In the United States, the role of primary
care physicians in behavioral medicine has significantly changed over the past
several decades (Olfson et al, 2002; Kroenke et al, 2010; Coyne et al, 2002).
Studies suggest that primary care physicians now prescribe more than 80% of
antidepressants and other psychotropic medications for the population
presenting with depressive disorders (Barkil-Oteo, 2013; Kroenke et al 2010). This
is a dramatic increase since the late 1980’s when only about 35% of
psychotropic medications were being prescribed by primary care physicians (Olfson
et al, 2002; Coyne et al, 2002). The number of patients that will be treated
for psychiatric illnesses by primary care physicians are expected to rise even
further, due factors such as the Affordable Care Act (ACA), which have made
medical and mental health care more available (Barkil-Oteo, 2013).
Now more than ever before, mental health
patients are being seen outside of traditional behavioral health modalities,
with primary care being the greatest sector (Wang et al, 2006). Perhaps
what is most alarming is that primary care physicians are more likely to treat
their patients with depression than refer them out to any mental health care
specialists (Gray et al, 2005; Kolbasovsky et al, 2005; Coyne et al 2002;
Olfson et al, 2009).
It
appears that our current understanding and management of Depressive Disorders
are fundamentally flawed. An under recognized percentage of
patients presenting with depressive symptoms are in fact incorrectly diagnosed
at presentation and therefore provide insufficient or misguided treatment
regimen (Clark, 2011). The
results of imprecise diagnosis and inappropriate treatment include suboptimal
rates of remission, diminished quality of life for patients and often tragedy
(Zimmerman, 2008; Basco et al, 2008; Wells et al, 2000).
While our arsenal of treatment modalities and
pharmacotherapeutics has expanded to an adequate degree (Olfson
et al, 2002), their
deployment is far too frequently misdirected and our rate of successful
outcomes is unacceptably low (Gelenberg et al, 2010; Gray et al, 2005).
Our empirical evidence of successful
treatment remains unimpressive and inadequate, despite increasing awareness of the
prevalence of depression, gradually diminishing stigma associated with the
diagnosis of depression, and an expanding and seemingly adequate arsenal of
psychopharmacologic and psychotherapeutic resources (Forand & DeRubeis,
2013). The primary care setting, therefore, is significant when addressing the
issues and improvement needed for diagnosis and treatment of depressive
disorders.
In order to examine the direction of
current psychiatric care, primary care physicians should be focused on since
they see the majority of depressive patients. While there is a flood of
research addressing issues in the primary care setting, there lacks qualitative
research with interviewing of primary care physicians to understand how they
are in fact experiencing treating psychiatric patients, and if this is where we
should address the issues and employ improvement needed for diagnosis and
treatment of depressive disorders.
References
Barkil-Oteo, A. (2013). Collaborative care for depression in primary
care: how psychiatry could "troubleshoot" current treatments and practices.
Yale Journal of Biology & Medicine, 86(2):139-46.
Basco, M.R., Jacquot, C., Thomas, C. & Knack, J,M, (2008).Underdiagnosing and Overdiagnosing
Psychiatric Comorbidities. Psychiatric
Times, 25:8–10
Clark, D. M. (2011). Implementing
NICE guidelines for the psychological treatment of depression and anxiety
disorders: The IAPT experience.
International Review of Psychiatry, 23(4), 318–327.
doi:10.3109/09540261.2011.606803
Coyne, J.C., Thompson, R., Klinkman M.S., Nease, D.E. (2002). Emotional
disorders in primary care. Journal of
Consulting and Clinical Psychology, 70(3):798-809.
Frankfort-Nachmias,
C., & Nachmias, D. (2008). Research methods in the social
sciences (7th ed.). New York: Worth.
