Common Mental Disorders Depression - New Zealand Doctor

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Background
1.1 Primary care challenges
The identification and management of mental disorders in primary care is a
challenging and complex process. Mental disorders are extremely common in this
setting, with over one third of adults attending primary care likely to have met the
criteria for a DSM-IV ® diagnosis within the past 12 months. 1
The identification of common mental disorders is dependent on a number of factors, not
least the availability of treatment resources that make identification worthwhile. There is
evidence that identification rates might be improved by encouraging disclosure, fostering
continuity of care and having a high index of suspicion with patients who have known
risk factors for common mental disorders. 2 However, practitioners rarely address mental
disorders in isolation from other health problems and must prioritise between competing
clinician, patient and practice needs, often within difficult time and resource constraints.
Low identification rates of mental disorders can be attributed partly to a process of
prioritisation, whereby practitioners treat only those with marked mental distress and
address other more urgent problems in patients with minimal functional impairment. 3
Presentations of psychosocial distress in primary care often do not correspond well
with standard diagnostic criteria, as subthreshold conditions are often associated with
significant functional impairment, while people meeting diagnostic criteria are not
always as disabled. 4,5 There is ongoing debate about diagnostic cut-off points. 6,7
A high proportion of patients in primary care practice present with medically
unexplained symptoms, that is, a mix of physical and psychological symptoms with no
identifiable pathology. 8 Although practitioners recognise that in most cases medically
unexplained symptoms are an expression of psychosocial distress, it can be difficult
to know what approach to take. A sense of frustration (and concern about missing a
possible biomedical disease) can make the patient-practitioner relationship difficult. 8
A British Columbia guideline on depression 9 claims that even when depression has
been recognised, treatment is often suboptimal. The guideline suggests that this is due
to the following problems, several of which may apply in New Zealand:
• patient reluctance to seek and/or comply with treatment, due to the stigma
associated with mental disorders
• inadequate dosage and duration of antidepressant therapy
• failure to educate patients about the nature of depression and to support
self-management
• failure to recommend evidence-based psychotherapy
Identification of Common Mental Disorders and Management of Depression in Primary Care 1