Readers of FmH know I harp on this theme. Now I can point to somebody else making the same point.

“Only about 40 percent of people in treatment for depression get adequate care, according to a survey of more than 9,000 Americans that was sponsored by the National Institute of Mental Health and released last week…

Dr. Ronald Kessler, a professor of health care policy at Harvard who was the lead author of the study, says a crucial problem is that general medical doctors tend to be the first line of defense against mental disorders as well as physical ones. Because they are not as well informed about depression as mental health specialists, he said, they are more likely to undertreat it — prescribing either too little medication or an inappropriate one, like an anti-anxiety drug.

These general practitioners, typically family doctors and internists, treat 70 percent of the people who seek help for depression, according to other research. And more of them are treating depression now than a decade ago, Dr. Kessler said, because the newer antidepressants — selective serotonin reuptake inhibitors — are safer and easier to prescribe than older drugs.

‘The companies that make these drugs are providing more educational material to general medical doctors,’ he said.”

Psychiatrists interviewed for this article hastened to add that they were not maligning their primary care colleagues’ abilities to treat all depression, but that severe or complicated cases should be referred to psychiatrists or psychologists. This, of course, leaves open the question of whether there would be adequate recognition of these critical cases.

“Most patients don’t come in and say, `I feel sad or depressed,’ ” he said. “They emphasize complaints like fatigue or insomnia or other physical manifestations of depression.”

Primary care MDs are generally more comfortable talking about these physical symptoms and may not get to the emotional crux of the matter. Engaging someone to talk about something uncomfortable in a comprehensive way is a skill and an art honed by the training and experience unique to mental health practitioners, as is adequate experience in psychopharmacology.

The article suggests that some managed care plans have some recognition of the problem and are reducing or eliminating reimbursement for primary care doctors to treat depression, forcing patients to be referred out to specialists. Frankly, I haven’t seen this happening in my part of the country. The rationale I hear over and over again from general practitioners to justify their reluctance to refer their patients out to mental health specialists is that it is ‘stigmatizing’ to the patients. I think this is largely a self-serving assumption on their part, and that they rarely broach the subject to assess their patient’s attitude. And, even if so, the doctor’s role in such a situation should more properly be an educational one, to advocate that their patient do the uncomfortable thing in their longterm best interest. After all, a large part of a doctor’s time is already spent educating patients to do things that initially strike them as unpleasant, uncomfortable or unpopular. But the major ‘training’ around treatment of depression the general practitioners are receiving these days are the pharmaceutical industry pitches persuading them of how easy depression is to treat with just a few swipes of the pen to prescribe a modern antidepressant. The industry knows that psychopharmacologically sophisticated psychiatrists are less likely to be pushed around by the ‘latest and greatest’ marketing claims (although, I hasten to add, readers will recognize that I have written with alarm about how busy psychiatrists have not been immune either from the tendency to stop educating themselves except via pharmaceutical representatives), so it is in their powerful vested interests to maintain the status quo. So primary care MDs will continue to treat depression; they will just avoid using the billing codes for emotional disorders if the patient’s insurance will not reimburse for that category of treatment. And if the insurance will not support a longer office visit for psychotherapy or counseling, the primary care MD will attempt to treat without that.