American health care systems and depression: the past, present, and the future.

American medicine has witnessed 3 major periods in this century that have all played key roles in the evolution of today's medical systems, practice, and education. The first of these periods followed the publication of the Flexner report in the early 1900s that was critical of the then current medical education system. The second came with the development of specialties in the 1920s and 1930s, and the third with the growth of HMOs and managed care and with the reemergence of primary care. Mental health practice has also evolved, moving from a specialist-based direct access to a primary care model. Although great strides have been made regarding the treatment of depression, an overwhelming majority of patients are still undertreated. Treatments for the future must focus on programs to improve recognition of depression, reduce stigma, and increase compliance.