Barriers to the diagnosis of depression in primary care.

Approximately 50% of people treated for depression receive treatment in primary care settings. However, studies have demonstrated that specific factors interfere with recognition of this disorder in the primary care setting and decrease the likelihood of an accurate diagnosis. Variables that relate to the patient include lack of awareness and understanding of the nature of the disease and its symptoms so that they can be accurately reported to the physician. Variability in clinical presentation and the presence of comorbid medical disorders also make detection difficult. Complaints of physical symptoms confuse the clinical picture. In addition, patients are ashamed to admit to psychological symptoms of depression and fear the stigma attached to it. Interfering factors that relate to the physician include a lack of knowledge about the disease and lack of training in its management that reduce the physician's ability to render a diagnosis and undermine confidence in the capacity to treat the illness successfully. Reluctance on the part of the physician to inquire frankly about depression also plays a role. Barriers that stem from the system include financing of care under capitated systems, other reimbursement issues, time available to care for patients, and continuity of the physician/patient relationship. A variety of tools are available to assist primary care physicians in the recognition and accurate diagnosis of depression. Use of these tools would increase the recognition and effective management of depression.