The diagnosis and management of depression and anxiety in primary care: the need for a different framework

There has been increased debate related to depression and common mental disorders over the past few decades. The high prevalence of depression in primary care, and the low recognition and treatment rates have inspired primary care psychiatry. Educating general practitioners, preparing practice guidelines and conducting courses to improve their clinical skills have been attempted. These efforts have resulted in the expectation that depression would be managed in primary care. However, despite piloting, field studies and acceptance by academic general practitioners, the watered-down psychiatric approach, when used in primary care, has few takers in actual practice.1,2 The culture of primary care psychiatry borrows heavily from academic psychiatry and attempts to adapt it to the reality of primary care. The compromise is uneasy, unstable and difficult to apply in general practice. This paper highlights the issues related to the diagnosis and treatment of common mental disorders, the issues related to their presentation and management in primary care and suggests alternative strategies.

Recent trends in medicine

Two trends have markedly affected the diagnosis and management of psychiatric presentations in primary care. Firstly, the growth of medicine over the past century has seen the decline of family medicine and general practice, and the meteoric rise of specialist approaches. Many problems presenting to primary care are now viewed from a specialist perspective. This is true across all medical disciplines and particularly true of psychiatric disorders in primary care. Secondly, the progressive medicalisation of distress has lowered thresholds for the tolerance of mild symptoms and for seeking medical attention for such symptoms.3 Patients visit general practitioners when they are disturbed or distressed, when they are in pain or are worried about the implications of their symptoms.4 However, …