To The Editor:
We thank Dr Nease for his editorial,1 but we think he was off-point on 2 issues: the use of diagnostic labels and the availability of primary care resources for treating depression. In our paper,2 we concluded that paroxetine or Problem Solving Therapy–Primary Care (PST–PC) was effective for patients with dysthymia but no more beneficial than frequent visits with nonspecific clinical management for patients with minor depression.
We agree with Dr Nease’s contention that depressive syndromes represent a continuum of severity, functional impairment, and chronicity. To date, most treatment trials have focused on treatments for the more severe end of this spectrum—major depressive disorder. We evaluated the efficacy of a commonly used antidepressant (paroxetine) and a psychologic treatment customized for primary care (PST–PC) in patients with dysthymia and minor depression. These diagnostic labels are recognized by primary care physicians and can be used within the larger context of the patient’s illness—their own unique experience of the disease—to inform discussions of prognosis and treatment. As in other illnesses with a spectrum of symptoms (eg, asthma) or clinical findings (eg, hypertension), the relevant question is: Where along the continuum of symptoms, clinical findings, or impairment is treatment beneficial? Our study provides needed guidance to primary care providers: Patients who suffer from dysthymia benefit from active treatment with medications or PST–PC, while those with minor depression improve equally well with medications, PST–PC, or increased contact with their provider.
We also disagree that PST requires resources not commonly available in primary care. In a recent survey of primary care–based depression care, approximately one third of practices reported on-site access to mental health professionals.3 That was the model used in our study and in my own practice—mental health professionals collaborating with primary care physicians to deliver care in the patient’s usual primary care setting. For interested clinicians, formal training manuals and training courses are available from Dr Mark Hegel at Dartmouth College.
John W. Williams Jr, MD
University of Texas San Antonio
James Barrett, MD
Dartmouth Medical School Hanover,
New Hampshire
References
- Nease DE. Dysthymia in primary care: who needs treatment and how do we know? J Fam Pract 2001; 50:413.
- Barrett JE, Williams JW, Oxman TE, et al. Treatment of dysthymia and minor depression in primary care: a randomized trial in patients aged 18 to 59 years. J Fam Pract 2001; 50:405-12.
- Williams JW Jr, Rost K, Dietrich A, Ciotti M, Zyzanski S, Cornell J. Primary care physicians’ approach to depressive disorders: effects of physician specialty and practice structure. Arch Fam Med 1999; 8:58-67.
Dr Nease Responded As Follows:
I appreciate the response from Drs Williams and Barrett to my commentary and the opportunity for dialogue. The imperative for treating based on a diagnostic label is: The shovel you use for heavy wet snow (major depressive disorder) can also be used for light fluffy snow (dysthymia). This imperative sidesteps the patient-oriented evidence issue: How deep is the snow, and do I really need a shovel? When is the dysthymia bad enough that I need to use paroxetine or PST–PC? Symptom severity categories are more predictive of impairment than diagnostic labels.1,2 For the purpose of defining who needs treatment, in primary care the labels from the Diagnostic and Statistical Manual of Mental Disorders alone are simply not good enough.3,4
Drs Williams and Barrett seem reassured by findings that mental health professionals (MHPs) are available on-site in a third of primary care practices.5 However, this finding is not generalizable to all settings. The cited study oversampled for physicians in geographic areas with greater managed care penetration, where one might be more likely to find on-site MHPs because of intentional design or more urbanized location. Moreover, MHP availability and contact does not necessarily equal collaboration6 and does not guarantee that the support is adequate for the demand. Even if we assume that one third of primary care clinicians have optimal collaborative options, there remains a sizeable majority in need.
Returning to my previous analogy, we all agree that it is snowing outside, and we may need a shovel. Does the type of snow alone (diagnostic label) tell us whether we need to get out the shovel, or do we also need to know the depth of the snow (severity)? Should we treat solely based on a diagnostic label? In primary care, I continue to argue that the diagnostic label is not enough; we also need to account for the severity dimension before we open the garage door.
Donald E. Nease, Jr, MD
University of Michigan
Ann Arbor