For Depression, The Family Doctor May Be The First Choice But Not The Best

Q: For most of his life, John Smythe of Glen Rock, N.J., struggled with a hot temper during day and insomnia at night. He thought of these problems as family traits; his parents had them, too. But two years ago his internist told him that they were signs of clinical depression. "A chill went down my spine," recalled Mr. Smythe, 60, who runs a small business. "Depression to me was somebody walking around moping, sort of withdrawn. It never occurred to me that there could be other symptoms."

A:Mr. Smythe is in a lucky minority. 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. The study defined "adequate treatment" as a course of at least 30 days on an antidepressant or a mood stabilizer, along with four visits to a doctor or at least eight 30-minute psychotherapy sessions with a mental health professional. 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 say the new findings should not be interpreted to mean that primary-care physicians are unqualified to treat depression. "The notion that everybody with depression should be treated by a mental health professional is ridiculous," said Dr. John Greden, a psychiatrist who is director of the Depression Center at the University of Michigan. Dr. Greden said many general practitioners could effectively treat people with mild to moderate depression. But he added that mental health professionals agreed that severe or intractable depression should be referred to a psychiatrist or a psychologist. "Just as you wouldn't want a primary-care physician to do coronary bypass surgery, you wouldn't want one to treat severe or complicated depression," said Dr. Greden, who works with primary-care doctors in Michigan on ways to improve the diagnosis and treatment of depression. They are though. Most of them at least. I once had a 'primary-care physician' prescribe me an anti-depressant for depression and he told me: "it isn't going to help you feel any better, you'll have to do that yourself", well then why the hell are you prescribing it to me you stupid ahole, if that's your attitude why not give me a sugar pill? (and by the effectiveness of the anti-depressant he gave me, he just may have) I tried to get the idiot to explain to me how the anti-depressant worked, as it was the first one I'd taken, and I was only 18 and was a little nervous about it, and he said: "it doesn't matter how it works", and that pissed me off, of course. I pressed the issue, and he danced around but it became clear that he had no idea how it worked and/or supposedly worked And so many times before I had gotten a psychiatrist I had to put up with the general practitioners and their staff of brats act 'uncomfortable' around me, and not because of how I acted, as I've better behavior than your general "mentally healthy" person, it was for no other reason than they knew I had/have depression and anxiety.

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