Improving Care for Depression: There's No Free Lunch

Primary care clinicians know depression well. It steals success and satisfaction from their efforts to improve physical health and robs patients of joy, social networks, productivity, and stable lives. Yet despite their generally reasonable basic knowledge about depression and sense of responsibility for alleviating it (1, 2), primary care clinicians continue to experience diagnostic and treatment failure (3). In answer to the pressing need to do better, the elegant study by Dobscha and colleagues in this issue (4) adds critical information to the existing body of work on improving depression outcomes in primary care, showing that in depression care, there's no free lunch.

Since the late 1980s, when researchers recognized that primary care is the major access point for depression care, studies have explored primary care–based interventions for improving depression outcomes. These studies showed that educational interventions alone, including reminders, did not improve depression outcomes (5, 6). High-quality randomized trials, however, showed that organizational interventions based on systematic, standardized approaches, or care models, for managing depression in primary care practices can improve depression outcomes (7, 8). Often termed “collaborative care for depression,” these care models feature an infrastructure for depression detection, assessment, triage to mental health specialty care, patient self-management, and treatment completion. The models often incorporate stepped care, meaning that more complex, treatment-resistant patients receive more intensive or specialized treatments (9). The core collaborative care resource is usually a depression care manager, commonly a registered nurse. The care manager fosters collaboration between patients, mental health specialists, and primary care clinicians and bridges the gaps in care through which hopeless, helpless, and side effect–prone patients with …