Current Psychiatry Reports

, Volume 14, Issue 4, pp 328–335 | Cite as

The Depression Treatment Cascade in Primary Care: A Public Health Perspective

  • Brian W. PenceEmail author
  • Julie K. O’Donnell
  • Bradley N. Gaynes
Psychiatry in Primary Care (BN Gaynes, Section Editor)


Major depressive disorder (MDD) is common and costly. Primary care remains a major access point for depression treatment, yet the successful clinical resolution of depression in primary care is uncommon. The clinical response to depression suffers from a “treatment cascade”: the affected individual must access health care, be recognized clinically, initiate treatment, receive adequate treatment, and respond to treatment. Major gaps currently exist in primary care at each step along this treatment continuum. We estimate that 12.5% of primary care patients have had MDD in the past year; of those with MDD, 47% are recognized clinically, 24% receive any treatment, 9% receive adequate treatment, and 6% achieve remission. Simulations suggest that only by targeting multiple steps along the depression treatment continuum (e.g. routine screening combined with collaborative care models to support initiation and maintenance of evidence-based depression treatment) can overall remission rates for primary care patients be substantially improved.


Major depressive disorder Depression treatment cascade Recognition Treatment Remission Primary care Public health 



BWP and BNG’s contribution to this paper was supported by grant R01MH086362 of the National Institute of Mental Health and the National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA. BWP is an investigator with the Implementation Research Institute (IRI), at the George Warren Brown School of Social Work, Washington University in St Louis; through an award from the National Institute of Mental Health (R25 MH080916-01A2) and the Department of Veterans Affairs, Health Services Research & Development Service, Quality Enhancement Research Initiative (QUERI). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIMH or the NIH.


Dr. Pence has received research support from the National Institute of Mental Health (NIMH) and received honoraria and research support from the National Institutes of Health (NIH).

Dr. O’Donnell reported no potential conflicts of interest relevant to this article.

Dr. Gaynes has received research support from the Agency for Healthcare Research and Quality (AHRC), the NIMH, and the NIH; has served as a consultant for Bristol-Myers Squibb; and has received payment for development of educational presentations from MedScape.


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289(23):3095–105.PubMedCrossRefGoogle Scholar
  2. 2.
    World Health Organization. The global burden of disease: 2004 update. 2004; Accessed 25 October 2010.
  3. 3.
    Greenberg PE, Kessler RC, Birnbaum HG, et al. The economic burden of depression in the United States: how did it change between 1990 and 2000? J Clin Psychiatry. 2003;64(12):1465–75.PubMedCrossRefGoogle Scholar
  4. 4.
    Birnbaum HG, Ben-Hamadi R, Greenberg PE, et al. Determinants of direct cost differences among US employees with major depressive disorders using antidepressants. Pharmacoeconomics. 2009;27(6):507–17.PubMedCrossRefGoogle Scholar
  5. 5.
    Pincus H, Tanielian T, Marcus S, et al. Prescribing trends in psychotropic medications: primary care, psychiatry, and other medical specialities. JAMA. 1998;279(7):526–31.PubMedCrossRefGoogle Scholar
  6. 6.
    Harman JS, Veazie PJ, Lyness JM. Primary care physician office visits for depression by older Americans. J Gen Intern Med. 2006;21(9):926–30.PubMedCrossRefGoogle Scholar
  7. 7.
    Gaynes BN, Rush AJ, Trivedi M, et al. A direct comparison of presenting characteristics of depressed outpatients from primary vs. specialty care settings: preliminary findings from the STAR*D clinical trial. Gen Hosp Psychiatry. 2005;27(2):87–96.PubMedCrossRefGoogle Scholar
  8. 8.
    Gaynes BN, Rush AJ, Trivedi MH, et al. Major depression symptoms in primary care and psychiatric care settings: a cross-sectional analysis. Ann Fam Med. 2007;5(2):126–34.PubMedCrossRefGoogle Scholar
  9. 9.
    World Health Organization. The global burden of disease: 2004 update. 2004;
  10. 10.
    Gartlehner G, Hansen RA, Morgan LC, et al. Comparative benefits and harms of second-generation antidepressants for treating major depressive disorder: an updated meta-analysis. Ann Intern Med. 2011;155(11):772–85.PubMedGoogle Scholar
  11. 11.
    • Katon WJ, Lin EH, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2011;363(27):2611–2620. This randomized controlled trial of a collaborative care treatment model for depression and chronic medical conditions demonstrated improvements in clinical indicators of cardiovascular disease and diabetes in the intervention arm relative to usual care.CrossRefGoogle Scholar
  12. 12.
    Trivedi MH, Rush AJ, Gaynes BN, et al. Maximizing the adequacy of medication treatment in controlled trials and clinical practice: STAR*D measurement-based care. Neuropsychopharmacology. 2007;32:2479–89.PubMedCrossRefGoogle Scholar
  13. 13.
    Mugavero MJ. Guidelines for improving HIV treatment “adherence”: The big picture. 6th International Conference on HIV Treatment and Prevention Adherence. Miami, FL 2011.Google Scholar
  14. 14.
    Hasin DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of major depressive disorder: results from the national epidemiologic survey on alcoholism and related conditions. Arch Gen Psychiatry. 2005;62(10):1097–106.PubMedCrossRefGoogle Scholar
  15. 15.
    Vasiliadis HM, Lesage A, Adair C, et al. Do Canada and the United States differ in prevalence of depression and utilization of services? Psychiatr Serv. 2007;58(1):63–71.PubMedCrossRefGoogle Scholar
  16. 16.
    • Mitchell AJ, Rao S, Vaze A. International comparison of clinicians' ability to identify depression in primary care: meta-analysis and meta-regression of predictors. Br J Gen Pract. ;61(583):e72-80. This meta-analysis compares the prevalence of depression in primary care practices across countries as well as primary care providers’ ability to identify depression.PubMedCrossRefGoogle Scholar
  17. 17.
    Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet. 2009;374(9690):609–19.PubMedCrossRefGoogle Scholar
  18. 18.
    Wang PS, Berglund P, Olfson M, et al. Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):603–13.PubMedCrossRefGoogle Scholar
  19. 19.
    Wang PS, Lane M, Olfson M, et al. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):629–40.PubMedCrossRefGoogle Scholar
  20. 20.
    American Psychiatric Association. Practice Guideline for the Treatment of Patients With Major Depressive Disorder. 3rd ed. Washington: American Psychiatric Association Press; 2010.Google Scholar
  21. 21.
    Agency for Health Care Policy and Research. Depression in Primary Care: Vol 2: Treatment of Major Depression. Rockville: US Dept of Health and Human Services; 1993.Google Scholar
  22. 22.
    Gaynes BN, Warden D, Trivedi MH, et al. What did STAR*D teach us? Results from a large-scale, practical, clinical trial for patients with depression. Psychiatr Serv. 2009;60(11):1439–45.PubMedCrossRefGoogle Scholar
  23. 23.
    Rush AJ, Kraemer HC, Sackeim HA, et al. Report by the ACNP Task Force on response and remission in major depressive disorder. Neuropsychopharmacology. 2006;31(9):1841–53.PubMedCrossRefGoogle Scholar
  24. 24.
    Carlin BP, Louis TA. Bayesian methods for data analysis. 3rd ed. Boca Raton: Chapman and Hall/CRC Press; 2009.Google Scholar
  25. 25.
    Katon WJ, Von Korff M, Lin EH, et al. The Pathways Study: a randomized trial of collaborative care in patients with diabetes and depression. Arch Gen Psychiatry. 2004;61(10):1042–9.PubMedCrossRefGoogle Scholar
  26. 26.
    • Pyne JM, Fortney JC, Curran GM, et al. Effectiveness of collaborative care for depression in human immunodeficiency virus clinics. Arch Intern Med. 2011;171(1):23–31. This randomized controlled trial of a collaborative care treatment model for depression and HIV in VA facilities (the HITIDES intervention) demonstrated improvements in depression and HIV-related symptomatology but not HIV medication adherence.PubMedGoogle Scholar
  27. 27.
    Katon WJ, Lin EH, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363(27):2611–20.PubMedCrossRefGoogle Scholar
  28. 28.
    • O’Connor EA, Whitlock EP, Beil TL, Gaynes BN. Screening for depression in adult patients in primary care settings: a systematic evidence review. Ann Intern Med. 2009;151(11):793–803. This review argues in favor of routine screening for depression in primary care settings.PubMedGoogle Scholar
  29. 29.
    Screening for depression in adults: U.S. preventive services task force recommendation statement. Ann Intern Med. 2009;151(11):784–792.Google Scholar
  30. 30.
    • Thombs BD, Coyne JC, Cuijpers P, et al. Rethinking recommendations for screening for depression in primary care. CMAJ. 2009;184(4):413–8.. This review identifies concerns with routine screening for depression in primary care. This review identifies concerns with routine screening for depression in primary care Google Scholar
  31. 31.
    Rost K, Nutting P, Smith J, et al. Improving depression outcomes in community primary care practice: a randomized trial of the quEST intervention. Quality Enhancement by Strategic Teaming. J Gen Intern Med. 2001;16(3):143–9.PubMedCrossRefGoogle Scholar
  32. 32.
    Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA. 2000;283(2):212–20.PubMedCrossRefGoogle Scholar
  33. 33.
    Whooley MA, Stone B, Soghikian K. Randomized trial of case-finding for depression in elderly primary care patients. J Gen Intern Med. 2000;15(5):293–300.PubMedCrossRefGoogle Scholar
  34. 34.
    Callahan CM, Hendrie HC, Dittus RS, et al. Improving treatment of late life depression in primary care: a randomized clinical trial. J Am Geriatr Soc. 1994;42(8):839–46.PubMedGoogle Scholar
  35. 35.
    Bergus GR, Hartz AJ, Noyes Jr R, et al. The limited effect of screening for depressive symptoms with the PHQ-9 in rural family practices. J Rural Health Fall. 2005;21(4):303–9.CrossRefGoogle Scholar
  36. 36.
    Jarjoura D, Polen A, Baum E, et al. Effectiveness of screening and treatment for depression in ambulatory indigent patients. J Gen Intern Med. 2004;19(1):78–84.PubMedCrossRefGoogle Scholar
  37. 37.
    Bosmans J, de Bruijne M, van Hout H, et al. Cost-effectiveness of a disease management program for major depression in elderly primary care patients. J Gen Intern Med. 2006;21(10):1020–6.PubMedCrossRefGoogle Scholar
  38. 38.
    Rubenstein LZ, Alessi CA, Josephson KR, et al. A randomized trial of a screening, case finding, and referral system for older veterans in primary care. J Am Geriatr Soc. 2007;55(2):166–74.PubMedCrossRefGoogle Scholar
  39. 39.
    Anderson IM. Selective serotonin reuptake inhibitors versus tricyclic antidepressants: a meta-analysis of efficacy and tolerability. J Affect Disord. 2000;58(1):19–36.PubMedCrossRefGoogle Scholar
  40. 40.
    Arroll B, Macgillivray S, Ogston S, et al. Efficacy and tolerability of tricyclic antidepressants and SSRIs compared with placebo for treatment of depression in primary care: a meta-analysis. Ann Fam Med. 2005;3(5):449–56.PubMedCrossRefGoogle Scholar
  41. 41.
    Beasley Jr CM, Nilsson ME, Koke SC, Gonzales JS. Efficacy, adverse events, and treatment discontinuations in fluoxetine clinical studies of major depression: a meta-analysis of the 20-mg/day dose. J Clin Psychiatry. 2000;61(10):722–8.PubMedCrossRefGoogle Scholar
  42. 42.
    Gartlehner G, Hansen RA, Thieda P, et al. Comparative Effectiveness of Second-Generation Antidepressants in the Pharmacologic Treatment of Adult Depression. Rockville (MD)2007.Google Scholar
  43. 43.
    MacGillivray S, Arroll B, Hatcher S, et al. Efficacy and tolerability of selective serotonin reuptake inhibitors compared with tricyclic antidepressants in depression treated in primary care: systematic review and meta-analysis. BMJ. 2003;326(7397):1014.PubMedCrossRefGoogle Scholar
  44. 44.
    Mottram P, Wilson K, Strobl J. Antidepressants for depressed elderly. Cochrane Database Syst Rev. 2006(1):CD003491.Google Scholar
  45. 45.
    Mulrow CD, Williams Jr JW, Chiquette E, et al. Efficacy of newer medications for treating depression in primary care patients. Am J Med. 2000;108(1):54–64.PubMedCrossRefGoogle Scholar
  46. 46.
    Williams Jr JW, Mulrow CD, Chiquette E, et al. A systematic review of newer pharmacotherapies for depression in adults: evidence report summary. Ann Intern Med. 2000;132(9):743–56.PubMedGoogle Scholar
  47. 47.
    Gilbody S, Bower P, Fletcher J, et al. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006;166(21):2314–21.PubMedCrossRefGoogle Scholar
  48. 48.
    Mitchell AJ. Clinical utility of screening for clinical depression and bipolar disorder. Curr Opin Psychiatry. 2012;25(1):24–31.PubMedGoogle Scholar
  49. 49.
    Williams Jr JW, Pignone M, Ramirez G, Perez Stellato C. Identifying depression in primary care: a literature synthesis of case-finding instruments. Gen Hosp Psychiatry. 2002;24(4):225–37.PubMedCrossRefGoogle Scholar
  50. 50.
    Benedetti F, Lanotte M, Lopiano L, Colloca L. When words are painful: unraveling the mechanisms of the nocebo effect. Neuroscience. 2007;147(2):260–71.PubMedCrossRefGoogle Scholar
  51. 51.
    Mora MS, Nestoriuc Y, Rief W. Lessons learned from placebo groups in antidepressant trials. Philos Trans R Soc Lond B Biol Sci. 2011;366(572):1879–88.PubMedCrossRefGoogle Scholar
  52. 52.
    Bing EG, Burnam MA, Longshore D, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry. 2001;58(8):721–8.PubMedCrossRefGoogle Scholar
  53. 53.
    Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001;24(6):1069–78.PubMedCrossRefGoogle Scholar
  54. 54.
    Hedayati SS, Minhajuddin AT, Toto RD, et al. Prevalence of major depressive episode in CKD. Am J Kidney Dis. 2009;54(3):424–32.PubMedCrossRefGoogle Scholar
  55. 55.
    Lippi G, Montagnana M, Favaloro EJ, Franchini M. Mental depression and cardiovascular disease: a multifaceted, bidirectional association. Semin Thromb Hemost. 2009;35(3):325–36.PubMedCrossRefGoogle Scholar
  56. 56.
    Asch SM, Kilbourne AM, Gifford AL, et al. Underdiagnosis of depression in HIV: who are we missing? J Gen Intern Med. 2003;18(6):450–60.PubMedCrossRefGoogle Scholar
  57. 57.
    Katon WJ, Simon G, Russo J, et al. Quality of depression care in a population-based sample of patients with diabetes and major depression. Med Care. 2004;42(12):1222–9.PubMedCrossRefGoogle Scholar
  58. 58.
    Hedayati SS, Minhajuddin AT, Afshar M, et al. Association between major depressive episodes in patients with chronic kidney disease and initiation of dialysis, hospitalization, or death. JAMA. 2010;303(19):1946–53.PubMedCrossRefGoogle Scholar
  59. 59.
    Mugavero M, Ostermann J, Whetten K, et al. Barriers to antiretroviral adherence: the importance of depression, abuse, and other traumatic events. AIDS Patient Care STDS. 2006;20(6):418–28.PubMedCrossRefGoogle Scholar
  60. 60.
    Leserman J. Role of depression, stress, and trauma in HIV disease progression. Psychosom Med. 2008;70(5):539–45.PubMedCrossRefGoogle Scholar
  61. 61.
    De Groot M, Anderson R, Freedland KE, et al. Association of depression and diabetes complications: a meta-analysis. Psychosom Med. 2001;63(4):619–30.PubMedGoogle Scholar
  62. 62.
    Lustman PJ, Anderson RJ, Freedland KE, et al. Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes Care. 2000;23(7):934–42.PubMedCrossRefGoogle Scholar
  63. 63.
    Bush DE, Ziegelstein RC, Patel UV, et al. Post-myocardial infarction depression. Evid Rep Technol Assess (Summ). 2005(123):1–8.Google Scholar
  64. 64.
    Gaynes BN, Rush AJ, Trivedi MH, et al. Primary versus specialty care outcomes for depressed outpatients managed with measurement-based care: results from STAR*D. J Gen Intern Med. 2008;23(5):551–60.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Brian W. Pence
    • 1
    Email author
  • Julie K. O’Donnell
    • 1
    • 2
  • Bradley N. Gaynes
    • 3
  1. 1.Department of Community and Family MedicineDuke Global Health Institute, and Center for Health Policy and Inequalities Research, Duke UniversityDurhamUSA
  2. 2.Department of EpidemiologyGillings School of Global Public Health, University of North CarolinaChapel HillUSA
  3. 3.Department of PsychiatryUniversity of North Carolina School of MedicineChapel HillUSA

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