Download Emotional Disorders in Primary Care

Journal of Consulting and Clinical Psychology
2002, Vol. 70, No. 3, 798 – 809
Copyright 2002 by the American Psychological Association, Inc.
0022-006X/02/$5.00 DOI: 10.1037//0022-006X.70.3.798
Emotional Disorders in Primary Care
James C. Coyne and Richard Thompson
Michael S. Klinkman and Donald E. Nease Jr.
University of Pennsylvania Health System
University of Michigan
Individuals with emotional disorders are more likely to use primary medical care than specialty mental
health services, but these disorders are likely to be undetected or inadequately treated. Recognition of the
importance of primary medical care for the treatment of mental disorder has resulted in pressing new
research priorities. One set of issues concerns the adequacy of existing nosological systems for
conceptualizing emotional disorder in primary care and identifying need for treatment. Another concerns
the difficulties translating efficacious treatment into effective strategies that can be integrated into the
competing demands of primary medical care. Psychologists have played only a limited role in defining
and addressing emerging questions. Irreversible changes in mental health services have created the need
for the development of a psychosocial perspective for what would otherwise be defined as narrowly
biomedical issues.
Beginning in the 1970s, a number of important developments
rapidly advanced our understanding of the nature of emotional
disorders outside of mental health settings. First, there were increasing refinements in diagnostic criteria as seen in the Research
Diagnostic Criteria (RDC; Spitzer, Endicott, & Robins, 1978),
followed by the third edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980), a revised DSM-III (DSM-III-R; American Psychiatric Association, 1987), and a successor (DSM-IV; American
Psychiatric Association, 1994).
Second, interview schedules including the Schedule for Affective Disorders and Schizophrenia (SADS; Endicott & Spitzer,
1978), the Diagnostic Interview Schedule (DIS; Robins, Helzer,
Croughan, & Ratcliff, 1981), the Structured Clinical Interview for
DSM-III (SCID; Spitzer & Williams, 1985), and the Composite
International Diagnostic Interview (CIDI; World Health Organization, 1990) incorporated these refined diagnostic criteria into
readily applicable assessment tools. No longer were researchers
forced to choose between defining emotional disorder in terms of
patients in mental health treatment or relying on some arbitrary
cutpoints on frustratingly nonspecific self-report scales. It also
became possible to begin to make cautious comparisons of emotional disorders across populations (Henderson, 1998).
Third, using these refined research diagnostic criteria, a number
of ambitious research projects examined the nature, prevalence,
and correlates of emotional disorder in the community. The most
notable of these projects were the Epidemiologic Catchment Area
(ECA) study (Regier, Myers, & Kramer, 1985; Robins et al.,
1981), the National Co-Morbidity Survey (NCS; R. C. Kessler et
al., 1994), and the Depression Research in European Society
(DEPRES) study (Lepine, Gastpar, Mendlewicz, & Tylee, 1997).
Such projects added to a wealth of accumulating data indicating
that emotional disorders were highly prevalent in the community
and personally and socially impairing.
In addition to prevalence rates, the ECA study yielded estimates
of the proportion of individuals with each disorder who received
treatment and of the type of treatment services received. It was
There are dramatic shifts occurring in the settings in which
emotional disorders are treated, how they are treated, and by
whom. The present discussion must be placed in the context of
these sweeping changes to fully appreciate the significance of
emotional disorders in primary care. Pressing new research priorities are being defined by policymakers who need an empirical
foundation for the key decisions they face. Yet with relatively few
exceptions (Arean & Miranda, 1996; Coyne & Schwenk, 1995;
Munoz, Hollon, McGrath, Rehm, & VandenBos, 1994; Schulberg
& Rush, 1994), psychologists have taken almost no role in defining the relevant research questions, generating the requisite findings, and posing empirically based solutions to the problem of
emotional disorders in primary care, where such disorders are
increasingly most likely to be treated. Aside from psychologists
not looking after their self-interests, they have failed to articulate
a perspective that could serve as a needed balance to what have
come to be a narrowly defined set of biomedical issues. The
absence of a clearly articulated psychosocial perspective is to the
detriment of all concerned and, most importantly, to those who
must pay for, deliver, or receive treatment for emotional disorders
in primary care. Like Rip Van Winkle, psychologists have slept
through a revolution, and as they awaken, they must grasp how
their world has changed.
James C. Coyne and Richard Thompson, Department of Psychiatry,
University of Pennsylvania Health System; Michael S. Klinkman and
Donald E. Nease Jr., Department of Family Medicine, University of
Michigan.
This work was supported by Center Grant MH 52129 – 06 and National
Institute of Mental Health Grant RO1MH43796. The opinions expressed
herein are the sole responsibility of the authors, but the contributions of the
following people were very much appreciated: Patricia A. Arean, Joseph J.
Gallo, Ashraf Kagee, Linda Kruus, Ira R. Katz, Steven C. Palmer, Melissa
W. Racioppo, and Joel Streim.
Correspondence concerning this article should be addressed to James C.
Coyne, Department of Psychiatry, University of Pennsylvania Health System, 11 Gates, 3400 Spruce Street, Philadelphia, Pennsylvania 191044283. E-mail: [email protected]
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SPECIAL ISSUE: PRIMARY CARE
found that most persons with emotional disorders did not get
treatment and that only a minority of the treatment received came
from specialized mental health services (Regier et al., 1993; Shapiro et al., 1984). The de facto mental health system in the United
States was found to consist not only of formal mental health
services but of general medical care, social services, and various
self-help efforts (Regier et al., 1993). Most people in the community with an emotional disorder visited a general medical provider
in the course of a year, and more persons with emotional disorders
were treated in this sector than by mental health professionals. Yet
most emotional disorders in people visiting a general medical
provider were undetected and untreated (Regier et al., 1993).
Similar results were obtained in the NCS (R. C. Kessler et al.,
1999) and DEPRES study (Lepine et al., 1997). Furthermore, even
when detected, emotional disorders were found likely to be inadequately treated or not treated at all (Katon, Von Korff, Lin, Bush,
& Ormel, 1992; Schulberg et al., 1997).
However, these findings may have become outdated in the face
of accelerating trends that place even more emphasis on primary
care as the site in which emotional disorders are treated. Both the
lay public and primary care physicians are more likely to accept
newer antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), venlafaxine, and nefazodone, than the antidepressants previously available. Patients are increasingly more likely to
seek and receive an antidepressant from a primary care physician
than from a psychiatrist. From 1991 to 1997, the annual number of
antidepressant prescriptions written by primary care providers in
the United States increased from nearly 25 million antidepressant
prescriptions to over 50 million, compared with an increase
from 15 to 33 million for psychiatrists (Hirschfeld, 1998).
Although the depressed elderly are presumed to be less likely to
be treated than younger depressed patients, a recent populationbased study in Ontario, Canada, found large and growing rates of
antidepressant prescriptions for the elderly, with over 17% of the
oldest women in the province receiving antidepressants in 1997
(Mamdani, Herrmann, & Austin, 1999). In a similar manner, 14.3% of elderly White individuals (but only 5.0% of African
Americans) in the Piedmont region of North Carolina were found
to be receiving an antidepressant (Blazer, Hybels, Simonsick, &
Hanlon, 2000). In France, between 5% and 7% of the general
population and 17% of the elderly were found to be chronic
users of anxiolytics and hypnotics (Pelissolo, Boyer, Lepine, &
Bisserbe, 1996). These high rates of prescription cannot be presumed to represent adequate treatment. Indeed, we will review
literature below suggesting that under conditions of routine care,
primary care patients do not obtain the anticipated benefits when
treated with antidepressants. However, these figures do suggest
that the assumption that most depression in primary care will go
untreated needs to be reexamined with contemporary data. Furthermore, these rates of treatment exceed the presumed prevalence
of depression among the elderly and raise the issue of specificity
of treatment with antidepressants: Patients may be receiving treatment who do not meet criteria for a condition for which the
efficacy of treatment with antidepressants has been established.
A considerable gap may still exist between the large number of
depressed patients being seen by general medical providers and the
smaller number obtaining effective treatment. The growing body
of research refining and evaluating solutions to these problems
includes investigations of integrating mental health profession-
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als—including psychologists—into primary care, as well as facilitating referral to them. However, other trends make it unlikely that
a reliance on mental health professionals will prove to be the major
means of improving the outcome of emotional disorders in primary
care. The cost of stationing mental health professionals in primary
care settings could prove prohibitive, and a recent review of the
impact of on-site mental health professionals found disappointingly modest effects on consultation, referral, and treatment in
primary care (Bower & Sibbald, 2000). Changes brought on by
health care system reform have further decreased the availability
of specialty mental health care to primary care patients and have
more generally restricted the intensity of treatment offered by
mental health professionals (Rosenheck, Druss, Stolar, Leslie, &
Sledge, 1999). These trends are likely to continue, and future
reforms and innovations in the treatment of emotional disorder in
primary care will undoubtedly rely heavily on what primary care
providers can accomplish, with and without the assistance of
practice nurses and master’s level professionals.
These profound changes should be of interest, if not disconcerting, to psychologists, but they are rarely acknowledged in the
mainstream outlets for clinical psychological research. Like Rip
Van Winkle awakening after the American Revolution and proclaiming “God Save the King!” clinician–scientists may find the
value of their contributions questioned if they attempt to go about
their usual research as if these changes have not occurred. For
instance, conventional comparisons between patients with major
depression and controls must now be qualified by a recognition
that depressed patients in primary care and other settings may
differ in significant ways from the more frequently studied but
smaller number of depressed patients in specialty mental health
settings and particularly from the even more select group being
enrolled in clinical trials in these specialized settings (Blacker &
Clare, 1987; Schwenk, Coyne, & Fechner-Bates, 1996). We need
to better understand the social processes that determine the preferences depressed individuals exercise in presenting or seeking
care in a particular setting. In a similar manner, psychotherapeutic
interventions for depression may be judged by their ability to be
deliverable by less-trained professionals in the midst of the competing demands of primary care (Mynors-Wallis, 1996). Therefore,
one could argue that little relevance to primary care can be claimed
for demonstrations showing that the highly trained professionals
can efficaciously deliver an intensive treatment to carefully selected depressed patients in a tertiary psychiatric setting. The
characteristics and treatment needs of depressed patients identified
during routine visits to primary care may be quite different than
those of patients self-selecting for treatment in specialty mental
health settings.
Nature of Emotional Disorders in Primary Care
The bulk of studies on emotional disorder in primary care have
focused on major depression not only because the disorder is
highly prevalent and a source of considerable impairment but also
because a full range of treatments are available for which efficacy
has been established (Depression Guidelines Panel, 1993). Psychological distress, however, is even more prevalent and readily
assessed with self-report screening instruments. Indeed, early studies of the performance of primary care providers in managing
depression often relied exclusively on self-report measures to
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COYNE, THOMPSON, KLINKMAN, AND NEASE
define depression. Yet it was subsequently recognized that most
patients who have elevated scores on screening instruments do not
meet criteria for a depressive disorder and that, by themselves,
such instruments provide distorted estimates of the need for treatment and the performance of providers. Still, attention has remained focused on how screening for psychological distress might
still serve as a tool in improving the detection and outcome of
depression. It was also noted that a considerable pool of patients
had significant depressive symptoms but did not meet criteria for
major depression. This raised questions about the adequacy of
conventional DSM-IV criteria for use in primary care, an issue that
has yet to be satisfactorily resolved. In particular, concerns remain
about whether minor depression should be given greater recognition as a diagnostic entity and therefore as a suitable target for
detection and treatment. More recently, attention has been turned
to anxiety disorders. This is justified not only by arguments about
their prevalence and associated impairment but also by findings
that newer antidepressants are efficacious for anxiety disorders.
Psychological Distress
A variety of self-report measures of distress have been used with
primary care populations, including the Center for Epidemiologic
Studies Depression scale (CES-D; Radloff, 1977), the Hopkins
Symptom Checklist (HSCL; Derogatis, Lipman, Rickels, Uhlenuth, & Covi, 1974), the Brief Symptom Inventory (BSI; Derogatis
& Melisaratos, 1983), the Beck Depression Inventory (BDI; Beck,
Ward, Mendelson, Mock, & Erlbaugh, 1961), and the General
Health Questionnaire (GHQ; Goldberg & Hillier, 1979), as well as
the Beck Depression Inventory, Primary Care edition (BDI-PC;
Beck, Guth, Steer, & Ball, 1997), a measure specifically designed
for use in primary care settings. With adjustments in cutpoints,
such instruments are equivalent in providing moderate efficiency
in first-stage screening for depression (see Coyne, Thompson,
Palmer, Kagee, & Maunsell, 2000, for a review). In general, these
instruments have relatively high sensitivity but limited specificity
(Mulrow et al., 1995). They may identify a pool of patients who
may have depression, but they do not provide a reliable diagnosis.
Consistent with other studies (e.g., Coulehan, Schulberg, Block,
Janosky, & Arena, 1990), Fechner-Bates, Coyne, and Schwenk
(1994) found that the CES-D had a sensitivity of 79.5% and a
specificity of 71.1% but a modest positive predictive value
of 28.5%, using a SCID-based diagnosis of major depression as the
comparison. Practically speaking, the CES-D identified more than
one in three patients as needing further evaluation, but less than
one third of these were actually depressed, and 1 in 5 depressed
patients would have been missed if a physician had relied exclusively on the screening to detect depression. Efforts to improve the
performance of the CES-D and similar instruments by raising
cutpoints, by modifying scoring, or by eliminating poor-performing
items inevitably involve some trade-off between sensitivity and
specificity (Santor & Coyne, 1997). There are inherent limitations
to self-report instruments as indicators of major depression.
What else do elevated scores on measures of distress indicate?
Fechner-Bates et al. (1994) found that taking into account any
DSM-III-R diagnosis of a depressive disorder only marginally
improved the performance of the CES-D as a screening instrument
and that most adjustment disorders were missed. It is readily
possible for patients to score in the distressed range without a
single depressive symptom, and less than half of distressed patients
have had 2 weeks of mood disturbance (Coyne & Schwenk, 1997).
Our experience with screening for distress in elderly primary care
patients is that over 40% of positively screening patients will not
be distressed 2 weeks later (J. Streim, personal communication,
March 6, 2000). Yet can nondepressed patients who screen positive, but who do not meet criteria for major depression, be viewed
as an at-risk population? With cases of major depression excluded,
an elevated score on the CES-D is so inefficient in identifying
patients at risk for subsequent depression (Munoz et al., 1995) that
an effect for any preventive intervention cannot be demonstrated
without a prohibitively large sample (see Coyne et al., 2000, for an
extended analysis of this problem). Undoubtedly, much of the
self-reported distress assessed in primary care samples reflects
psychosocial problems, physical symptoms including pain, and
unhappiness, which are not appropriately construed as emotional
disorders (Coyne & Kagee, 2000).
Major Depression
The first wave of primary care office-based studies found that
major depression was highly prevalent among primary care patients but was often undetected and untreated by primary care
physicians. Estimates of prevalence ranged from 4.8% to 13%
(Barrett, Barrett, Oxman, & Gerber, 1988; Coyne, Fechner-Bates,
& Schwenk, 1994; Katon, 1987; L. G. Kessler, Cleary, & Burke,
1985; Schulberg et al., 1985), and even the lowest estimate may
still make major depression the most common condition in primary
care, perhaps exceeding hypertension (Katon & Schulberg, 1992).
Studies that use results of semistructured interviews as the criterion for diagnosis and formally solicit diagnoses from the primary
care physicians find as many as 50%–70% of patients with a
current major depression are missed (Coyne, Schwenk, & FechnerBates, 1995; Gerber et al., 1989; Perez-Stable, Miranda, Munoz, &
Ying, 1990; Von Korff et al., 1987). Taken together, this body of
research has been widely interpreted as upholding the view that
undetected depression among primary care patients is a major
public health problem.
However, interpretation of such prevalence data is more complex. Many depressed patients have few or no symptoms beyond
what is needed to meet criteria for a diagnosis and are not substantially impaired (Coyne et al., 1994). The cases missed by
physicians are disproportionately milder cases (Coyne et al.,
1995). Furthermore, the symptoms of many depressed primary
care patients, and particularly the symptoms of those patients who
are not detected as having depression by their physicians, are in a
range of severity in which antidepressants have not been shown to
have a decided advantage over placebos (Elkin et al., 1989; Paykel,
Hollyman, Freeling, & Sedgwick, 1988). Furthermore, patients’
willingness to accept an antidepressant is a strong predictor of
whether they will be detected (Rost et al., 2000), suggesting a role
for patient preference in the process of detection. In addition,
patients with less severe depression are also less likely to accept
treatment (Grembowski, Martin, & Patrick, 2001). On the other
hand, primary care patients who present with mild major depression and remain undetected may suffer later exacerbation of symptoms when they no longer are in contact with their physician (Rost,
Zhang, Fortney, Smith, & Coyne, 1998).
SPECIAL ISSUE: PRIMARY CARE
Minor Depression
Estimates of the rates of minor and intermittent depression
insufficient to meet criteria for current major depression range
from 2% to 9% among primary care patients (Barrett et al., 1988;
Hoeper, Nycz, Cleary, Regier, & Goldberg, 1979; Ormel, Van Den
Brink, Koeter, & Giel, 1990), but there is ambiguity as to the
clinical significance of these conditions. It has been suggested that
minor depression represents a source of considerable impairment
and a risk for major depression such that early intervention could
reduce unnecessary suffering and disability (Broadhead, Blazer,
George, & Tse, 1990; Horwarth, Johnson, Klerman & Weissman,
1992; Wells et al., 1989). However, controlled studies of intervention for minor depression in primary care have produced quite
modest and even null effects, in part due to the improvement in
symptoms among these patients regardless of intervention (Barrett
et al., 1999; Katon et al., 1995; Williams et al., 2000). In general,
although minor depression may entail severe functional impairment (Callahan et al., 1994), few treatments have been shown to be
effective with this disorder (Coyne et al., 1995). There appears to
be an emerging paradox concerning depressive symptoms and
conditions that are not sufficient to meet full criteria for major
depression. Namely, although such conditions are less severe than
major depression, it may be more difficult to demonstrate that they
benefit from treatment (Callahan, 2001).
However, the clinical significance of minor depression may vary
according to whether such symptomatology reflects a general
vulnerability to major depression (Coyne & Katz, 2001). Given the
recurrent nature of major depression, prior depression is an excellent marker for this vulnerability (Coyne, Pepper, & Flynn, 1999).
Yet, in contrast to the DSM-IV, which makes past major depression
an exclusion criteria, studies of minor depression typically do not
take history of depression into account. Individuals with a history
of major depression actually spend more time with subsyndromal
depressive symptoms than in full episodes of major depression
(Judd et al., 1998b). However, most individuals experiencing mild
symptoms do not progress to a full episode of depression, with
only 9%–21% of women and 4%–13% of men becoming clinically
depressed in their lifetime (R. C. Kessler et al., 1994). The finding
that subsyndromal symptoms in recovered depressed persons are
an important predictor of rapid relapse (Judd et al., 1998a) adds to
the weight of evidence that both recent and more distant history of
depression should be routinely assessed and taken into account in
the interpretation of depressive symptoms.
Anxiety Disorders
Although anxiety disorders are believed to be the most common
psychiatric disorder in primary care (Sherbourne, Jackson,
Meredith, Camp, & Wells, 1996), they have only begun to be
given attention other than as a comorbidity of depression. Panic
disorder and general anxiety disorder can be highly impairing, but
the common phobias, which contribute to the high prevalence of
anxiety disorders, are not (Nisenson, Pepper, Schwenk, & Coyne,
1998). Although comorbid anxiety disorders facilitate the detection of depression, there has been a concern in the past that this
contributed to the inappropriate treatment of depression with benzodiazepines (Depression Guidelines Panel, 1993). However,
newer antidepressants, including the SSRIs, can also be effective
801
for anxiety disorders, potentially reducing this problem (Uhlenhuth, Balter, Ban, & Yang, 1999). The availability of these newer
antidepressants will give rise to simplified treatment algorithms
that do not require primary care providers to make complex
diagnostic distinctions or treatment choices. The apparent efficiency of such algorithms may make it more difficult for consumers and nonphysician mental health professionals to argue for the
necessity of offering psychosocial interventions in primary care as
alternatives to these algorithms.
Mixed Anxiety–Depression
Katon and Roy-Byrne (1991) have provided a comprehensive
review concerning evidence for a mixed anxiety– depressive disorder among primary care patients. The DSM-IV includes such a
condition, requiring 1-month mood disorder and other affective
symptoms, but only as a set of criteria for further study rather than
an accepted diagnosis. Such mixed states are highly prevalent
(Barrett et al., 1988). There is evidence that primary care providers
take into account both anxious and depressive symptoms in deciding caseness for major depression (Nisenson et al., 1998) and that
a substantial proportion of patients receiving antidepressants have
mixed anxiety and depressive symptoms without meeting full
criteria for major depression (Sireling, Paykel, Freeling, Rao, &
Patel, 1985). Some anxious– depressed patients suffer substantial
impairment and may be at risk for subsequently full criteria major
depression. However, other such patients are not impaired and
recover without formal treatment. Nease, Volk, and Cass (1999)
used cluster analysis to examine mood and anxiety symptoms in
primary care patients and found that patients clustered into four
groups, all of which displayed some mixture of mood and anxiety
symptoms at varying levels of severity, rather than into groups of
mostly pure mood, mostly pure anxiety, and mixed mood and
anxiety symptoms. Patients with mood and anxiety disorders were
distributed throughout all the groups, suggesting that coexisting
mood and anxiety symptoms are the rule rather than the exception.
Katon and Roy-Byrne suggested that further research is needed to
resolve the apparent heterogeneity of mixed anxiety– depressive
disorder and its relation to major depression. They note that the
bulk of available studies are limited by the absence of data concerning lifetime psychiatric disorder or a longitudinal perspective.
Controversy Over Diagnostic Criteria
The controversy over the adequacy of psychiatric diagnostic
criteria for primary care patients (Barrett et al., 1988; Nease et al.,
1999) is rather different from the disputes familiar to psychologists
concerning the suitability of self-reported distress as an equivalent
to diagnosis (Coyne, 1994; Vredenburg, Flett, & Krames, 1993).
The key issues in primary care are how to best identify patients
who are both significantly impaired by emotional distress and
likely to benefit from specific treatments while minimizing unnecessary treatment. The prevailing view has emphasized treatment of
any patients who currently meet diagnostic criteria. However, this
approach leaves out a number of intermediate steps that are important in primary care: namely, assessment and interpretation of
the severity of current symptoms in light of prior history, as well
as the negotiation toward the patient’s acceptance of the diagnosis
and treatment plan. In other words, determining whether patients
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currently fit into traditional diagnostic categories is only one step
in identifying those who will accept and benefit from treatment.
Primary care providers must make diagnostic judgments in a
context in which most patients are suffering some physical and
emotional discomfort, and therefore, the risk of a lowered threshold for diagnosis is that a large number of patients will be inappropriately labeled as having an emotional disorder. Many depressed patients have only the minimum number of symptoms
required for a diagnosis, meaning that interpretation of one or two
symptoms makes the difference between an accurate diagnosis or
a false positive or a false negative diagnosis. Symptoms may not
be numerous or severe enough to warrant a formal diagnosis at an
index visit, yet these symptoms may intensify when the patients
are no longer in contact with their physician (Rost et al., 1998). A
history of prior depression can be crucial in interpreting current
presentation. Issues in assessing anxiety disorders are more complex, in that it is more difficult to reliably establish a prior history,
and the revised criteria presented in the DSM-IV may not be
clinically valid (Bienvenu, Nestadt, & Eaton, 1998). Although
intended to distinguish generalized anxiety from normal worrying,
the increase in the required duration of symptoms from 1 month
to 6 months may not be an acceptable means of drawing this
distinction in primary care. Finally, unlike patients seeking treatment in specialized mental health settings, patients identified as
having emotional disorders in primary care may not be ready to
accept and benefit from treatment (Rost et al., 2000; T. L. Thompson, Mitchell, & House, 1989).
These factors may help to explain evidence that primary care
providers often reject formal psychiatric nosology and instead rely
on their own assessment of current symptoms and their knowledge
of the patient (Klinkman, Coyne, Gallo, & Schwenk, 1998; Valenstein et al., 1997). Primary care providers are widely criticized for
missing major depression (Depression Guidelines Panel, 1993).
Yet when compared with formal diagnostic criteria, they make
more false positive diagnoses than false negatives (Klinkman et
al., 1998). Many false positive patients have a mix of affective
symptoms and a history of depression, and it is not clear that the
primary care providers’ judgments are clinically invalid.
A diagnostic system that was more clinically useful and acceptable in primary care would better accommodate the number and
severity of a full range of affective symptoms and, importantly,
incorporate more of a temporal perspective. Prior history would be
given weight in interpreting ambiguous presentations of symptoms, but some diagnoses would still be best resolved only with
extended observation or “watchful waiting” (Freedman, 1989).
Improving the Outcome of Depression in Primary Care
Dominant View: Screen, Detect, Medicate, and Observe
Improvement
As we have noted, most efforts to improve the outcome of
emotional disorders in primary care have centered on depression.
Identification of depression as highly prevalent, but largely untreated in primary care, was the impetus for development (by the
U.S. Public Health Service Agency for Health Care Policy and
Research [AHCPR]) of practice guidelines for the management of
depression (Depression Guidelines Panel, 1993). These guidelines
advocated front-loading strategies to improve the outcome of
depression: increased case finding with routine screening as a key
means of facilitating physician detection of depression. Although
they acknowledged the efficacy of psychotherapy for mild and
moderate depression, they put greater emphasis on medication as
the first line of treatment (Munoz et al., 1994).
Initial clinical trials confirmed that screening led to increased
detection and treatment of major depression (Magruder-Habib,
Zung, & Feussner, 1990; Rand, Badger, & Coggins, 1988; Shapiro
et al., 1987). Yet enthusiasm for the routine screening for depression
(Depression Guidelines Panel, 1993) has been dampened by repeated
findings that screening and feedback to providers do not improve
the outcome or adequacy of treatment of depressed patients in
primary care (Callahan et al., 1994; Dowrick & Buchan, 1995;
Moore, Silimperi, & Bobula, 1978; Reifler, Kessler, Bernhard,
Leon, & Martin, 1996; Scott & Freeman, 1992; Shapiro et al., 1987).
To be of benefit, screening must be integrated with additional
enhancements of routine care, and even then, the benefits are not
assured (Callahan et al., 1994). Moreover, potential drawbacks of
routine screening include the risk of encouraging providers to
overdiagnose and treat patients who are distressed but not depressed (Klinkman, Coyne, Gallo, & Schwenk, 1997) and the
commitment of considerable resources to interview assessments of
patients who are not found to be depressed. Screening for distress
is clearly not a panacea for the problem of depression in primary
care (see Coyne et al., 2000, for a review). A recent meta-analysis
failed to find that routine screening improved the outcome of
depression in general medical care (Gilbody, House, & Sheldon,
2001), and a cost-effectiveness analysis concluded that screening
was justified under only highly restricted conditions (Valenstein,
Vijan, Zeber, Boehm, & Buttar, 2001). However, both of the analyses
may still have been overly optimistic in their conclusions, because
they made unrealistic assumptions about rates of treatment in the
absence of screening and about the effectiveness of treatment under
conditions of routine care (Coyne, Palmer, & Thompson, 2001).
One important limitation on the effectiveness of routine screening as a means of improving the outcome of depression is that it
depends on the effectiveness of initiating treatment of patients who
are found to be depressed. Ormel et al. (1990) reported that
although detection of depression was associated with fewer patients meeting diagnostic criteria for depression at 1 year, treatment of depression was not associated. Brugha, Bebbington, MacCarthy, Sturt, and Wykes (1992) noted equivalent outcomes for
major depressive disorder patients not receiving antidepressant
treatment and for those receiving treatment. A number of studies in
both North America and Europe found either modest short-term
benefits for detection and treatment or, more consistently, none at
all (Coyne, Klinkman, Gallo, & Schwenk, 1997; Pini, Perkonnig,
Tansella, Wittchen, & Psich, 1999; Rost et al., 1998; Simon et al.,
1999; Tiemens, Ormel, & Simon, 1996). Indeed, Schulberg et al.
(1996) found that the improvement rates of depressed patients
provided antidepressant treatment by primary care physicians was
only 48%, which is lower than the rates of improvement often
found with placebos administered in the context of randomized
clinical trials in specialty mental health settings.
Next Wave of Physician- and Practice-Centered Strategies
for Improving Outcome
Renewed efforts to improve the outcome of depression in primary care tend to presume that the difficulty lies with primary care
SPECIAL ISSUE: PRIMARY CARE
physicians. Physician-centered interventions have included a variety of educational strategies, feedback and supervision, and academic detailing. In a review of the literature from 1966 –1998 for
all emotional disorders in primary care, Kroenke, Taylor-Vaisey,
Dietrich, and Oxman (2000) reported changes in diagnosis and
treatment for the majority of interventions but improvement in
patient symptomatology for only 4 of 11 studies, with some of this
improvement short-lived. For instance, Katon et al. (1995) examined the effect of a collaborative management protocol including
training, conferences, and a review of each case by a psychiatrist.
Although considered a successful trial, the intervention improved
outcomes for only those patients with major depressive disorder
who required adjustment of their medication regimen during the
intervention period. Lin et al. (1997) later found that none of the
short-term improvements in depression treatment persisted after
the collaborative care intervention ended.
Several newer primary care interventions have also failed to
improve outcomes. In a particularly ambitious study, Goldberg et
al. (1998) randomized 15 practices with 95 practitioners and 1,177
depressed patients to either academic detailing, continuous quality
improvement, or routine care but were unable to demonstrate
improvement in patient outcomes for the active intervention
groups. Katon and colleagues (Katon et al., 1999) have now
reported a stepped collaborative care trial, which provided collaborative care intervention for only those patients whose depressive
episodes had not resolved at 6 – 8 weeks. They found improved
outcomes at 3 and 6 months, although differences in outcomes
were of marginal statistical significance at the 6-month measure.
Tiemens et al. (1999) implemented a 20-hr training program for
primary care physicians on detection, diagnosis, and treatment,
finding an initial improvement in short-term outcomes for depressed patients but no effect by 1 year. C. Thompson et al. (2000)
carried out a randomized, controlled trial of a practice-based
educational intervention based on clinical practice guidelines in 60
primary care practices in the United Kingdom and found no effect
on either recognition or clinical outcome.
Results from recent studies examining both practice-level interventions and outcomes monitoring are just now becoming available. These studies show minimal short-term improvements in
selected patient outcomes when compared with routine care (Rollman et al., 1999; Sherbourne et al., 1999), but even these minimal
improvements may not be maintained (Lin et al., 1997, 1999) and
are unlikely to result in improved quality of life or daily functioning (Revicki, Simon, Chan, Katon, & Heiligenstein, 1998; Simon
et al., 1998). Trials with multiple outcome assessments showed
narrowing of differences between intervention and control arms
over time (Hunkeler, 1999). An important but often overlooked
finding in this generation of clinical trials is that routine or usual
care arms often show short-term improvements in outcome measures approaching that of intervention arms. It is clear that not all
patients require intensive intervention, and better identification of
those who do could provide a means of better allocating resources.
Whither Psychotherapy in Primary Care?
The AHCPR Depression Guidelines are widely interpreted as
emphasizing medication, and most efforts to improve the outcome
of depression in primary care have a similar bias. Collaborative
mental health care has generally come to mean psychiatrists or
803
nurse specialists providing enhanced management of medication.
Some ongoing multisite trials for which results are not yet available prescribe psychotherapy as a second line of treatment for
patients who refuse medication or who are inadequately responsive
to it (Schulberg et al., 2001; Unützer et al., 2001). All of this
reflects the profound medicalization of the issue of emotional
disorders in primary care. On the other hand, data demonstrating
the effectiveness of psychotherapy provided to depressed primary
care patients within the constraints of that setting are quite limited.
Schulberg et al. (1996) showed in intent-to-treat analyses that
interpersonal psychotherapy (IPT) was equivalent to enhanced
management of antidepressants, and both were superior to routine
care, despite that only 42% of the patients receiving IPT and 33%
receiving antidepressants completed the trial. Secondary analyses
showed that this effect also held for severely as well as mildly and
moderately depressed patients (Schulberg, Pilkonis, & Houck,
1998). Two studies have failed to show a benefit for cognitive
therapy over routine care by primary care physicians (Scott &
Freeman, 1992; Teasdale, Fennell, Hibbert, & Amies, 1984), but
another study showed a benefit (Ross & Scott, 1985). Reviewing
the outcome studies available through 2000, Schulberg, Raue, and
Rollman (in press) concluded that, overall, manualized psychotherapies were superior to routine care for depressed primary care
patients.
Yet there remains the practical issue of skilled therapists willing
to adhere to manualized treatment being readily available in primary care. Both IPT and cognitive therapy require highly skilled
therapists, and their efficacy may depend on the degree to which
therapists adhere to the manualized treatment manuals (Frank,
Kupfer, Wagner, McEachran, & Cornes, 1991). Mynors-Wallis
and colleagues (Mynors-Wallis, 1996; Mynors-Wallis, Davies,
Gray, Barbour, & Gath, 1997; Mynors-Wallis & Gath, 1997;
Mynors-Wallis, Gath, Day, & Baker, 2000) have tested a problemsolving treatment (PST) for depression that is specifically designed
to be feasible for clinicians who are not highly trained in providing
therapy. The most recent trial using PST randomized patients to
one of four treatment groups: PST administered by a nurse, PST
administered by a general practitioner, antidepressant medication,
or combination treatment with PST and medication (MynorsWallis et al., 2000). No differences in outcomes were seen at 6, 12,
or 52 weeks, although all groups showed significant levels of
improvement. The authors concluded that their results demonstrate
the effectiveness of PST at levels equal to that of antidepressants,
although it is unclear whether the study was sufficiently powered
to detect differences between the groups.
What effectiveness can be expected for routinely referring depressed primary care patients to psychotherapists? Phrased in this
way, effectiveness depends not only on the efficacy of treatment
but on uptake—patients accepting the referral and adequately
completing the course of treatment. Psychotherapy may appeal to
the substantial numbers of primary care patients who reject antidepressants (Rost et al., 2000). Schulberg et al. (1996) and others
have demonstrated that treatment effects are found even when
depressed primary care patients with substantial physical comorbidity are not excluded from a clinical trial. Yet, however encouraging such data may be, policymakers may remain unconvinced of
the benefits of referral of depressed primary care patients until
effectiveness can demonstrated under conditions of routine care.
Aside from issues of patient uptake, there are unanswered ques-
804
COYNE, THOMPSON, KLINKMAN, AND NEASE
tions about psychotherapists’ performance outside of clinical trials
in which treatment fidelity is monitored and enforced. Practicing
clinicians tend to express reservations about adherence to manualized treatment as being too rigid (Addis & Krasnow, 2000).
Moreover, some data are not reassuring that concern the effectiveness of routinely provided psychotherapy. Lambert, Hansen, and
Finch (2001) examined effectiveness data for over 10,000 patients
receiving psychotherapy in a health maintenance organization. At
least 21 sessions were required for 50% of the patients to show
clinically significant improvement, and it was estimated that at
least 40 sessions and sometimes the addition of medication would
be required for 75% of patients to show clinically significant
improvement. Effectiveness of psychotherapy in this study was
undoubtedly limited by the nonspecificity of the treatment provided, as well as the nonspecificity of the conditions being treated.
Lambert et al. (2001) noted that a substantial percentage (10%–
20%) of the patients were already highly functioning and therefore
could not be expected to show substantial gains from treatment.
These data are thus not decisive, even if they suggest that routine
psychotherapy may require more sessions to be effective than
many patients and third party payers are willing to accept. However, it is likely that policymakers will require compelling effectiveness data as well as efficacy data if they are to be convinced of
the benefits of referring depressed patients to psychotherapy. Such
demonstrations should be seen as an important research agenda.
Competing Demands on Primary Care as a Treatment
Setting for Emotional Disorder
There is a certain Willie Suttonism to the focus on emotional
disorders in primary care.1 A large number of individuals with
emotional disorders are to be found there, and many of them will
not have consulted a mental health professional. Primary care
providers are prepared to dispense medications that have proven
efficacious in clinical trials. Yet the results obtained with this
treatment do not match what is obtained in clinical trials, and a
variety of interventions to improve patient outcomes have not had
marked success. In light of this, greater attention needs to be given
to some of the difficulties posed by primary care as a treatment
setting.
During routine clinical encounters, primary care physicians deal
with multiple health problems and multiple priorities encompassing multiple domains, biomedical as well as social and emotional.
This complex balancing act must take place over 12–15 min under
usual circumstances (6 min in the United Kingdom), setting limits
on what can be accomplished and placing negotiation at the center
of every primary care encounter (Klinkman, 1997). The various
practice- and physician-centered efforts to improve the outcome of
emotional disorders have minimized the role of the patients in this
negotiation. The assumption seems to be that they are passive,
open to discussion of their problems in terms of emotional disorder, and willing to accept treatment with an emphasis on medication. Yet visits to primary care start with patients’ declaration of
the reason for the encounter (for example, “My back hurts,” or “I
need you to check my cholesterol”), which sets the agenda for the
encounter (Lamberts, Meads, & Wood, 1985), and patient responses to clinician questions can encourage, discourage, or deflect subsequent inquiry about symptoms and complaints. As we
have noted, depressed patients’ interest in antidepressants is a
strong predictor of whether their emotional disorder will be detected (Rost et al., 1998), and this is consistent with other evidence
indicating the importance of patient preference (Dew, Dunn, Bromet, & Schulberg, 1988; Olfson, 1991).
A close examination of recent primary care-based interventions
may illustrate the degree to which patient preferences shape treatment. Katon and colleagues (Katon et al., 2001) recently reported
a relapse prevention program with primary care patients diagnosed
with recurrent depression. Although the trial specifically targeted
patients who had already been diagnosed and had accepted treatment in the past, the results of recruitment efforts were sobering.
Only a little more than half (53.6%) of patients eligible for the
study were successfully enrolled, and most of the failure to enroll
was due to patient refusal or dropout before enrollment; in fact, by
the conclusion of the study, more patients had refused or dropped
out than those originally enrolled (Katon et al., 2001). In a lessselect sample of patients, one would expect an even lower level of
uptake. A recent trial by Wells and colleagues (Wells et al., 2000)
illustrated this. In investigating a quality improvement program,
they screened a large number of primary care patients. Of the
patients who were screened and eligible to participate, only 35%
were enrolled; the rest refused or dropped out before the beginning
of the trial (Wells et al., 2000). Most intervention trials report
similar levels of uptake, despite aggressive recruiting and the
provision of free medication or psychotherapy. These problems are
likely to be magnified outside of traditional intervention trials,
when these barriers to treatment are not addressed.
Klinkman’s (1997) model of competing demands of psychosocial care depicts detection and treatment of emotional disorder as
dependent on the interactive effects of patient, clinician, and
practice ecosystem factors, balanced over time in a setting of
shifting clinical priorities and competing demands for the time and
attention of both clinician and patient. Hohmann’s (1999) contextual model for clinical mental-health-effectiveness research similarly portrays treatment outcomes as a direct result of a complex
therapeutic process, as influenced by characteristics of caregiver
and client, their respective personal and professional networks, and
larger organizational and personal cultures. The two models are
strikingly similar: both emphasize the central role of the patient as
well as the provider, both postulate multiple influences on the
behavior and decisions of the central actors, and both place treatment in the context of an organizational environment. Greater
understanding of the variables and psychosocial processes identified by these models as relevant to the treatment of emotional
disorders in primary care is crucial to improving the outcome of
this care.
Emotional Disorders in Primary Care:
Missed Opportunity or New Frontier?
Our discussions should convey the significance of emotional
disorders in primary care and how current understanding is dom1
William Francis Sutton Jr., also known as Willie Sutton and Willie the
Actor, was a celebrated American bank robber and prison escapee. The title
of his autobiography, Where the Money Was (written with Edward Linn;
Sutton & Linn, 1976) echoed his allegedly often repeated reason for
robbing banks: “Because that’s where the money is.”
SPECIAL ISSUE: PRIMARY CARE
inated by a biomedical perspective, to which psychologists have as
yet contributed little. We can point to the largely disappointing
results of efforts to improve the outcome of emotional disorders in
primary care and call for a greater role for psychologists. However,
it may be unrealistic to expect that primary care will be deemphasized as a key context for the treatment of emotional disorders or to expect a wholesale integration into primary care of
psychologists providing conventional psychotherapy. Nonetheless,
there are key ways in which psychologists can have a crucial role
in redefining a research agenda for emotional disorders in primary
care, and in doing so, they can identify a place for the discipline’s
unique expertise. There are a number of pressing needs:
1. Develop a nosological system for emotional disorders in
primary care that takes into account that many patients will not
present with clearly defined symptom patterns. Such a system
would undoubtedly require a temporal perspective to explicate
patients’ presentation and will need to be validated in terms of its
ability to predict benefit from treatment.
2. Address accelerating rates of the prescription of psychotropic
medication, particularly among the elderly. Efforts to increase the
detection and treatment of emotional disorder need to be tempered
with greater attention to when medication is inappropriate and
when it can be terminated. Reduction in the inappropriate prescription of antidepressants and anxiolytics should be identified as an
important mental health outcome.
3. Explicate the relevant patient variables and social processes
affecting problem definition, acceptability of treatments, and preferred providers and settings. This would involve attention to the
trade-offs and commitment of resources patients are willing to
accept and an underlying conceptualization of patients as decisionmaking consumers, not simply passive recipients of treatment.
4. Explore the relationship between symptom relief and the
associated personal and social problems patients seek to have
addressed in primary care. This involves attention not only to
functional outcomes but to the interpersonal circumstances that
give rise to emotional disorder and leave patients vulnerable to
relapse. Indeed, the potential for this role in relapse prevention is
validated by a recent meta-analysis of cognitive– behavioral treatment outcomes (Gloaguen, Cottraux, Cucherat, & Blackburn,
1998). The value of psychotherapeutic intervention should be
defined in part by a rehabilitative function not served by medication alone.
5. Explicate the relevant provider and practice variables that
affect how treatments are delivered. The lack of acceptance of
psychiatric nosology by primary care providers, the ineffectiveness
of screening-based feedback in improving outcomes, and the disappointing effects of educational strategies and practice guidelines
on provider behavior all point to the need for a better understanding of providers.
6. Develop brief, structured psychological treatments compatible with the competing demands and staffing of primary care. Just
as SSRIs allow simplified treatment algorithms for treating emotional disorders, it should be possible to develop algorithms for
psychological treatments that exploit common elements or mechanisms. For instance, there has been lively debate as to whether
similarities between behavioral activation for depression and exposure for anxiety might allow for simplified strategies for treating
anxiety and depression (Arean & Coyne, 2000).
805
7. Identify what bundling of skills and services might make
integration of psychologists into primary care more cost-effective
and acceptable. For instance, roles in the diagnosis and treatment
of emotional disorder might be supplemented with activities such
as health promotion and pain management. The opportunities
related to health psychology and behavioral medicine in primary
care may be complementary to those related to a role in the
management of emotional disorders.
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Received January 17, 2001
Revision received October 7, 2001
Accepted October 7, 2001 䡲