A national survey recently identified one-third of Americans as having experienced symptoms of either clinical depression or generalized anxiety disorder (GAD), yet only one-fifth had been diagnosed as having clinical depression or GAD. Surprisingly, only half of those diagnosed had received treatment.

To get a clear understanding of the American public’s awareness of available treatments for clinical depression and GAD, expectations for recovery from these illnesses, and views on how primary care physicians play a role in this recovery, the Mental Health America (NMHA) funded the America’s Mental Health Survey. Roper Starch Worldwide Inc. conducted the survey, which polled a nationally representative sample of 3,288 adults by telephone.

Researchers found that although the majority of survey respondents were aware that treatments are available for both clinical depression and GAD, few expect a full recovery from these illnesses. With 61 percent of Americans with symptoms of GAD or clinical depression wanting their primary care physician to be more involved in their mental health, the call is on for primary care physicians to start communicating with their patients and conduct more screenings for mental illness.

One might ask why so few Americans with a diagnosis of depression or GAD are being treated. "There are a huge number of barriers to treatment of depression in primary care," said J. Sloan Manning, M.D., a family physician and researcher who collaborated on the survey. "That half of the group who were diagnosed received treatment is good news." He compared this finding with data collected in the 1980s showing that only one-third of patients with these diagnoses were getting treatment.

Manning, who is an associate professor of family medicine at the University of Tennessee, pointed to a web of problems in diagnosis and treatment. "Some patients aren’t aware that they have a diagnosis of mental illness and don’t want one. Some primary care physicians are not comfortable treating these folks because their training didn’t prepare them adequately."

Manning also believes that depression is difficult to treat because it may be a number of different illnesses, not just one. Some patients in primary care don’t respond to standard treatments, and this can be a problem. On one hand, he explained, there are multiple, time-consuming strategies to use with those who don’t get well after the first round of treatment. On the other hand, physicians who turn to these strategies face time constrants that can prevent them from following through with second- or third-line treatments.

According to Manning, patients with undiagnosed depression or anxiety can have a number of medical comorbidities and are sometimes referred to as the "frequent fliers" of primary care. Some patients frustrate physicians with vague, somatic complaints and have the greatest amount of contact with office staff. "They frequently talk to the telephone nurses and the physicians on call, and are often seen in the emergency room," said Manning.

In this age of burgeoning research in neuroscience, only 41 percent of Americans surveyed felt that a complete recovery from clinical depression or GAD could be expected. Americans diagnosed with clinical depression or GAD who saw their primary care physician first had higher recovery expectations than did their counterparts who saw psychiatrists first.

Jeffrey Kelsey, M.D., Ph.D., who also collaborated on the study, offers an explanation: "Those who saw a psychiatrist first probably had a more severe form of the illness. Some may be only partially treated, have lingering feelings of guilt, and believe that they don’t deserve to feel any better," he said.

Kelsey, an assistant professor of psychiatry at Emory University, was discouraged that so many Americans did not have high hopes for recovery. "We have so many different and effective treatments for these illnesses. With aggressive care, we can get the vast majority of people well."

One key point brought out by the survey findings is that primary care doctors need to talk to patients about their mental health. Moreover, both Manning and Kelsey agree that more communication is needed between psychiatry and primary care. Kelsey believes that it is important to utilize practice settings where primary care and psychiatry are intermixed, and Manning reinforced this point. "Treatments such as counseling and crisis management are located across town at the community mental health clinic. People don’t want to go there, because to enter is to identify oneself as having a mental illness."

Manning spoke proudly of the mood disorder clinic located within the department of family medicine at the University of Tennessee, where patients who would usually be sent to community mental health centers are kept within the primary care system. "We take care of those people who are diagnostic dilemmas or who don’t respond to first-line treatments," said Manning. Not only do these more complex patients receive treatment, but also they receive special attention by a treatment team consisting of students and practitioners in mental health and family medicine, who offer input and receive training.