We thank Drs. Theleritis and colleagues for pointing out the importance of depression in causing increased mortality due to suicide. As they say, the adverse effects of depression on cardiovascular health and other chronic disease outcomes are well documented. We agree that these effects, in combination with the low quality of care we observed, are cause for alarm. Our comments on mortality related to depression come from a different perspective, however, and we are grateful for the opportunity to clarify.

For many conditions, avoidance of death and hospitalization are critical drivers for quality improvement. For patients hospitalized with congestive heart failure, for example, the observed high short-term rates of death and repeated hospitalization have enabled studies to validate quality improvement programs against both economic and mortality outcomes. In the case of depression, however, hospitalization is relatively rare and effects on death occur over a prolonged period. Also, in our studies, we protect people from death due to suicide by intervening if they disclose significant suicidal risk. So, despite having screened more than 50 000 patients to identify our samples and having enrolled more than 1000 patients with major depression, we have no documented episodes of suicide and few deaths during our period of observation.

Hospitalizations during a 6-month period ranged from 19% at the Veterans Affairs Greater Los Angeles Healthcare System to around 5% to 7% for the remaining organizations, with very few admissions due to poor mental health. In the absence of mortality or mental health hospitalization as outcomes, we must validate our quality measures or improvements against such outcomes as depression symptoms, as we did in our study, or against intermediate consequences of those symptoms, such as functional status deficits or employment loss.

Effective care models for improving depression outcomes have been developed and validated in many randomized trials. The quality deficits we identify show why education and reminders alone do not improve care. Had the quality deficits been found in the primary care clinicians' ability to recognize depression, trials testing reminders might have had significant effects. In our study, however, clinicians accurately suspected depression. The deficits were in areas less easily addressed through reminders. We found, for example, a deficit in clinicians' assessments of the factors necessary to decide on an appropriate treatment for depression. Assessment includes ascertaining the presence of diagnostic criteria and other critical treatment factors, such as history of depression, suicidality, alcohol use, anxiety, and bereavement. Improving primary care clinician assessment of depression requires time for and experience with psychological interviewing or testing, and this is hard to find in a 10-minute, multipurpose primary care visit. Similarly, improving patient completion of depression treatment requires methods for actively monitoring and encouraging adherence, objectively monitoring symptoms, and changing medications when necessary—processes that are not consistent with the usual primary care pattern of 3- to 6-month return visits. In the studies reviewed by Gilbody and colleagues (1), the most effective interventions provided primary care clinicians with access to depression care management and collaboration with mental health specialists.