Depression in Primary Care

Table of Contents


Health:“A state of complete physical, mental, and social well being, and not merely the absence of disease or infirmity.” – World Health Organization, 1948


Chronic medical illness and depression have a bidirectional relationship:




Facts to Consider

  • Up to 75% of all mental health care is delivered in primary care settings.
  • Primary care providers (PCPs) are usually the first providers a patient encounters
  • Stigma prevents patients from seeking mental health treatment from a mental health provider
  • The shortage of mental health providers increasingly places pressure on Primary Care Providers 
  • There is significant overlap between symptoms of depression and common medical conditions (e.g., pain, fatigue, insomnia, appetite changes).
  • Up to 17% of adults experience one major depressive episode in their lifetime
  • 5%-10% of patients seen in primary care settings meet criteria for major depressive disorder
  • 1 in 4 patients in primary care clinics have sub threshold depression or persistent depressive disorder
  • Untreated depression in medical populations is associated with greater somatic symptom burden, poorer quality of life, and overall worse outcomes
  • Risk for depression increases with number of medical diagnoses
  • Depression is associated with higher rates of health care utilization (Cost of medical care for depressed patients is 50% higher than for non-depressed patients)
  • Depressed patients tend to be less adherent with medical treatment, less productive at work (or unemployed/on leave), and more resistant to medical treatment


Myths and Misconceptions

  • Depression is “normal” and “understandable” under certain circumstances and does not require treatment (Depression is not a “normal response” to anything)
  • Normal sadness and depression are the same thing (NOT TRUE)
  • Depression due to acute and/or chronic pain is “understandable” and does not require treatment (NOT TRUE)
  • Pain and other somatic symptoms are uncommon presenting complaints in patients with depression (NOT TRUE)
  • “Antidepressants don’t really work” (NOT TRUE)


Screening for Depression


Patient Health Questionnaire 2 (PHQ-2)


  1. ‘‘Over the past 2 weeks have you felt down, depressed, or hopeless?”
  2. “Over the past 2 weeks have you felt little interest or pleasure in doing things that normally interest you or bring you happiness?”


  • If yes to either 1 or 2, investigate further…


Patient Health Questionnaire 9 (PHQ-9)

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Diagnosing Depression


Differential Diagnosis



Treatment Options


Psychotherapy Options


  1. Cognitive Behavioral Therapy
  2. Interpersonal Psychotherapy
  3. Psychodynamic Psychotherapy
  4. Behavioral Activation
  5. Supportive Psychotherapy


Pharmacotherapy Options


  1. Selective Serotonin Reuptake Inhibitors (SSRIs)
  2. Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
  3. Bupropion
  4. Mirtazapine
  5. Trazodone
  6. Vortioxetine
  7. Tricyclic Antidepressants (TCAs)
  8. Monoamine Oxidase Inhibitors (MAOIs)





Depression Treatment Algorithm




Quick Reference: Medication Tables







PHQ-9 Tool