NEW YORK (Reuters Health) - Primary care physicians are proficient in identifying depression in their patients, but the care they provide to those patients often does not meet practice guidelines, a study shows.

Dr. Lisa V. Rubenstein of the Veterans Affairs Greater Los Angeles Healthcare System at Sepulveda and colleagues with the Rand Health Program of Santa Monica, California, analyzed data from three clinical trials conducted between 1996 and 1998 on implementation of practice guidelines for depression.

The team evaluated the care of 1,131 depressed patients in 45 primary care practices in 13 states.

As the researchers report in the September 4th issue of the Annals of Internal Medicine, they found that clinician adherence to guidelines was 79% when it came to detection of depression.

However, quality of care was low on a number of indicators, falling to 20%-38% adherence to guidelines for management of suicide risk, alcohol abuse, care of the elderly patient with depression, and care of patients requiring frequent adjustment of their treatment regimens.

"Primary care clinicians recognize depression (but) these clinicians do not carry out the assessment and follow-up activities recommended by the guidelines," Dr. Rubenstein told Reuters Health.

Physicians "usually failed to refer seriously ill or complex patients to mental health specialists," with only 30% doing so. Furthermore, "only 46% of patients overall and only 26% of elderly patients, in particular, completed a minimally adequate course of treatment with either antidepressants or psychotherapy," Dr. Rubenstein said.

"In follow-up, these clinicians usually did not adjust treatment among patients who remained depressed (only 38% did so)," she noted. "Once patients were on antidepressants, those who actually took their medications and recovered were usually simply continued on medications."

The team found that greater adherence to practice guidelines was associated with significantly fewer subsequent depressive episodes. "This positive effect lasted for up to two years," she commented.

Dr. Rubenstein said that she would give primary care physicians "an 'A' for being aware and concerned about depression; a 'D' for integrating care with mental health specialists, for finding out enough about patients' depression status and history, and for ensuring completion of treatment; and an 'F' for recognizing substance abuse and for treating elderly patients, whom the literature shows benefit as much or more than younger patients from treatment."

In concluding, Dr. Rubenstein noted: "Providing help to primary care clinicians with assessing depression and educating patients -- an activity that takes about 40 minutes -- and providing brief, frequent, usually telephone-based follow-up to reinforce self-management and treatment, is effective."

Ann Intern Med 207;147:320-329.

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