Although many patients do not recognize or voluntarily admit symptoms of depression, Dr. Platt reminds us that compassionate and alert physicians can often detect these initially "hidden" depressive disorders. In such cases, formal case-finding instruments may be unnecessary or serve only to confirm suspected diagnoses. The U.S. Preventive Services Task Force does not recommend formal depression screening but does recommend that clinicians maintain a high index of suspicion for depression—in essence recommending, as Dr. Platt does, that physicians diagnose depression through a careful history (1). Yet many patients with depression remain undiagnosed and many patients who are diagnosed receive inadequate treatment (2).

Given this situation, health care organizations have considered ways of assisting physicians in diagnosing or treating depression more effectively, usually through educational programs or formal depression screening. Less often, organizations have offered intensive interviewing courses, particularly to trainees. (Intensive interviewing courses have shown promise in increasing the detection of depression in one study [3], but the costs of providing this training and the frequency with which it must be offered are unclear.) Health care organizations have seldom implemented multimodal programs to increase the effectiveness of depression treatment.

In our article, we note that meticulous attention must be paid to both the costs of intervention to increase detection and the effectiveness of treatment. From the tone and content of his letter, we suspect Dr. Platt is highly adept at identifying depressed patients and is also adept at communicating these skills to students. If Dr. Platt and his students efficiently identify depressed patients within the context of a thorough interview and provide effective treatment—by carefully educating their patients, monitoring them closely after treatment initiation, paying close attention to issues of adherence, changing antidepressants when response is inadequate, and appropriately referring patients to mental health specialists—their interventions are likely to be highly cost-effective (4). However, some physicians may be less adept at identifying depression, and most physicians require support to provide the complex but essential components of depression treatment. Even after extensive education, physicians who do not receive systematic support for treatment have difficulty maintaining optimal practices (5).

We commend Dr. Platt for his efforts to train young physicians to carefully listen to their patients and remain alert for depression. However, without organizational support for systematic follow-up, highly attuned physicians or repeated screening programs can add only limited value.