The recognition of depression in general practice

Whilst general practitioners recognise much of the psychiatric morbidity suffered by their patients, a review found that overall around half goes unrecognised (Goldberg & Huxley, 1980). In major depression specifically, around a half of those identified by psychiatric research interviews go unrecognised by general practitioners, whether the patients are attending with a new episode of illness (Bridges & Goldberg, 1987) or for any reason (Skuse & Williams, 1984; Freeling et al., 1985). Although another 10% are subsequently recognised and 50% of those unrecognised will remit, the remaining 20% may remain unrecognised even after six months and may develop a chronic depression (Freeling et al., 1985).

General practitioners have a difficult and highly skilled task when faced with several presenting problems first to make a decision about the likelihood of a patient having a physical disorder, and if so whether it is mild or potentially life threatening, whilst simultaneously considering the possibility of emotional disorder also. With depression, this task is also made difficult by the frequency in general practice of presentations with somatic symptoms and of depression related to physical disorders.

Reasons why depression is missed

Two broad reasons why depression is missed in general practice settings are:

First, that patients whose depression is correctly recognised differ systematically in their personal characteristics (i.e. demographic, psychiatric or physical characteristics) or in what they mention to their general practitioners from those patients whose depression is missed (Box 10.1).