Wishing Upon a STAR*D: The Promise of Ideal Depression Care by Primary Care Providers

Most primary care practices do not have delivery systems in place that can mimic STAR*D care patterns. The STAR*D sequence of care included visits at two-week intervals over the three months after initial diagnosis. The lack of timely appointments with primary care physicians is known to be a problem ( 7 ), and thus it is highly unlikely that a depressed patient could receive this level of consistent follow-up. What happens during a primary care appointment is also an issue. A recent study found that the median time spent on a mental health topic in a primary care setting is two minutes, and mental health is addressed with only 25% of depressed patients ( 8 ).

Care management could provide the frequent contacts that occurred in the STAR*D trial or help address the competing demands that prevent primary care physicians from having the time to address mental health topics during visits ( 9 ). However, most primary care practices consist of groups of three or fewer physicians ( 10 ), and sustaining a full-time care manager would be difficult for small practices. Telephone care management ( 11 ) could overcome this barrier if pooled across clinics. However, this requires systemic organization, such as a practice network ( 12 ), which is usually not in place in the current health care environment. Care management could be organized at a health plan level, such as through a health maintenance organization or a managed behavioral health organization ( 13 ). Current arrangements for providing mental health care, in which a primary care practice may interact with multiple managed behavioral health organizations, may make it difficult for most practices to finance and coordinate care management ( 14 ).

Primary care physicians cannot bill for depression care services when these services have been carved out to managed behavioral health organizations that do not include primary care physicians in their network of providers ( 15 ). Primary care clinicians are also unpaid for the extra work required to meet standard protocols or guidelines for providing mental health care. Furthermore, care management for depression in primary care is not reimbursed by major insurers at this time.

In the STAR*D trial, responses to the first level of treatment were similar for patients who were treated in primary care or mental health specialty care. It will be important to determine whether outcomes differ by setting for patients whose depression failed to remit after the initial treatment. These individuals may need specialty mental health care, and unfortunately, access under current systems of care still needs improvement. Collaborative care models that incorporate improved access to mental health specialty care are more effective than those without such access ( 1 ).

Some patients prefer psychotherapy over pharmacotherapy ( 16, 17 ) and should be able to receive psychotherapy initially. Making short-term psychotherapy available to depressed patients in primary care was found to have a positive impact on health outcomes for more than two years ( 18 ). These services are not easily accessible from primary care clinics, and primary care clinics are often unwilling to set up the services needed to conduct psychotherapy within their clinics, such as setting aside an office for a mental health specialist or introducing problem-solving therapy by depression care managers.