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"Just as you wouldn't want a primary-care physician to do coronary bypass surgery, you wouldn't want one to treat severe or complicated depression," said Dr. Greden, who works with primary-care doctors in Michigan on ways to improve the diagnosis and treatment of depression.
But there are many obstacles to receiving adequate care from a general practitioner, even for mild or moderate depression, experts say. For one thing, Dr. Greden says, primary-care physicians do not receive enough training on how to recognize the condition.
"Most patients don't come in and say, `I feel sad or depressed,' " he said. "They emphasize complaints like fatigue or insomnia or other physical manifestations of depression."
So their doctors tend to treat the physical symptoms, Dr. Greden added, by prescribing sleeping pills for insomnia, for example, instead of looking for the underlying causes.
Another obstacle is that many general practitioners are uncomfortable talking about depression, said Dr. David Kupfer, chairman of psychiatry at the University of Pittsburgh Medical Center, who has studied trends in treating depression.
"If a patient talks about his sleep problems, the doctor won't ask about other possible depression symptoms," he said.
Yet another obstacle is time. Doctors in managed-care plans have a financial incentive to see as many patients as possible each day. Dr. Cohen, the internist, said the time pressure discouraged many of his colleagues from asking the necessary questions to find out whether patients are depressed.
"One colleague said to me, `I see so many patients a day, I don't want to open up a can of worms,' " he said.
When they do diagnose depression, primary-care doctors often fail to provide enough information on drugs' side effects, patients say. Yet unpleasant side effects from antidepressants llike anxiousness, weight gain and loss of sexual desire are among the main reasons that patients stop taking antidepressants.
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Howard Smith says the benefits of antidepressants can take a few weeks to show up.
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"I've rarely heard any patient say, `My family doctor explained it all to me,' " said Howard Smith, director of operations for the Mood Disorders Support Group, an organization in New York City that operates support groups for people with depression and bipolar disorder.
Mr. Smith says the side effects can start within a day of two of beginning an antidepressant, but the benefits often take a few weeks to show up. "So patients call their doctors and complain that they feel sicker, and the doctors tell them to stop the medication or they prescribe something else," he said.
If doctors took the time to explain to their patients that the side effects were often temporary, he said, many more would continue treatment and have their depression effectively managed.
Dr. Cohen said most primary-care doctors did not know about the nuances of the many antidepressants — which ones are best for particular symptoms and what to do if the lowest dose does not work.
"Internists are grilled on how to use multiple medications for diabetes or hypertension and how to switch medications if the first one doesn't work," he said. "But there's not as much education geared to internists on dosing and switching antidepressants."
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