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James Pretzer September 4th, 2004 09:38 PM

Treating Depression in Primary Care (medical) settings
There's been quite a bit of work in recent years trying to improve the treatment of depression in medical settings since many depressed individuals either seek treatment from their primary care physician or seek treatment for physical complaints when the main problem is depression. It is great that CT is an effective treatment for depression. Unfortunately, simply publishing treatment guidelines regarding when to prescribe antidepressants and when to refer for therapy has not proven to be an effective way to improve the quality of care that most patients recieve.

A recent Medscape article ( describes an ambitions new project and gives an idea of what is needed to produce system-wide improvement. Links within the article give additional information and include a good bibliography on related topics (http://www.depression-primarycare.or...commended/#top).

roland rogiers November 7th, 2004 06:22 PM

Re: Treating Depression in Primary Care (medical) settings
I'm working as a psychologist and trained CBtherapist in the Dep. of General Practice, Faculty of Medicine, Ghent University, Belgium.Some years ago, we developed some courses (15 hours p. course) "non drug approach" for general practitioners in vocational training & experienced GP's. We are trying to implement cognitive behavioral interventions into primary care. Topics: depression, anxiety disorders, insomnia. Medical Unexplained Complaints is in the pipeline. I was wondering if I could contact some colleagues who are doing same work.

mugwump November 8th, 2004 02:14 AM

Re: Treating Depression in Primary Care (medical) settings
Good afternoon

in australia, a fair bit of effort is being put into training GPs in CBT and associated psychological strategies. some research is also being done related to this.

some good websites related to this are and go to the websites related to research

these webistes refer specifically to training for GPs in psychological strategies

good luck with it

roland rogiers November 8th, 2004 06:55 PM

Re: Treating Depression in Primary Care (medical) settings
Good evening,Mr. /Ms Mugwump
Was my first contact with bol and bingo, thanks to you.
Did some surfing to the very interesting sites you suggested. I will contact them hoping we could exchange some ideas and experiences.
Thank you very much.

mugwump November 8th, 2004 08:12 PM

Re: Treating Depression in Primary Care (medical) settings
Good luck with the searching

the sphere group is particulary focused on gps and training them in cbt - it has trained a significant number of gps in cbt using experienced gps as part of the training team. on that website their is a pdf file --- which outlines a study to examine the effectiveness of teaching gps cbt

be interested to hear what you are doing in belguim


roland rogiers November 10th, 2004 11:27 AM

Re: Treating Depression in Primary Care (medical) settings
Dear Sir,

Don't know what happened on my way to the forum, but I lost two times my answer.
Thank you for your interest. What we are doing in Belgium? At the Ghent University, Dept. General Practice, we developed some training packages, in which we try to implement cognitive behavior interventions in general practice.
Topics: anxiety, depression and insomnia. Motivating chronic users of benzodiazepines and Medical Unexplained Complaints are in the pipeline.
For example: module depression: 15 hours. We provide this training for GPs in vocational training (year 2+3) and more experienced GP.
1. alerting signals, diagnosing depression and talking about suicidal ideas + management of suicidal patient
2.scheme for indication criteria short term treatment by the GP. Assessing resources, skills in making the complaints concrete, personality disorder, global social functioning, motivation
3. psycho-education : construction of a common "sickness-theory" (what is depression? Why do I have a depression?) and common "treatment-theory": what can I do about it: drug treatment (by a GP, using guidelines & EBM) and non-drug treatment.
4. activating the patient by use of the miracle question ( de Shazer) and working with scales
5. some principles of cognitive therapy: identifying disfunctional ideas and cognitive patterns and how to challenge them
6. some ideas about follow up, relapse prevention and referral

Some GP are member of a intervision group and have some booster sessions and recently back up from a internal forumgroup
Feedback: not easy to implement in GP but they feel more comfortable in working with depressive patients and they work more goal-oriented.
We don't have done any research about our model, but we hope we can do so the next years.
I saw that you are working on a dept gen practice and I'm interested in your experiences and ideas about these topics
Kind regards
Roland Rogiers

James Pretzer March 8th, 2005 10:42 AM

Treating More Than Depression in Primary Care (medical) settings
Obviously, CBT can be used to treat more than depression in medical settings. An abstract of an article in the current edition of Archives of General Psychiatry regadring the treatment Panic Disorder in primary care settings can be found at:

The conclusion: “…Delivery of evidence-based CBT and medication using the collaborative care model and a CBT-naïve, midlevel behavioral health specialist is feasible and significantly more effective than usual care for primary care panic disorder…”

Note that in this study and some of the others, mental health professionals are providing the CBT, not the physicians. From my experience on the faculty of the Department of Family Medicine at Case Western Reserve, my sense is that anyone who can make it through med school can be taught to do CBT but there are several drawbacks to having the physicians do CBT:
  1. If they don't already have psychotherapy training, they'll need basic therapy training, not just training in CBT. This would be a significant amount of training.
  2. In the U.S. medical system, most primary care physicians simply don't have the time to provide more than a few minutes of counseling.
  3. If the physician spends a significant amount of his or her time doing counseling, this would result in a significant drop in income.
  4. In most settings, it would be more cost effective to have a social worker or psychologist providing counseling. Doing this would generate additional income for the practice and improve patient care.

So why don't primary care practices have social workers and/or psychologists on staff to provide treatment? Actually, some do. However, there is extra administrative complexity in doing this and the fragmentation of health care funding in the U.S. complicates things. If the physician is a provider for some insurance companies and not others, while the therapist is a provider for some of those incurance companies but not all of them, referrals from the physician to the therapist become much more complex. Unfortunately, most insurance companies are not accepting new providers so the therapist is not likely to be able to get on the same panels as the physician.

James Pretzer May 16th, 2005 07:56 PM

More on Depression in Primary Care (medical) settings
Medscape has another good article on depression in primary care medical settings which can be found at

(If you aren't already registered with Medscape, you'll need to register to read the article.)

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