I agree with Drs. Pincus and Sacks about the essential role that primary care clinicians must play in diagnosing depression. Because most depressed patients first present in primary care settings, linking their symptoms to depression and persuading them of the diagnosis are what I consider reasonable expectations. In this regard, the resources identified by Pincus and Sacks and their call for universal training are timely.

Detection of depression, however, is necessary but not sufficient. Once recognized, depression requires empathetic responses, attentive listening to the individual story, separation of the medical from the psychosocial, and a reasoned rather than a reflexive prescription of antidepressants. A "go slow" approach may be needed to overcome the understandable reluctance of some patients to immediately embrace a diagnosis that society all too often stigmatizes. Although the brevity of primary care visits may be a business priority, depression does not lend itself to short cuts. Rather, longer initial appointments, more frequent follow-up visits, or other system changes are necessary.

Another option is collaborative care [1], in which primary care providers work together with mental health specialists in the first few critical months of initiating treatment, educating the patient, maintaining compliance, and inducing remission. Team care is not unique to depression. For example, primary care providers often enlist other providers in caring for the diabetic patient (dieticians, podiatrists, ophthalmologists) or the geriatric patient (social workers, physical therapists, audiologists). In Field of Dreams, after all, nine players were required to field a team, not just a pitcher.

Although the individual and societal costs of untreated depression are undeniable [2-4], a cost-offset debate continues to handicap the optimal financing of depression management. Skeptics insist that the treatment of mental disorders is justified only if overall health care costs diminish or at least do not increase. This economic standard is higher than that typically required for medical disorders. The alleviation of suffering is often not a cost-neutral venture, whether the illness stems from physical or psychological disorders.

Pendulums may swing too far. Whereas treatment of depression was once considered predominantly the territory of mental health specialists, cost-containment imperatives threaten to shift the entire responsibility onto the shoulders of primary care physicians without providing the additional time and resources that busy practitioners need. I do not intend to let primary care physicians off the hook, but it isn't fair to let them wriggle on the hook alone.