ELSEVIER Psychiatry and Primary Care Recent epidemiologic studies have found that most patients with mental illness are seen exclusively in primary care medicine. These patients often present with medically unexplained somatic symptoms and utilize at least twice as many health care visits as controls. There has been an exponential growth in studies in this interface between primary care and psychiatry in the last 10 years. This special section, edited by Wayne J. Katon, M.D., will publish informative re- search articles that address primary care-psychiatric issues. Nondetection of Depression by Primary Care Physicians Reconsidered James C. Co ne, Ph.D., Thomas L. Schwenk, M.D., and Suzanne Fee i: ner-Bates, Ph.D. Abstract: This article examines the rates of detection for major depression and other depressive disordqs by fumily physicians as well as the differences between defectedand undetected cases in terms of a variety of demographic and clinical variables. A total of 2,580 family practice pafients completed a screening form and were rated by their physician. Patients with elevated Center for Epidemiologic Studies-Depression Scale (CES-D) scores were oversampled for possible interviews using the Structured Clinical interview for DSM-111-R (SCID). In the resulting weighted sample, family physicians detected 34.9% of cases of major depression and 27.9% of cases of any depres- sive disorder. Detection was associated with pharmacological and psychological intervention. However, the undetected cases tended to be mildly depressed and higher functioning. Presence of a current anxiety disorder facilitated defection. Overall, the mildness of undetected depression and associated impairment have implicafions for estimates of the consequences of primary care physicians’ low rates of nondetection and for the develop- ment of interventional strategies to improve their performance. Introduction Only about 20% of persons with major depressive disorders are seen by mental health professionals, and though over half are seen in primary medical care [l], many will go undetected by their physi- cian. Conceptualization of the problem posed by undetected depression in primary medical care has Department of Family Practice, The University of Michigan Medical Center, Ann Arbor, Michigan Address all correspondence to: James C. Coyne, Ph.D., De- partment of Family Practice, University of Michigan Medical Center, Ann Arbor, MI 48109-0708. General Hospital Psychiatry 17, %12, 1995 0 1995 Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 undergone a number of distinct refinements in the past decade and a half. Initial specification of its scope relied largely on research in which self- report questionnaires were used to idmtify de- pression and chart notation served as the criterion for its detection [2-51. The findings of such studies need to be interpreted with an understanding that most of the elevated scores on screening question- naires do not actually represent d@nos&le de- pression [6,7] and that for a variety of reasons, chart notes give an underestimate of physician rec- ognition of depression @I. The second wave of re- search relied on the results of semistructured in- terviews as the criterion for diagnosis, typically ad- ministered by trained, but often lay intirviewers, and formally solicited diagnoses from the physi- cians [9-111. The rather consistent conclusion of this literature was that primary care physicians do indeed miss many of the depressive disorders that are presented to them, perhaps as much as 50%- 70% of persons with a current depressive dimrder. This body of research is generally seen as uphold- ing the view that undetected depression among primary care patients is a major public health prob- lem. We are now entering a third phase in which this conclusion is being subjected to critical scrutiny. At issue is not whether primary care physicians miss depression, but rather the implications of their apparently high rates of nondetection. Until now, the unquestioned logic has been that depres- sion is a debilitating, but readily treated condition, 3 ISSN 01~8343/95/$9.50 SSDI Ol63-8:30(94)00056-l