Series Editors: Nicholas A Keks, MPM, PhD, FRANZCP; Graham 0 Burrows, AO, MD, FRANZCP MJA Practice Essentials 3. Assessment of anxiety and depression in primary care Steven R Ellen, Trevor R Norman and Graham D Burrows A general practitioner who sees 40 patients a day can expect that eight will require support or treatment for anxiety or depression - and that's not counting those whose disorders go unrecognised. D epressive and anxiety disorders are common, occurring in up to 25% of primary care patients,' and are more dis- abling, both socially and in terms of physical functioning, than many chronic physical illnesses, such as diabetes, hyperten- sion, arthritis and back pain .s-' The economic impact is immense, both in direct costs to health care systems and in indirect costs to the community.' Despite this, there is considerable evidence that the medical profession deals poorly with these disorders. In up to half of patients presenting with anxiety or depression, the diagnosis is missed, and in those who are recognised a significant proportion are not treated.':" Most patients with these disorders present and are managed in primar y care settings.s-? This article reviews the prevalence, recognition and assessment of depressive and anxiety disorders in primary care . Prevalence of depression and anxiety in primary care The most thorough large-scale study is the World Health Orga- nization [WHO] study on psychological disorders in primary care. I Over 25000 consecutive adults were screened at 15 sites in 14 countries. Over 5000 were further assessed with detailed psychi- atric interviews. A quarter had a recognisable mental disorder, the commonest being a depressive disorder (11.7 %) or an anxiety dis- order (10.5%), with 4.6% having both. Only half of the mental dis- orders were recognised by the primary care physician; among those patients with a recognised mental disorder, halfwere offered drug treatment. A similar study in Australia of 4867 patients of 117 general prac- titioners found that 35.6 % had elevated scores on a screening test for mental illness, while 20.6% had been treated for anxiety or depression in the previous 12 months. Treatments included med- ications (52 %), referral to a specialist (24%) and non-drug advice (70%), with 91% of patients reporting their treatment or advice as reasonably good or very good. The high prevalence rates in primary care patients are not sur- University of Melbourne Depar-tment of Psychiatry, Austin and Repatriation Medical Centre, Melbourne, VIC. Steven R Ellen , MMed(Psych), FRA NZCP, Lecturer. Trevor R Norman, PhD, Associate Professor. Graham D Burrows, AO, MD, FRANZCP, Professor of Psychiatry. No reprints will be available from the author. Correspondence: Dr S R Ellen, University of Melbourne Department of Psychiatry, Austin & Repatriation Medical Centre, Heidelberg, VIC 3084. 328 Mental Health A fully rigged ship running onto the rocks - a common theme in anxiety. This painting was shown at the 1950 International Exhibition of Psychiatric Art, and is now in the Cunningham Dax Collection of Psychiatric Art in the Mental Health Research Institute of Victoria. Reproduced with permission. Synopsis Depressive and anxiety disorders are common in primary care settings, yet up to half the patients who present with these disorders may not be diagnosed and others may not be treated . • The cornerstone of detection is an understanding of the common presenting symptoms and syndromes. • Patients with depression or anxiety frequently present complaining of physical symptoms, which may obscure the psychiatric diagnosis. • The doctor 's consu ltation technique is important: an empathic style, open questions and a willing- ness to hear the patient out will help reveal the diagnos is. • Clinical depression is diagnosed when there are at least three or four symptoms (low mood, loss of interest, sleep disturbance, lost concentration, fatigue, disturbed appetite, agitation or retardation, feelings of worthlessness or guilt, suicidal thoughts) present every day for at least two weeks. • Anxiety disorders include panic disorder, phobias, obsessive-computslve disorder, post-traumatic stress disorder and generalised anxiety disorder. • Screening tools (simple questionnaires designed to identify signs and symptoms of anxiety and depression) can be effective. • Once a depressive or anxiety disorder is detected , possible causes to be explored include underlyi ng medical conditions, psychiatric conditions, and drug or alcohol use. MJA 1997 ; 167: 328-333 MJA Vol 167 15 September 1997