Depression in the Family Physician's Office: What the Psychiatrist Needs to Know: The Michigan Depression Project

A rapidly growing body of research suggests that depression in primary care may differ from thatin psychiatry in its nature, severity, comorbidity, and responsiveness to treatment. The Michigan DepressionProject is a long-term series of studies designed to explore the twin assumptions that depressedprimary care patients are similar to depressed psychiatric patients and that identical treatmentwill benefit both groups. Major findings are (1) criterion-based diagnosis of major depressive disorderin primary care includes many patients with mild depression and little to no impairment; (2) the onsetof depression among family practice patients—but not psychiatric patients—is usually preceded by asevere life event; (3) in primary care, outcome for patients with undetected depression appears to becomparable to that for those with detected depression; and (4) family physicians appear to employhistorical cues in assigning the diagnosis of depression to distressed and impaired patients. The resultsof the Michigan Depression Project and the recent work of other researchers suggest that the challengesfacing primary care physicians in the diagnosis and treatment of depressed patients are daunting.These challenges lead to a set of consultative skills and behaviors on the part of psychiatrists thatmay be different than generally expected. One-time, stand-alone psychiatric consultations are oftenneeded, because neither the primary care physician nor the patient desires the psychiatric care to be"carved out" from the continuing care of a set of chronic problems. Future intervention studies shouldcompare subgroups of patients who appear most in need of treatment (on the basis of functional impact)with those who are mildly depressed and barely meet diagnostic criteria. These studies will helpprimary care physicians focus their energies and therapies where they will have the most benefit intreating what is clearly a common and important, but still poorly understood, problem in primary caremedical practice.