Depression in Primary Care Setting


Any form of mental illness has been for a long time and for many societies around the world considered as a stigma. It is in most cases difficult to understand, by the patient or individual himself, much less by the people around him no matter how close they may be related. Its characteristic varies from the many kinds of mental illnesses that have been identified of late, but just the same, most forms of mental illness remain elusive to pin down exactly why it occurs or how to effectively prevent and treat it.

This paper will try to discuss ways in which primary care and mental health services can respond to mental illness across individuals, groups, and communities with consideration to how health and social policy play into these understanding and services. It will focus on depression as a distinct type of mental illness.



Depression is considered a psychological or psychiatric disease and was ranked first amongst all physical conditions as the World Health Organisation’s Global Burden of Disease study as the leading cause of years lost to disease rated at 11.9% (Ustun et al, 2004). It is a syndrome that refers to sadness described by the Diagnostic and Statistic Manual of Mental Disorders (DSMMD) as a feeling of sadness, helplessness or hopelessness. Depression has also been related to heredity, sleep difficulties, hormones, stress, alcohol or drug use, malfunction of the neurotransmitter, injury, and exposure to substances or chemicals (Farrow, 2003). Its causes vary from person to person with multiple syndromes. Some of the factors viewed to cause depression include traumatic life experiences, personality, loss, lifestyle, disease or illness, and even nutrition. Depression was for a long time considered unreal and believed to be a disorder only of the middle-aged and the elderly, excluding teens (Evans et al., 2005). It was later established through research that the primary onset of major depression usually takes place in adolescence and young adulthood (Evans et al., 2005). Depression’s connection to suicide makes it the most generally considered mental health dilemma because of its effect on individuals, families, and society.

Depression can be a constant, persistent, and serious illness (Evans et al., 2005). The lifetime occurrence of depression among individuals at present is likely to be 14.0% (Substance Abuse and Mental Health Services Administration [SAMHSA], 2005). A 2004 estimate places 2.2 million adolescents aged 12 to 17 with one major depressive episode or MDE (SAMHSA, 2005). Depression is more regular among males that insets prior to puberty stage. In adolescence, occurrence turns out to be more common among females (Evans et al., 2005). Even though it is more common in female adolescents, depressive signs/indications and the analysis of depression have an important influence on male morbidity and mortality.

The DSMMD, Fourth Edition (DSM-IV) diagnostic criteria for depressive disorders placed gender distinctions in symptom appearances. Males appear to develop more obvious violent behavior notable from elementary and latency years (Jackson & Lurie, 2006). Even though there are a few special cases, the majority of studies have acknowledged that male adolescents respond to a depressed mood in a more aggressive, annoyed behavioral manner, while females act in a thoughtful manner (Jackson & Lurie, 2006). Facts from qualitative studies on adults proposed that men display high-risk inadequate adaptation behaviors as a way of bettering depressive symptoms. It was also proposed that reporting of symptoms is reduced to keep away from the stigma of suffering and perception of weakness or susceptibility (Brownhill, Wilhelm, Barclay, & Schmied, 2005). Studies on the relapse of as well as a long-term outcome of primary care for depression showed a recurring rate for 10 years or less at around 30-40%. Long-term follow-up studies still have not been conducted. Yiend et al (2009) found in a limited sample of primary care patients with over 20 years found over 60% recurrence although the time of the first recurrence is delayed.

There are four major mechanisms to the introduction of treatment of depression before the clinician can take upon the variety of recommendations and management choices:

  1. Patient/family education: The education of the patient and family must center on depression as an illness and its combined symptoms of a disease (Brent & Birmaher, 2002; Jackson & Lurie, 2006). Relating depression as a medical sickness may assist the patient/family to understand the significance of the problem and require treatment. Patients are frequently reassured that depression is ordinary and well-thought-out as a medical illness and is not an indication of a pathetic character (Jackson & Lurie, 2006).
  2. Identify/mitigate hopelessness by recognizing and justifying desperation, which is connected to pulling out from treatment and suicidal behavior. This may be established in part through teaching and discussion of the potentials of treatment (Brent & Birmaher, 2002).
  3. Create a no-suicide contract: A no-suicide agreement must be set up to outline an oral and written contract if and when suicidal thinking is apparent (Brent & Birmaher, 2002). This type of safety agreement used alone is not sufficient to put off suicide (Jackson & Lurie, 2006) but can regularly test the capability of the patient and family to solve the problem and shape a therapeutic association with the treating clinician (Brent & Birmaher, 2002).
  4. Remove all firearms from the home: take away all firearms from the home for the reason that their presence is a risk factor for suicide (Brent & Birmaher, 2002). This is particularly true for depressed male patients.

Access to Mental Health Services

For patients, recognition and management of depression rely in great part on right to use of health care services. Some primary care clinicians could not follow the course of action connected to depression for reasons including lack of knowledge, skills, or time.

For clinicians who do follow guidelines, the shortage of mental health specialists makes it complicated for PCCs to present required referrals. In addition, patients also meet financial barriers to services.

In 2006, Kapphahn et al. inspects a number of factors that influence admittance, as well as insurance status, mental health equality and other legislation, and dealing with care preparations that “carve-out” mental health services to an organization different from the organization providing physical health services (Kapphahn et al, 2006). These carve-outs, recognized in both public and private insurance, frequently prevent reimbursement even in a preliminary evaluation and recommendation from a PCC. Therefore, patients and their families have to find a way for the system to get the required care with restricted management from a PCC. Insured patients have more way into mental health care than the uninsured, according to Kapphahn et al. (2006). Insurance, however, may not cover optional services for depression, particularly outpatient mental health services.

The National Health Services, NICE and Mental Health

The National Health Services through their Standard One project ensures that health and social services help promote mental health at the same time reducing discrimination and social exclusion of individuals or groups with mental health issues. It ensures to change people’s attitudes towards mental health illness through the Councils and Care Trusts. Government agencies and organizations are expected to promote mental health for all, fight discrimination against individuals with mental health problems, and encourage their inclusion in social activities (DOH, 1999). The NHS places a high priority on mental health through the National Service Framework (NSF) for Mental Health. The NHS Plan ensures extra resources to modernize and deliver the NSF in creating extra secure beds, 24-hour staff beds assertive outreach teams, and access to 24-hour services for individuals with complex mental health needs (DOH, 2009).

Primary Care for Depression

Among studies in the UK, there is a general consensus about depression as similar in all ages with identified factors as loss and grief, social isolation, medical illness, and disability (Jorm, 1998). It is however believed that the first point of access to mental health care is the general practitioner (GP) and they are also expected to directly provide most of the treatment for common mental disorders and referral to specialist mental health services. An average British GP is said to have about 30 cases of depression amongst older patients at any given time while the GP may see 7 to 10 new cases each year (Anderson, 2001). It was suggested however that only about 38% of those identified with depression receive treatment and referral (Crawford, Prince, Menezes and Mann, 1998). It suggests a lack of response by GPs and is seen as more problematic than a lack of recognition. Patients from black and minority groups are also less likely than their white patient counterparts to be recognized with the problem in primary care (Bhui et al, 2002). While there is a basic reliance on GP management of depression, there is a growing expectation from practice nurses on the management of depression in primary care. Their regular contacts with patients who either have other related illness or admittedly have depression make them well-placed to observe patients’ behavior, attitude and demeanor indicative of depression although problems related to its recognition is still persistent identified as denial of the illness as a medical problem therefore unnecessary to be discussed with the doctor; downplaying of the difficulties and symptoms as unimportant for the GP; admission of depression is a sign of weakness; and knowledge that depression is a mental illness, therefore, carries a stigma (Murray et al, 2006).

GPs in the UK are guided to manage depression within primary care by prescribing anti-depressants as a first-line treatment indicating that primary care physicians are expected to be able to diagnose and treat clinical depression in their daily practice. However, modern medication is seen to have a minimal impact on the long-term outcome of depression requiring psychiatric treatment. Studies indicate that relapse is up to 75%, with extensive disability or suicide at more than 20% of cases (Kennedy et al, 2003; Furukawa et al, 2008). Another study indicated that 91% of 258 patients remained clinically depressed after ten years of medication (Solomon et al, 1997). These alarming issues of depression are addressed through the National Institute of Clinical Excellence (NICE) guidelines for depression in the UK. It requires screening of depression under primary care in the community and residential settings as well as general hospital settings for high-risk groups indicated through past history, significant physical illnesses causing disability, and other mental health problems such as dementia. The guideline also indicates that depression management should conduct initial treatment for at least 6 weeks prior to considering or switching antidepressants seen as ineffective. A minimum of 12 months is suggested for the use of antidepressants as treatment (Rasmussen, 2008).

The aim of the NICE guideline is to recognize depression in primary care, manage mild, moderate and severe depression within primary care with a structured framework, involve specialist mental health teams, and prioritize treatment in co-morbid depression anxiety. The guideline also recommends mild depression-guided self-help, computerized CBT, exercise and short psychological interventions while antidepressant medication, psychological interventions and social support are recommended for moderate depression NICE, 2004). Appendix A shows the diagram provided for Mild Depression Care Pathway.

The DOH acknowledges the importance of Primary Care Teams as partners in the efficient and effective delivery of comprehensive mental health services including those with depression. As already mentioned, the majority of depression patients are managed in primary care. It has been signified that one in four of all GP consultations will have a mental health component. The contribution of primary care to dealing with depression is represented in the NSF’s Primary Care standards 2 & 3. The NHS Plan focused on:

  • “patient information and empowerment, for example, patient involvement in decisions about their care;
  • prevention and risk management, for example, patients know who to contact in an emergency and better physical health care for people with mental health problems;
  • partnerships, for example with users and carers and with mainstream services like education and employment;
  • new professional resources, including 1000 new mental health workers and 500 gateway workers;
  • better performance, assessed through patient satisfaction, levels of psychiatric morbidity and access to NHS Direct,” (DH, 2002, p 18 ).

These goals on prevention, partnership and empowerment, highlight the role of primary care as a resource for mental health promotion as well as the center of a whole system approach to address the problem of depression.

Mental health workers in primary care are part of the primary care team expected to provide information, assessment, screening and onward referral when needed. They are trained in brief interventions such as anxiety management (DH, 2002).

The Health Improvement Plan set out to attain by April 2001 some 25% of PCGs with Trust status (PCTs), about 50% of the population provided with primary care from within PCTs. This also provides opportunities for primary care to engage with organizations in the community, voluntary and informal care sectors to address depression and other mental health problems (DH, 2002).

The PCG has developed for itself local adaptation of the health authority’s strategy as PCGs/PCTs established health improvement sub-committees and developed sub-district health strategies focused on mental health promotion based on local needs.

A core aim is to reduce discrimination against people with mental health problems and increase access to mainstream employment, housing and leisure facilities (DH, 2002). Access to health promotion, screening and other prevention services is also explicitly highlighted for patients to address physical health needs which may be neglected (Plummer and Gray, 2000).

The strategies set out include linking with relevant local authority departments such as the social services, housing, education, leisure and employment as well as with Community Strategies, Local Agenda 21 Strategies, Community Safety Partnerships, Sure Start Programmes and Lifelong Learning Development Plans (DH, 2002).

Excluded groups such as the homeless and minority ethnic groups, with difficulty in accessing primary care, were also included in the program. The health and social care agencies were also encouraged to employ those with mental health problems as specialist clinics for mental health problems are also established (Plummer and Gray, 2000).

Treatment for depression has generally been through the prescription of antidepressants where months of depression are parallel to months of medication. Patients who suffer recurrence usually received medication. Community care is a current trend that is believed to have an impact in lessening hospital admission for severe cases. Psychological interventions such as cognitive-behavioral therapy have also been recommended as a first-line treatment for depression (NICE, 2004) but lack of availability has been noted (DH, 2007).

Issues in Recognition and Treatment of Depression

Despite the fact that one in four adults will become affected with some mental health problem throughout their life span, for several patients, it is significant to examine mental illness as a continuing care issue, and in this situation, many people with chronic disease do not receive a suitable care (Epping-Jordan, 2004). For instance, only 50% of people with depression in the UK and 15% of people with continuing mental health problems such as major depression in the USA have a record of getting care considered as evidence-based (Wang, 2000). This may also be because people with depression do not look for the care that they have to (Gask, 2003). Patients with depression may not sense that they ought to have to take up a GP’s time and that GPs may not listen and cannot appreciate how they feel. This makes methodical follow-up significant, as well as making sure that the patients feel involved in their care (Gask, 2003).

Further research put forward that GPs appear to be affected in treatment decisions by the seriousness of a patient’s symptoms rather than the social background of suffering patients may find themselves in (Hyde, 2005). However, adherence to a social model may also have an effect on therapeutic rejection (Hyde, 2005). Patient assessments of mental health perceive depression as both an ‘illness’ and a way of thinking and being (Gask, 2003). Consequently, a holistic approach is necessary, with emotional, physical and spiritual factors being taken into account (Dowrick, 2004). People with ordinary mental health problems are usually hesitant to take on in the ‘user movement’, which has been more effective for those who experience ‘severe and enduring mental illness, which typically means those that are previously in contact with specialist services. If clients who partake are not a member of local patients, this may weaken the efficiency of user/patient participation in developing new primary care-based mental health services that especially meet the needs of people treated only in primary care settings (Dowrick, 2004). However, user participation needs primary care practitioners to see patients with serious mental illness as associates and to see their beliefs as applicable and important (Lester, 2006).

Quality of care can be described as whether patients can get through successful care, in conformity of need, resulting in preferred health results; however, as a perception, quality of care is at its total when applied to an individual’s encounter with and experience of healthcare (Campbell, 2000). Participatory research strategies, such as focus groups or in-depth interviews are a useful means of guarantying that service users are mixed up in preparation and delivering health services in the order of a definite issue (Lester, 2006). The program must also center on care pathways (Appendix A) for individuals and the usually appearing problems, not just general issues such as approval and a move away from focusing on the care of populations to individual patients (Callay, 2005).

Primary mental healthcare includes a wide variety of agencies and stakeholders, and patients frequently have numerous and varied needs and problems for which desired results are challenges and are not at all times simply measured. Since depression is complex, its assessment must also be comprehensive.

Nevertheless, quality developments need to focus on numerous levels and to hold close a selection of methods, including awareness to patient narratives as well as quality signs and questionnaires. It is critical to see depression through the eyes of individual patients. General questionnaires cannot reproduce the multiplicity of the individual patient accounts. Likewise, information that the patients react may relate to different situations and diagnoses.


Mental health policies and health agencies work hand-in-hand with primary care providers in order to successfully attain the management and treatment of depression patients. Much lay in the hands of general practitioners with their direct access to health information about possible patients who or who may not want their illness to be “discovered”. Through the deep knowledge, understanding and communication skills of primary care practitioners about depression, patients are assured that depression is another medical illness that should be treated as much as influenza and other diseases. Patience and care are expected from primary care practitioners as much remain to be understood about depression.


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Mild depression care pathway
Source: NICE, 2004.
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