November 2011  << Back  

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Depression in Primary Care. Evidence and Practice

Richard Balon, MD

Wayne State University, Detroit, MI, USA

Edited by Simon Gilbody and Peter Bower. New York, NY: Cambridge University Press; 2011; ISBN 978-0-521-87050-4; pp 172; $49.99 (paperback).

One of the editors of this book, Simon Gilbody, states, “There is an increasing consensus that the best place to treat depression is in primary care” (p 1). That has been a mantra of many policy makers and, of course, many primary care physicians. Whether you agree or disagree with this statement, most, if not all, would agree treating depression in the primary care setting (and not just in those settings) could be improved. Any text summarizing the know-how and how to improve it would be welcomed by most practitioners. Seduced by the title and by the fact that United Kingdom-based texts usually bring refreshing views, I was looking forward to reading this slim volume on “evidence and practice of depression in primary care.”

The book is edited by 2 health services researchers who profess to have a “bit of a reputation as systematic reviewers” (p xi) and add “systematic reviews are sometimes seen as largely technical in nature…” and “they are also seen as the preserve of methodologically and statistically minded types, the sort of people who are excessively concerned with minutiae and routinely miss the wood while comprehensively searching for the best concealed trees” (p 1). In a way, this statement should serve as the first warning about this volume’s readability and usefulness, but the editors added 1 of the reasons for putting together this book was “to show that reviews can be more than that—that it is possible to link the review process with complex policy issues, and to use the insight generated from the reviews to assist in decision making….” (p xi).

The book consists of a Preface and 13 chapters. Chapter 1, “Depression in primary care,” is a simplistic yet complicated overview summarizing the reasons why depression should be treated in primary care; what is the definition of evidence-based medicine; what is primary care and primary mental health care; what is depression; what are the pathways to care for depression in primary care; and what are the policy goals in primary care mental health. As this description suggests, this text is mostly for policy makers. Chapter 2, “Models of care for depression,” reviews models of quality improvement in primary care mental health—the education and training model, the consultation-liaison model, the collaborative care model, and the referral model—and the relationships between models and policy goals. Outlining these models of care serves as a starting point for several chapters later in the book. Chapter 3, “Linking evidence to practice,” provides a fairly good explanation of randomized controlled trials in evidence-based practice and includes brief reviews of randomization and selection bias, power and sample size, cluster trials, explanatory and pragmatic trials, and reporting on trials. The chapter ends with a discussion of systematic reviews in evidence-based practice. This discussion serves as a prelude to the next chapter, “Anatomy of a review.” As one may expect from the editors’ admission that they are systematic reviewers, this chapter really is a detailed guide on how to do a systematic review, from developing the research question and a comprehensive search to extracting data and appraising the quality of study design and analyzing outcome data. The next 4 chapters (5 through 8) are systematic reviews and assessment of the evidence concerning the previously mentioned models of care for depression, ie, the education and training model, the consultation-liaison model, the collaborative care model, and the referral model. Chapter 9, “Summary of the evidence,” is, as the title suggests, a brief summary of the evidence. Chapter 10, “Making it happen,” attempts to help to translate the evidence in depression care, which is a hard task as the authors conclude this chapter with a statement that “the science of implementation is in its infancy, although the evidence base is growing rapidly” (p 125).

The following 2 chapters provide the “United Kingdom perspective” and the “United States perspective.” The chapter on the United States perspective suggests the best outcomes for treating depression in primary care come from collaborative care programs that apply chronic disease management models. The last chapter, “Conclusions,” reviews the summary of the evidence, limitations of the evidence, and some suggestions for future research.

The authors outline the purpose of this book at several places, stating first that “the purpose of this book is to produce an accessible summary of the clinical and economic evidence to ensure that the delivery of primary care mental health reflects its evidence” (p 12), and later adding, “the purpose of this book was to outline the application of the techniques of evidence-based practice and systematic review to decisions about the best way to manage depression in primary care” (p 111). The authors also state “this book is not meant to provide an answer to the problems of delivering services for depression. The area is too complex, and too value-laden, to submit to such a straightforward approach” (p xi). Second and last warning!

The authors are correct that the book does not provide an answer to the problems of delivering care for depression. It is not clear what answers this book does provide. It also is not clear who can really benefit from reading this volume; maybe some highly interested health services researchers. The cover suggests this book will assist practitioners, researchers, and policy makers alike. That is a real stretch. I am not sure whether any clinician can benefit much from reading this text. I am also inclined to say policy makers will not either. This is basically a difficult-to-read collection of solid health services review papers under a bit misleading title (Depression in Primary Care. Evidence and Practice). Save your money and time.