening
questionnaires for depression have minimal impact
on the detection, management or outcome of
depression by clinicians.64, p 1
In contrast, the updated US Preventive Services Taskforce
report65 found good evidence that screening improves the
accurate identification of depressed patients in primary
care settings.p 784 However, it recommends against routine
screening for adults unless staff-assisted depression care
supports are in place to assure accurate diagnosis, effective
treatment and follow-up.65, p 784 The key issue appears to be
that screening can improve recognition and diagnosis,66 but
that physicians do not act to initiate treatment and follow
patients.

Educational Interventions Directed at Primary Care

Physicians

Educating practising primary care physicians about MDD,

its detection, and treatment has not been found to improve
recognition, treatment, or outcomes.6668 Education about
MDD combined with a treatment guideline and training on
how to implement it may offer some benefits.68 However, the
problem of inadequate depression treatment may begin
and may need to be addressedmuch earlier, in residency
training. A recent survey69 of US residency training
directors in Psychiatry, Internal Medicine, Obstetrics and
Gynecology, Pediatrics, and Family Medicine found that
a large majority of Family Medicine residency directors
were satisfied with the psychiatric training their residents
received, and considered that training to be optimal or
extensive. The contrast between the educators impressions
about the quality of psychiatric training that Family
Medicine residents receive, and what the literature shows
about the actual mental health practices of FPs deserves
further attention. We were unable to access data related to
Canadian residency programs.

caregivers, and provider reminders and feedback. Three

systematic reviews were able to perform meta-analyses
of results; Badamgarav et al56 found an effect size of 0.33
(95% CI 0.16 to 0.49) for depression symptom improvement
with disease management interventions; Gensichen et al59
reported an effect size of 0.40 (95% CI 0.60 to 0.20) for
sustained improvement in depression symptoms with case
management, compared with care as usual, and NeumeyerGromen et al62 reported a risk ratio of 0.75 (95% CI 0.70
to 0.81) for depression severity improvement. These effect
sizes range from small to large, respectively.

Collaborative Care

Collaborative care has received mixed reviews.58,7274

In part, this is likely due to the differing definitions of
collaborative care, and the weighting of its components in
reviews and meta-analyses. Bower et al58 found a positive
effect of collaborative care on AD use (OR 1.92; 95% CI
1.54 to 2.39) and depression outcomes (SMD 0.24; 95% CI
0.17to 0.32). The review by Williams et al63 of multifaceted
interventions (not specifically identified as collaborative
care) found that there was an 18.4% median increase in
depression response during 3 to 12 months (range 8.3%
to 46.0%), compared with usual care, and that this benefit
was confined to patients with MDD, rather than minor
depression. In that review, all of the studies included case
management, and 85% included case manager supervision
by a mental health professional. Many collaborative care
interventions involve elements of case management and
(or) disease management; where these are significant
components of collaborative care, outcomes are likely to
fall within the ranges for case management cited above.

Summary and Synthesis

MDD is highly prevalent in primary care. Prevalence

rates vary with geographical region and with the research
instrument used, but estimates in the neighbourhood of
10% to 12% are probably realistic.

Traditional Consultation to Primary Care Physicians

As the number of elderly patients in primary care increases

rapidly during the next 2 decades, the need for optimal
recognition and treatment of depression will become even
more important. Easy-to-use screening instruments that are
sensitive to common symptom profiles in the depressed
elderly should be available to FPs.

Depression Case Management and Disease

Management

Many elderly patients will also have chronic physical

diseases. Rates of MDD are much higher in patients with
chronic physical diseases, and the likelihood of MDD
increases with each disease. Moreover, depression has
a powerful, independent effect on health scores in these
people. A paradigm shift away from sequential treatment
of single disorders in favour of concurrent, comprehensive
treatment is likely to be needed. This is an ideal role for
Family Medicine.

Surprisingly, we were able to locate only one systematic

review of consultation-liaison in primary care.70 This study
found that it had no significant effect on AD use (RR 1.23;
95% CI 0.91 to 1.66) or depression outcomes (SMD 0.04,
95% CI 0.21 to 0.14).

Depression
case
management59,66
and
disease
56,57,62,63,71
appear to offer significant benefits.
management
In most studies, case management involved practice nurses
providing some combination of patient education and
support, with follow-up to monitor adherence and response.
Disease management strategies most often included
patient and provider education, multidisciplinary teams of
446 W La Revue canadienne de psychiatrie, vol 58, no 8, aot 2013

Low rates of recognition of MDD in primary care remain

a serious concern. At best, 50% of patients with research
interviewconfirmed MDD are recognized by their FP.
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Depression in Primary Care: Current and Future Challenges

Errors of judgment regarding severity of symptoms may

account for a significant proportion of underrecognition.
The failure of the results of screening tools and expert feedback to lead to treatment by the FP is a puzzle that remains
unsolved; it is unclear whether physicians do not agree with
the information provided, whether they lack the knowledge
and (or) skills to proceed with treatment, or whether they
feel that the patient does not require and (or) wish treatment.
Treatment rates are also low, even when MDD has been
diagnosed by the FP. Most population studies and studies
set in primary care report maximum treatment rates of less
than 60%. This clearly leaves scope for considerable improvement, but understanding why there is such a large gap
between diagnosis and therapeutic action must be the first
step.
Regarding the quality of treatment achieved in primary
care, adequate levels of follow-up are frequently lacking.
Improving the frequency and quality of follow-up visits is
an important and achievable step toward improving depression care.
Finally, more systematic, qualitative research is needed to
understand the reasons for underdetection and the factors
that influence whether and how FPs treat MDD. Family
Medicine professional groups and educators should play a
key role in developing this research and exploring opportunities to enhance current training programs.

Acknowledgements

The Canadian Psychiatric Association proudly supports the

In Review series by providing an honorarium to the authors.

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