The Treatment of Depression in Primary Care
A cross-sectional epidemiological study
Background: General practitioners play a key role in the care of patients with depressive disorders. We studied the frequency and type of treatment of depressive disorders in primary care.
Methods: In a cross-sectional epidemiological study on a particular day in six different regions in Germany, 253 physicians and 3563 unselected patients were asked to fill in a questionnaire assessing the diagnosis and treatment of depression. A total of 3431 usable patient data sets and 3211 sets of usable data from both the patient and the physician were subjected to further analysis.
Results: 68.0% of the 490 patients in primary care who were classified as depressed according to the Depression Screening Questionnaire received treatment from their general practitioner or in other care settings; the probability of being treated by the general practitioner was higher for patients whose diagnosis was recognized by the general practitioner (92.8%) than for the remaining depressed patients (47.8%). On the day of data recording, 54.1% of the depressed patients were under treatment by the general practitioner and 21.2% had been referred to specialized treatment. Approximately 60% of the depressed patients were not being treated, as recommended in the guidelines, with antidepressant drugs, psychotherapy, or both. The likelihood of being treated in conformity with the guidelines depended on whether or not the general practitioner had made the diagnosis of depression (odds ratio [OR] = 7.5; 95% confidence interval = [4.9; 11.6]; p <0,001); it was also higher if the general practitioner had an additional qualification in psychotherapy (OR = 1.9; [1.1; 3.4]; p = 0.022).
Conclusion: The finding that a relevant proportion of patients with depressive disorders in primary care are inadequately treated indicates the need to improve general practitioners’ ability to diagnose these conditions and determine the indication for treatment.
Depression is one of the most commonly occurring mental disorders (1) and is associated with considerable individual and social costs (2, 3). Early detection and effective treatment of depression are thus of major importance. Quality-assured standards have been established for the diagnosis and optimal management of depression (S3 guideline/national care guideline for unipolar depression) (4–6). Nevertheless, a high proportion of patients still do not receive adequate treatment (7), with correct recognition of the disorder being among the most important predictors of guideline-oriented therapy (8, 9).
Primary care physicians play a key role in the care of patients with depression. They are usually the point of first contact with the healthcare system and can detect depression at an early stage, decide whether to initiate treatment themselves or refer the patient to a specialist; they therefore pave the way for treatment according to the guidelines (10–12).
Recent findings on the frequency and quality of treatment of patients with depression by primary care physicians in German-speaking countries are based on secondary data analyses (7, 10) that provide no information about the considerable proportion of people with depression whose disorder is not detected or diagnosed. The most recent epidemiological survey of depression in the area of primary care in Germany took place at the end of the 1990s in the context of the Depression 2000 study, which found—together with a high prevalence of depression on the reference date— room for improvement in the detection and treatment of depressive disorders (13, 14). We therefore decided to conduct again an epidemiological study to obtain up-to-date information on the treatment of patients with depression in the primary care setting following the publication of the S3 guideline.
Study design and sample
Late in 2013 and early in 2014, within the framework of a nationwide epidemiological study program into the treatment of depression in the primary care setting (the VERA study) and on the basis of a regionally clustered random selection of primary care physicians in six regions of Germany, 269 such physicians (response rate 5.8%) were recruited to participate in the study. In a preliminary study, they first had to provide information about themselves and their offices. Subsequently, 253 doctors with 3563 unselected patients (response rate 55.9%) participated in the cross-sectional survey on the reference date by filling in a patient or physician questionnaire. This resulted in 3431 evaluable patient questionnaires. For 3367 patients both questionnaires had been completed, and in 3211 cases both were suitable for analysis. This sample formed the basis for the greater part of the results presented here. Details of study conduct and the samples of physicians and patients can be found in the eMethods and in eFigure 1.
Documentation of depression
Symptoms of depression were self-reported by the patients by means of the Depression Screening Questionnaire (DSQ) (15). The DSQ comprises 12 questions about symptoms during the foregoing 2 weeks designed to ascertain whether the ICD-10 criteria of depressive episodes (16) are fulfilled. The ICD-10 study diagnosis “depression” was coded if four or more symptoms were endorsed, including at least three present “on most days” (17) (eBox). According to these criteria, n = 490 patients (14.3%) had depression (including n = 451 [14.1%] for whom a physician questionnaire had been completed).
Furthermore, the physicians assessed the presence of depression and other mental disorders and classified them as “definite,” “subthreshold,” “questionable,” or “absent.” If depression was diagnosed, its severity was estimated.
Documentation of treatment
Both the physicians and their patients were asked about the treatment of depression (eTable 1). In the physician questionnaire, the doctors gave an account of their interventions on the study day (reference date) together with any existing ongoing treatments. The patients were asked to document current treatments. Thus, we describe the treatment given by the physician on the reference date (data from the physician questionnaire) (Table) and any existing treatments beyond that received on the reference date (data from the physician and patient questionnaires) (eTable 2). Just as in previous studies (18), the data provided by the physicians and by the patients were somewhat divergent (Cohen’s kappa 0.20–0.40). In order to ensure maximum sensitivity in identification of treatments, all treatments were assumed if they were mentioned by either the patient or by the doctor (19, 20).
Adherence to guidelines
To facilitate estimation of the extent to which treatment adhered to the guidelines, all measures mentioned were assigned to one of the following categories: (1) psychotherapy, (2) antidepressants, (3) other treatment, (4) no treatment (eTable 1). Interventions on the reference date and any ongoing treatments were included. According to the S3 guidelines, both psychotherapy and antidepressants are indicated for the treatment of depression.
Frequency analyses were used to report physicians’ intervention behavior when they diagnosed depression, independent of the results of the DSQ (physician’s diagnosis “definite depression,” n = 353 [10.7%]). In addition, physicians’ interventions in patients with the ICD-10 DSQ study diagnosis of depression were investigated. In all analyses that included data provided by the physicians, the investigation sample comprised those patients for whom both DSQ data and diagnostic information in the physician questionnaire were present (n = 3211). Individual analyses that include only data provided by patients relate to the sample of 3431 patients.
Analyses of treatment were stratified according to the detection of depression by the primary care physician. The physician classified the DSQ cases as definite/subthreshold depression (correct detection) or as questionable depression or questionable/subthreshold/definite other mental disorder (unspecific case detection) (eFigure 2). Furthermore, in each case stratification according to the severity of depression was carried out. To identify physician characteristics (= independent variables) associated with guideline-adherent treatment (= dependent variables), we performed logistic regression analyses and determined the odds ratio and 95% confidence intervals. As physician characteristics, age, sex, additional qualification in psychotherapy, additional qualification in basic psychosomatic care, and self-reported familiarity with the S3 guideline were included. Because several patients were recruited in each participating office, we made allowance for possible cluster effects in the logistic regressions by means of robust standard errors.
Incidence and types of treatment on the reference date
Active waiting with a repeat visit was extremely rare on the reference date (three patients among all cases of depression detected by the physicians, none of them initially diagnosed on the reference date) (Table). In the majority of cases the physician provided treatments on the reference date, regardless of whether the patient fulfilled the diagnostic criteria according to the information they supplied themselves or as assessed by the physician. The most commonly occurring interventions were discussions/consultations, followed by drug treatment. A small proportion of the physicians carried out psychotherapy themselves (mild depression: 2.3 to 5.9%; moderate depression: 4.7 to 12.0%; severe depression: 12.5 to 15.8%). Depending on depression diagnosis (self-reported or diagnosed by the physician) and on depression severity, the proportion of patients referred for specialist care varied between 15.1% and 60.6%. In the majority of referrals, the primary care physician continued to be involved in the patient’s treatment (Figure 1). Both for patients treated by the primary care physician and for those referred to specialists, detection of depression by the primary care physician—compared with nondetection or assignment of another diagnosis—was associated with a higher probability of the respective intervention by the primary care physician on the reference date.
Incidence and types of previous treatments
For 53.3% of patients with a diagnosis of depression according to the DSQ and 79.9% of those with a corresponding diagnosis from a physician, ongoing treatment was stated by the physician or the patient on the reference date (eTable 2). Ongoing drug treatment was found more frequently than psychotherapy. Psychotherapy was reported for 23.7% of the DSQ cases and 34.8% of the physician-diagnosed cases. The most frequently specified medications were selective serotonin reuptake inhibitors (SSRI), selective serotonin–norepinephrine reuptake inhibitors (SSNRI), and noradrenergic and specific serotonergic antidepressants (NaSSA). Treatment with tricyclic antidepressants (TCA) and substances other than antidepressants was infrequently mentioned. For most interventions, the likelihood of treatment increased with the severity of the depression and with the physician’s detection of depression reported by the patient in the questionnaire.
Adherence to guidelines
Figure 2 shows the proportions of patients with guideline-oriented treatment (psychotherapy and/or antidepressants), other treatment (intervention, but no antidepressants or psychotherapy), and no treatment. Both interventions on the reference date (including referral to a psychiatrist, a psychotherapist, or a hospital) and ongoing treatments are included. Among correctly detected DSQ cases, the proportion without any intervention was low (from 2.6% for severe depression to 9.3% for mild depression). In cases of depression not detected by the physician or diagnosed by other means, the corresponding figures were 37.5% for severe depression and 54.0% for mild depression. Overall, 68.0% of DSQ cases received an intervention on the reference date, either at the hands of the primary care physician or in other care settings. There were indications of undertreatment as defined by the S3 guideline (no antidepressants or psychotherapy in mild or moderate depression, no combination treatment in severe depression) in 58.6% of the DSQ cases overall, but the rate was lower in correctly detected DSQ cases (33.5%) than in undetected cases (79.1%; OR = 7.5 [4.9; 11.6]; p <0.001). The most pronounced signs of undertreatment were found for severe depression (60.0% overall, 39.5% if detected, 93.7% if not detected). The 37.9% rate of undertreatment in undetected mild depression did not decrease when physicians’ data on active waiting with a repeat visit were taken into account.
More female than male physicians dispensed treatment in accordance with the guidelines (OR = 1.64 [1.04; 2.60]; p = 0.034). The physicians’ age made no difference in this respect. Moreover, patients with depression were more likely to be treated according to the guidelines by physicians with an additional qualification in psychotherapy (55.8%) than by those with no such qualification (39.7%; OR = 1.9 [1.1; 3.4]; p = 0.022). This did not apply to an additional qualification in basic psychosomatic care (OR = 1.04 [0.66; 1.62]; p = 0.862). Self-reported familiarity with the S3 guideline showed a tendency towards association with guideline-adherent treatment of patients with depression (OR = 1.5 [0.98; 2.3]; p = 0.058).
The main findings of this cross-sectional epidemiological investigation into the frequency and nature of treatment of patients with depression in primary care are the following:
- The majority of primary care patients with depression received treatment/intervention of some kind.
- According to a survey carried out on a reference date, approximately half of the patients with depression are treated by the primary care physician themselves, while around one fifth are referred to specialist care.
- Primary care patients with depression were more likely to receive pharmacological treatment than psychotherapy. This was also true for those with mild depression.
- Indications of undertreatment are found in more than half of primary care patients with depression, in that they did not receive antidepressants or psychotherapy as recommended in the relevant guidelines. Treatment according to the guidelines depended strongly on correct detection of the depression by the primary care physician and was more likely if the latter had an additional qualification in psychotherapy.
The rates of treatment for depression in primary care in this study are relatively high compared with both the general population (11) and health insurance data (21). Almost all patients in whom the primary care physician diagnoses depression receive some kind of treatment. Together with the introduction of the S3 guideline, the reason for the high treatment rates may be heightened awareness of mental disorders in general and depression in particular.
The involvement of primary care physicians in the treatment of depressed patients is also relatively high. In 80% of the cases of depression they detect, they carry out the treatment themselves. This is a slightly higher proportion than was found in a similar study at the turn of the century (12) and corresponds with more recent health insurance data (10). In detected cases of depression, physicians treat just over a third of patients with antidepressants, independent of disease severity. A noteworthy aspect is the sharp decrease in the use of TCA from around 32% in 2000 (12) to approx. 0 to 6% in our study. As could be expected, the proportion of psychotherapeutic interventions in primary care is small, although much higher in severe depression. Shortages in the provision of specialized care may be relevant, leading suitably qualified primary care physicians to decide to offer psychotherapy themselves.
Along with interventions by the primary care physicians, the majority of patients with depression showed indications of further ongoing treatments where pharmacological treatment was found more frequently than non-medicinal interventions. This is in agreement with health insurance data (22) and was also found for mild depression, which suggests that the S3 guideline’s recommended preference of psychotherapy over medication for mild depression has not yet been widely adopted. In this respect, some authors have already pointed to possible overmedication in the treatment of mild depression (23), although the findings are inconsistent (7). It may be that the limited psychotherapy resources tend to be reserved for severe cases of depression. With regard to the other ongoing drug treatments, as in primary care, TCA and non-antidepressant medication were rarely prescribed. This indicates good implementation of the S3 guideline with respect to the use of effective and ideally well-tolerated substances.
Assessment of adherence to the guidelines showed that as many as around 70% of patients with depression correctly diagnosed by primary care physicians receive either psychotherapy or treatment with antidepressants. In undetected cases (other or no diagnosis), however, the proportion was barely one quarter. Such a large discrepancy cannot be explained exclusively by treatment by the primary care physician; rather, it points to a central role of primary care physicians as “gatekeepers,” not only treating patients themselves but in particular also initiating necessary treatments by referring patients elsewhere. This requires efficient detection of depression. Although combined treatment with psychotherapy and antidepressants, as advised in the guidelines, is used more often in severe depression than in mild and moderate depression, less than two thirds of patients with severe depression are treated in this way. In this respect, implementation of the guideline is not yet satisfactory. However, no conclusions can be drawn here about the reasons (e.g., failure to recognize the indication or refusal by the patient).
The limitations of this study have to be considered when interpreting its findings. This was a cross-sectional investigation. Data on the course of the disorder and its treatment could not be taken into account. Because the survey took place on one particular day, not all primary care interventions could be recorded. The presented frequencies of interventions by the primary care physicians are conservative estimates. On the other hand, the use of statements from both the physicians and their patients in estimating ongoing treatments tends to result in overestimation of treatment rates. Confirmation of the treatment data, e.g., by comparison with health insurance data, was not possible in this study. Assessment of guideline adherence can be estimated only roughly, because numerous aspects (duration, dosage, change of treatment) could not be taken into account. Furthermore, questions on overtreatment of mild and moderate depression cannot be answered by means of these cross-sectional data. Although the DSQ is based on established diagnostic criteria (16, 24) and possesses good sensitivity and specificity, the method has limitations regarding the correct classification of patients with depression and can by no means be viewed as the gold standard (25–29). This must be considered particularly with regard to “detected cases.”
As in other recent studies (30, 31), the response rate among the physicians was relatively low. The sample of physicians is characterized by high proportions of female physicians and young doctors compared with figures on all non-hospital physicians registered in Germany in 2014 (eMethods, eFigure 1).
The results of this primary care study show that a high proportion of patients with depression receive treatment or an intervention of some kind. The treatment of depression in general and adherence to the prevailing guidelines in particular depends largely on correct diagnosis by the family doctor. Our findings underline the importance of primary care physicians in the management of depression as well as the need for training of medical students and young doctors in the diagnosis of depression and the indications for various forms of treatment. A disease management program for depression could help to reduce the rate of undertreatment (32, 33).
Funding and acknowledgements
The VERA project was financially supported by the German Federal Ministry of Health (Bundesministerium für Gesundheit, BMG) and conducted at the Institute of Clinical Psychology and Psychotherapy of TU Dresden and at the Center for Clinical Epidemiology and Longitudinal Studies (CELOS) leadership of Prof. Dr. Katja Beesdo-Baum and under the co-leadership of Prof. Franziska Einsle and PD Dr. Susanne Knappe. Partners in the project were the German Depression Relief Foundation (Stiftung Deutsche Depressionshilfe), the German Alliance Against Depression (Deutsches Bündnis gegen Depression e. V.; PD Dr. Christine Rummel-Kluge and Ines Heinz, Leipzig), and the Center for Evidence-Based Health Care at the Medical Faculty of TU Dresden (ZEGV; Prof. Dr. Jochen Schmitt). Scientific assistants in the VERA study were Gesine Wieder, Lisa Knothe, Denise Küster, Janine Quittschalle, Diana Pietzner, Abdelilah El Hadad, and Sebastian Trautmann. The fieldwork was supported by regional alliances against depression (Leipzig region: Nicole Koburger, Bettina Haase; Berlin region: PD Dr. Meryam Schouler-Ocak, Theresa Wilbertz; Munich region: Rita Wüst, Dr. Joachim Hein; Fulda region: Dr. Ulrich Walter; Hamburg region: Dr. Hans-Peter Unger) and by a large number of students. Associate partners and advisors of the VERA team were: Prof. Antje Bergmann, Department of General Medicine, TU Dresden; Prof. Ulrich Hegerl, Department of Psychiatry and Psychotherapy, Leipzig University; Prof. Hans-Ulrich Wittchen and Dr. Michael Höfler, Institute for Clinical Psychology and Psychotherapy, TU Dresden; Dr. Lars Pieper, Torsten Tille, and Henning Schmidt, Center for Clinical Epidemiology and Longitudinal Studies (CELOS), TU Dresden; Prof. Jürgen Hoyer, Behavioral Psychotherapy and Outpatient Psychotherapy Clinic, TU Dresden; Prof. Andrea Pfennig, Psychiatric Epidemiology and Outcome Research, TU Dresden; Dipl.-Psych. Christian Klesse, Department of Psychiatry and Psychotherapy, Freiburg University Hospital, member of the S3 guideline group. The study was supported by the Saxony Association of General Medicine (Sächsische Gesellschaft für Allgemeinmedizin, SGAM; Dr. Johannes Dietrich and Dr. Andreas Schuster) and by AOK Plus (Dr. Ulf Maywald and Andreas Fuchs).
We thank all participating physicians, medical assistants, and patients for their commitment to the study.
Conflict of interest statement
Prof. Hoyer has received reimbursement of congress attendance fees from AstraZeneca.
PD Dr. Rummel-Kluge has received speaker’s fees from Servier and Jansen.
Prof. Hegerl has been member of the Advisory Boards of Lundbeck and Servier, consultant for Bayer Pharma and speaker for Roche Pharma within the past 3 years.
PD Dr. Schouler-Ocaker has received speaker’s fees and reimbursement of travel costs and congress attendance fees from Forum für medizinische Fortbildung GmbH and Lundbeck GmbH.
Dr. Unger has received speaker’s fees from Otsuka and support for training courses in his department from Servier and Jansen.
Dr. Walter has received reimbursement of travel costs and congress attendance fees from Servier and Merz and speaker’s fees from Lundbeck.
Dr. Hein owns shares in Eli Lilly.
Prof. Pfennig has received assistance with travel costs and congress attendance fees from Otsuka and speaker’s fees from Otsuka and Lundbeck.
Prof. Schmitt has received institutional financial support for research projects from Sanofi, Novartis, ALK, Pfizer, and MSD.
Prof. Bergman receives royalties or author’s fees from Thieme Verlag for the chapter “Angststörungen, Psychotherapie” in the textbook “Duale Reihe Allgemein- und Familienmedizin”.
Prof. Wittchen is faculty member of the Lundbeck Foundation and member of the ThINC-it Steering Board, Lundbeck.
The remaining authors declare that no conflict of interest exists.
Manuscript submitted on 28 September 2016, revised version accepted on
11 July 2017
Translated from the original German by David Roseveare
Prof. Dr. rer. nat. habil. Katja Beesdo-Baum
Technische Universität Dresden
Institute of Clinical Psychology and Psychotherapy
Behavioral Epidemiology & Center for Clinical
Epidemiology & Longitudinal Studies
Chemnitzer Str. 46, 01187 Dresden, Germany
Cite this as:
Trautmann S, Beesdo-Baum K, Knappe S, Einsle F, Knothe L, Wieder G, Venz J, Rummel-Kluge C, Heinz I, Koburger N, Schouler-Ocak M, Wilbertz T, Unger H-P, Walter U, Hein J, Hegerl U, Lieb R, Pfennig A, Schmitt J, Hoyer J, Wittchen H-U, Bergmann A: The treatment of depression in primary care—a cross-sectional epidemiological study. Dtsch Arztebl Int 2017; 114: 721–8.
eMethods, eFigure, eBox, eTables:
Psychiatry Psychiatr Epidemiol 2012; 47: 475–86 CrossRef MEDLINE
*2 The remaining authors are listed at the end of the article.
Institute of Clinical Psychology and Psychotherapy, TU Dresden:
Dr. Trautmann, Prof. Beesdo-Baum
Behavioral Epidemiology, TU Dresden: Dr. Trautmann,
Center for Clinical Epidemiology and Longitudinal Studies, TU Dresden:
Institute of Clinical Psychology and Psychotherapy, TU Dresden: PD Dr. Knappe, Dr. Einsle, Dipl.-Psych. Knothe, Dipl.-Psych. Wieder, M.Sc.-Math. Venz, Prof. Hoyer, Prof. Wittchen
Behavioral Epidemiology, TU Dresden: Dipl.-Psych. Knothe, Dipl.-Psych. Wieder, M.Sc.-Math. Venz
Center for Clinical Epidemiology and Longitudinal Studies, TU Dresden: M.Sc.-Math. Venz, Prof. Wittchen
German Depression Relief Foundation, Leipzig: PD Dr. Rummel-Kluge, Prof. Hegerl
German Alliance Against Depression, Leipzig: Dipl.-Psych. Heinz, Prof. Hegerl
Leipzig Alliance Against Depression, Leipzig: Dipl.-Psych. Koburger
Department of Psychiatry and Psychotherapy, Leipzig University Hospital, Leipzig: PD Dr. Rummel-Kluge, Dipl.-Psych. Koburger, Prof. Hegerl
University Department of Psychiatry–Charité, St. Hedwig Hospital, Berlin: PD Dr. Schouler-Ocak, Dr. Wilbertz
Harburg Alliance Against Depression, Asklepios Hospital Harburg:
Academy for Suicide Prevention, Health Network East Hesse, Fulda: Dr. Walter
Munich Alliance Against Depression, Munich: Dr. Hein
Clinical Psychology and Epidemiology, Faculty of Psychology, University of Basel: Prof. Lieb
Department of Psychiatry and Psychotherapy, Faculty of Medicine, TU Dresden: Prof. Pfennig
Center for Evidence-Based Health Care (ZEGV), Faculty of Medicine, TU Dresden: Prof. Schmitt
Department of Psychiatry and Psychotherapy, LMU Munich: Prof. Wittchen
General Medicine, Faculty of Medicine, TU Dresden: Prof. Bergmann
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