Barriers to Effective Management of Depression

The previous section described the characteristics and impact of depression and related behavioral disorders. In this section, some of the attitudinal, organizational, and financial roadblocks to the optimal management of depression are summarized.

The Stigma of Depression

A problem that touches on nearly every aspect of the recognition, diagnosis, and treatment of depression is the continued stigma attached to disorders perceived as “mental” rather than “physical” in origin.[1]

This dichotomy and the ideas it engendered led to the separation of “mental” health treatment from the treatment of physical health, and the sequestering of those suffering from severe emotional or behavioral disorders in asylums, especially during the 19th century.[1]

Public attitudes toward behavioral health continued to be influenced by this early separation of “mental” and “physical” health. Even at the midpoint of the 20th century, most people only identified patients with the most severe forms of behavioral disorders (such as psychoses) as “mentally ill.” Depression and anxiety were not recognized by most people as clinical states and were commonly confused with ordinary unhappiness or worry.[1]

By the 1990s, public awareness and the knowledge about behavioral disorders, and their basis in both biologic and environmental factors, had improved substantially. However, for many this knowledge does not eliminate the stigma attached to these disorders. The willingness of individuals affected with depression to discuss their illness with physicians and other health care providers is directly influenced by lingering concerns about being ostracized or discriminated against if diagnosed with a “mental illness.”[1]

The 1999 Surgeon General’s report on mental health states that public awareness and advocacy programs, in addition to better treatments for behavioral disorders, should help reduce the stigma and fear associated with depression and other behavioral disorders. A recent study of the effectiveness of various methods for reducing fears about mental illness among college students suggested that education through replacement of myths with facts about depression is useful. This approach can be implemented at the level of either the practice site or the health plan.

Public Support for Mental Health Care Funding is "Soft"

One of the carryovers from the historic segregation of behavioral from physical health care is that public willingness to fund treatment of behavioral disorders is not as strong as the willingness to support funding of treatment for physical disorders. Public opinion polls have suggested that willingness to pay for mental health services diminishes when costs are factored in, although there is greater support for care of more serious disorders, such as schizophrenia or major depression.[1]

For most purely physical disorders, treatment costs are usually borne by insurance coverage, even when such treatments precede the development of the disorder itself. For example, reimbursement is routinely provided for cholesterol-lowering statin medications in treating patients with high levels of low-density lipoprotein (LDL) cholesterol, whether or not these patients have symptomatic cardiovascular disease. The relationship between high LDL-cholesterol and cardiovascular diseases is well established, and the toll of these disorders in terms of direct costs and lost productivity has been amply documented.

The economic impact of depression and other behavioral disorders is far more clearly appreciated now than in the past. The high level of effectiveness of certain risk-factor reduction, screening, or treatment modalities has been demonstrated. However, partly because of continued stigma and misunderstanding, it has been difficult to link payment with the provision of effective care and the willingness to fund it.[1]

Gaps in Recognition 

Successful treatment of depression relies first upon accurate diagnosis. The high prevalence of depression and related disorders, failure of patients to recognize the signs and symptoms of the disease, and the frequent presentation of depression with nonspecific physical symptoms suggest that the primary care setting is highly important as a focus for initial diagnosis. However, a number of studies have suggested that only about half of patients with depression are accurately diagnosed at the primary care level; and of those recognized, fewer than 10% will be effectively treated.[2] Diagnosis by primary care physicians (PCPs) may be hampered by a variety of factors:

  • Limited awareness regarding the high prevalence of depression and its frequent manifestation through nonspecific physical symptoms. A blood pressure check is a routine part of a visit, yet depression is more prevalent than hypertension. 

  • Variable training especially in the use of screening tools and algorithms, treatment options, and clinical practice and referral guidelines. 

  • Perceived lack of time and/or resources for adequate workup This in part stems from the varying awareness of rapid screening tools to detect depression, coupled with actual or perceived limitations in the adequacy of reimbursement for the time required. Time constraints may also affect coordination of care with mental health professionals. 

  • Underappreciated ability to provide effective treatment, especially during maintenance therapy or for patients with early mild depression or risk factors. Brief counseling and pharmacologic therapy with ongoing brief counseling have been shown to be effective in many instances.[3]-[5]

These gaps are magnified because of a corresponding lack of awareness among the public and patients about depression, its symptoms, and its consequences. In part, this lack of awareness is reflected as one cause of the well-documented failure of most people, even those with severe behavioral disorders, to seek help (although clearly disease denial and fears of being labeled as “mentally ill” play a role in this as well). Estimates of the rate of treatment seeking vary; however, most analyses have concluded that only about one third of those with diagnosable behavioral disorders seek treatment.[1] There are a number of reasons why people fail to seek treatment including:

  • Lack of awareness of the prevalence of depression and other related disorders
  • Lack of understanding that depression may appear as fatigue, insomnia, apathy, inability to concentrate, or other symptoms seemingly unrelated to mood
  • Lack of knowledge that depression frequently occurs in the presence of medical and behavioral disorders
  • Lack of appreciation of the contribution of recognized risk factors (age, gender, family history) to depression

Combined with the ongoing stigma attached to behavioral disorders, the lack of public awareness contributes to low rates of treatment seeking that is either self-motivated or encouraged by family and friends.

Cultural and Ethnic Influences

Diagnosis and treatment can also vary by culture and ethnicity. A recent study of patients in an urban practice suggested that Hispanics may have significantly higher rates of depression than non-Hispanic whites and African Americans.[6] However, behavioral health disorders are less likely to be detected among Hispanics and African American than among non-Hispanic whites.[7] Even when detected, the rates of treatment among Hispanics (20%) and African Americans (16%) are lower than among whites (24%).

Cultural differences can contribute to differing presentations. For example, Hispanics may be more likely to report primarily physical, rather than emotional, symptoms, as in the case with nervios or ataque de nervios. Symptoms can include headache, trembling, tingling, inability to concentrate, or dizziness, but the underlying issues are related to a vulnerability to life’s problems due to the interaction of past stresses. In one study, major depressive disorder was almost ten times as prominent in Hispanic patients who had suffered ataques than in those who had not.[8]-[10] A similar pattern of “somatization” has been found among Asian immigrants and refugees.[11] The reporting of symptoms may reflect cultural heritage in such a way that the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV:) criteria for specific disorders may not apply. As a result, the DSM-IV-TR with text revisions includes, as an Appendix, a description of “culture-bound syndromes,” disorders that are perceived or described in a way specific to a given culture, as well as possible corresponding diagnoses.[9]

In addition, in some cultures, behavioral disorders may not be viewed as “diseases” that require treatment. Instead, individuals in these cultures or subcultures, including Hispanics, may seek assistance from religious or folk healers rather than or before consulting a physician.[8] Finally, language barriers can magnify the cultural and ethnic influences.

A Fragmented Delivery System for Behavioral Health Care

A wide range of provider types are involved in the diagnosis and treatment of behavioral disorders, often with little or not coordination. Researchers have used the term “de facto mental health service system” to describe this approach, but the use of the word “system” implies greater consistency and coordination than is typically present. The system comprises four major sectors[1]:

  • Specialty Mental Health
  • General Medical/Primary Care
  • Human Services
  • Voluntary Support

In Tables 1 and 2, the percentage of US adults (aged 18 years and over) and US children and adolescents (aged 9-17 years) who receive services from these sectors each year is summarized.

Each sector functions more or less independently, and each provides different patterns of care and services. In addition, the professional groups represented within the various sectors have their own sets of intervention goals and standards. The quality of care provided by each sector, and associated outcomes, have not been extensively compared.[1]

Each of these sectors also has distinct patterns of funding, which may be public or private. Publicly funded services are either operated directly by government agencies (at the federal, state, or local level) or rely on the government for financing. The private sector includes services directly provided by nongovernmental agencies and those financed by nongovernment funds (employer-provided insurance is included in this category).[1]

To provide the most effective care on a patient-by-patient basis, the services provided by each of these sectors, ideally, should coordinate with each party involved in treatment awareness of the activities of other parties. However, coordination of care between sectors is frequently poor or absent, and the burden for facilitating communication falls to the patient.[1]

Table 1. Percentage of Adults Using Behavioral Health Services in One Year*[1]

Total Health Sector 11%
Specialty Mental Health 6%
General Medical 6%
Human Services 5%
Voluntary Support 3%
Any of the Above Services 15%
*Subtotals do not add to total because of overlap (persons using more than one type).

Table 2. Percentage of Children/Adolescents* Using Behavioral Health Services in One Year**[1]

Total Health Sector 9%
Specialty Mental Health 8%
General Medical 3%
Human Services 17%
School Services 16%
Other Human Services 3%
Any of the Above Services 21%
*Aged 9 to 17 years
**Subtotals do not add to total because of overlap (persons using more than one type).

Behavioral Health Service System

The “de facto mental health service system” comprises four major sectors from which patients seek help for behavioral disorders[1] :

Specialty Mental Health: Professionals dedicated to and trained specifically for treatment of behavioral health, including psychiatrists, psychologists, psychiatric nurses, and others. They may operate in both inpatient and outpatient facilities, although the latter now predominate.

General Medical/Primary Care: Health care professionals who treat a broad array of medical and behavioral disorders in both inpatient and outpatient settings. This sector includes PCPs, pediatricians, obstetrician/gynecologists, internists, and nurse practitioners. For most patients, this is the first point of contact for behavioral health complaints (although they may present as physical symptoms), and for a substantial fraction it is the only point of contact.

Human Services: These consist of social service agencies, school-based counseling services, vocational rehabilitation, criminal justice services, and others. Many are publicly funded, although religious counselors also are included in this category.

Voluntary Support: Representing primarily self-help and peer-counseling programs, this sector is rapidly increasing in importance, especially in the area of addictive disorders.

In addition to difficulties in coordinating care across sector boundaries, communication within the health sector (which comprises the Specialty Mental Health and General Medical sectors) can be a problem. Because depression is so often associated with both medical and behavioral comorbidities, its evaluation and treatment should be combined with a comprehensive medical assessment. But if patients seek behavioral care from Specialty Mental Health providers and medical care from the General Medical sector, providers from one sector may be unaware of assessments and treatments provided in another sector.

NCQA has incorporated recommendations and benchmarks for Continuity and Coordination of Care into its accreditation standards for MCOs. These specifically address the need to exchange information and coordinate the management of coexisting medical and behavioral disorders.[12]

Funding Patterns Affect Access

Payment and financial concerns are also potential barriers to effective management of depression and other behavioral disorders. Under traditional fee-for-service plans, “mental” health coverage typically was, and continues to be, handled differently than “medical” coverage. It is common from some plans to seek to limit expenditures for treatment of behavioral disorders using several tools, including:[1]

  • Covering or enrollment exclusions
  • Lower annual or lifetime limits on reimbursement
  • Higher deductibles or copays
  • Limitations on duration of covered treatment

These limitations reflect in part the ongoing stigma associated with behavioral health problems. However, they were also instituted in response to studies that appeared to show that reducing restrictions on care resulted in a far greater increase in the use of behavioral health services, relative to medial/surgical services.[1]

It is important to note that while the benefit structure for behavioral health is determined by the specific health plan, the pressure for cost containment has often come from employers. This has been an important factor in the growth of managed care, and in turn, policies and programs to reduce the cost of behavioral care.[1]

There have been a number of efforts to require funding parity for care of behavioral disorders through legislative action at the state and federal levels. However, the impact of one such effort, the federal Mental Health Parity Act, has been reduced by exemptions (for small businesses) and applicability only to “catastrophic” coverage. State parity laws have likewise been limited in scope and impact. In part, the reluctance to improve parity through legislation is the result of limited information on the financial impact of such mandates.[1]

The inequality between coverage for behavioral care and for medical/surgical care can create enormous financial risk and hardship. The estimated out-of-pocket expenditures for behavioral care were recently compared with those for medical/surgical care, using a model of typical employer-provided health coverage (Table 3).[15]

As managed care has become a dominant force in the United States, funding for treatment of behavioral disorders has continued to be handled along a track separate from that of medical/surgical expenses. It is common for treatment of behavioral disorders to be handled by “carve outs,” using providers and administrative procedures different from medical expenses. MBHOs operate under accreditation standards and guidelines similar to those applied to MCOs.[1][16]

Are EMRs the Answer?

Electronic medical records (EMRs) have been proposed as a way to overcome the communication and coordination problems typical in behavioral health care. EMRs permit a comprehensive record of a patient’s diagnoses and treatments to be disseminated to all caregivers. The transition from paper-based medical records to computerized health information management (HIM) promises to ensure more timely access to patient records for all caregivers.

Patient privacy is a significant concern with EMRs, especially in the area of behavioral health. The Health Insurance Portability and Accountability Act (HIPAA) includes specific provisions to ensure confidentiality and patient access to records. Although these regulations affect most medical providers, the degree to which they will be observed in the Human Services sector remains unclear. In addition, there may be problems with data compatibility between sectors.

In addition to enabling better tracking of patient diagnoses and treatments, EMRs have also been considered as a way to “push” better care. In a recent study, patient scores on a depression screening questionnaire were forwarded to the patient’s PCP, along with a notation regarding scores considered to be indicative of depression. This resulted in the PCPs making a number of new diagnoses of depression and starting treatment with antidepressants among patients scared as positive for possible depression. These patients were also followed up 90 days later with a second screening; results showed a drop in depression scores, suggesting a positive response to treatment.[13]

On the other hand, a recent study in which PCPs were provided with electronic care guidelines along with a “flag” indicating a diagnosis of depression showed little effect on process-of-care measure or patient outcomes six months later.[14]

Table 3 Comparison of Out-of-Pocket Expenditures for Medical/Surgical Care and Behavioral Care[15] 

Scenario Out-of-Pocket Expenses
$35,000 medical/surgical expenses in one year $1,500
$60,000 medical/surgical expenses in one year $1,800
$35,000 behavioral care expenses in one year $12,000
$60,000 behavioral care expenses in one year $27,000

Managed care has had the desired effect of reducing the cost of behavioral health services.[1] However, there is concern that cost reduction has come at the expense of high quality care, including reduced specialty referrals and limitations on the length or cost of treatment. In addition, the complexity of benefit design and reimbursement policies can in themselves raise barriers to treatment. They can also distort the treatment process by encouraging patients to use services that represent the lowest out-of-pocket cost rather than the most effective treatment.

Initial comparative studies have shown that both policies and outcomes vary widely between managed care plans. One study showed that the rate of outpatient follow-up visits for depression after discharge from a hospital stay ranged from 39% to 92%. In addition, the rate of rapid rehospitalization following discharge from the hospital for treatment of a behavioral disorder (an indicator of inadequate treatment and/or discharge planning) ranged from 2% to 41% of discharges, depending on the plan.[1]

The traditional fee-for-service model used by both traditional and managed care plans presumes that quality of service is a given, and that such service routinely produces optimal outcomes. However, this presumption of high quality care may not hold uniformly in the treatment of behavioral disorders. In addition, this model is based primarily on acute-care scenarios and may not reflect treatment needs for chronic or long-term conditions. Improved measurement tools for analyzing quality of care may help managed care plans better evaluate the cost-effectiveness of various interventions, helping them to control costs without a negative impact on quality.

Managed care companies and government agencies typically use administrative data systems to analyze quality of care. For example, the HEDIS® measures for quality of care quantify the number of physician visits, new prescription and prescription refill rates, and/or other assessments with respect to disease prevalence and impact within the covered population. Clinical outcome data systems, which incorporate measures of patient outcomes, are more complex and expensive than administrative data systems. However, clinical outcome data systems may ultimately provide a better way to analyze and compare the effectiveness of treatment under different plans.[1][17]

In general, the current pattern of incentives in the treatment of behavioral disorders (both in and out of managed care) does not encourage an emphasis on quality. The Surgeon General’s report has defined a set of objectives for coverage of behavioral health care (see box below) based on interventions demonstrated to be effective.[1]

There is evidence that optimizing quality of care need not increase, and may even reduce, the overall cost of treatment for behavioral disorders. Recently, clinical outcomes data was used to document care improvements and cost reductions following the introduction of a managed care “carve out” by a private employer. The overall cost reductions were shown to be the result of fewer outpatient sessions, reduced risk of hospitalization, reduced hospital length of stay, and lower per-unit costs of service.[18]

As with all areas of health care, behavioral health care involves a balancing act: provide the best possible patient outcomes while keeping per-patient and total costs at acceptable and affordable levels. The desired outcome for most purely physical disorders is usually clear; however, treatment goals and outcomes for depression and related disorders are often not well defined.

Goals of Behavioral Care Insurance: What Should Be Covered? 

The Surgeon General’s report on mental health (1999) summarized the optimal extent of insurance coverage for treatment of behavioral disorders based on a study of treatments demonstrated to be effective. The recommended services for coverage include [1]:

  • Crisis services (hospital and other 24-hour access points)

  • Intensive community services (such as partial hospitals)

  • Ambulatory/outpatient services (psychotherapy)

  • Medical management (medication monitoring, care of comorbidities)

  • Case management

  • Psychosocial rehabilitation

  • Intensive outreach for severe disorders

Screening and Assessment

There is no universally accepted tool for the assessment of disease severity and response to treatment in depression; it is also unclear whether such assessments should focus on symptoms, ability to function, or some combination of the two. A wide range of assessment instruments (see box below) has been used in clinical studies and clinical practice, resulting in a similarly wide range of definitions for remission and recovery.[19]

In other areas of medicine, clinical practice guidelines are frequently used as a framework by which to assess the quality of care. The American Psychiatric Association (APA) has published clinical practice guidelines for the treatment of major depressive disorder, bipolar disorder, and panic disorder. These extremely informative publications, however, are structured as “literature reviews” and are clearly aimed at practicing psychiatrists, making them difficult to use in primary care settings or as assessments of treatment quality and effectiveness.[20]-[22]

In 1993, the Agency for Health Care Policy and Research (AHCPR), the forerunner to the Agency for Healthcare Research and Quality (AHRQ), issued a set of guidelines for the assessment, diagnosis, and treatment of depression in the primary care setting. These guidelines provided clear-cut algorithms involving the selection of assessment instruments, treatment priorities, and approaches to management; and they were designed to be user-friendly and useful in decision making.[19][23]

However, at over 10 years of age, the AHCPR guidelines are somewhat outdated and have not been revised to reflect new information

Which Tool to Use?

One problem in evaluating the quality of care in depression is the inability to clearly define treatment goals and successes. This problem is reflected in the variety of self-assessment and clinician-administered interview tools used to evaluate the presence and severity of major depressive disorder. [19], [23]

Self-Assessment Tools:

  • General Health Questionnaire (GHQ)
  • Center for Epidemiological Studies Depression Scale (CES-D)
  • Beck Depression Inventory (BDI)
  • Patient Health Questionnaire-9 (PHQ-9)
  • Zung Self-Rating Depression Scale (ZSRDS)
  • Inventory for Depressive Symptoms-Self Report (IDS-S)

Clinician-Rated Tools:

  • Hamilton Rating Scale for Depression (HAM-D)
  • Montgomery-Asberg Depression Rating Scale (MADRS)
  • Inventory for Depressive Symptomatology-Clinician Rated (IDS-C)
  • Schedule for Affective Disorders and Schizophrenia (SADS)

At the time of original release, SSRIs, which are now a mainstay of first-line therapy, were relatively new. Since then, a great deal of data on comparative treatment efficacy has been amassed, as well as data on the use of agents such as atypical antipsychotics in the management of mood disorders. More recently, the Institute for Clinical Systems Improvement (ICSI) has published a set of guidelines for management of major depressive disorder in primary care. These algorithm-based guidelines may provide a model for implementation of new quality measures.[24]

Most well-designed clinical studies of depression therapy have focused on pharmacologic interventions. In general, the competitive environment associated with antidepressant medications has led study designs to converge with respect to assessment instruments and definitions of treatment effectiveness. However, the ability to evaluate and compare the cost and effectiveness of pharmacologic treatment has focused on short-term efficacy, rather than on continuing care. For example, the APA Practice Guideline for Major Depression cites a review of 315 studies on the short-term efficacy of new pharmacotherapies alone, but mentions only about 20 studies on the use of antidepressant medications in maintenance treatment.[20]

In contrast, well-designed studies of the effectiveness of nonpharmacologic therapies (psychosocial intervention) are few and far between. Some types of interventions have never been assessed in clinical trials. Studies of other interventions have been hampered by inconsistent definitions of treatment response, by being poorly designed or having no controls, and by study populations that do not reflect diagnostic criteria, among a host of other problems.[20]

The inability to directly compare pharmacologic and nonpharmacologic treatment modes has made it nearly impossible to assess the best mix of therapeutic approaches with regard to treatment cost and effectiveness.

Conclusion

In summary, a number of significant barriers have limited the ability to manage depression and related behavioral disorders. These include gaps in knowledge and training, poor coordination across treatment sectors and between providers, inconsistent definitions of treatment goals and treatment successes, and disproportionate financial burdens on those seeking care. In the next section, we examine more closely the personal, social, and economic benefits that can be expected with better management of these disorders.

References

[1] - US Department of Health and Human Services, 1999. Mental Health: A Report of the Surgeon General. Available at http://www.surgeongeneral.gov/library/mentalhealth/home.html. http://www.surgeongeneral.gov/library/mentalhealth/home.htmlAccessed January 7, 2004.

[2] - Ferguson JM. Depression: diagnosis and management for the primary care physician. Prim Care Companion J Clin Psychiatry. 2000;2:173-178.

[3] - Piterman L, Blashki G, Liaw T. Depression in general practice. Aust Fam Physician. 1997;26:720-725.

[4] - Rost K, Nutting P, Smith JL, Elliott CE, Dickinson M. Managing depression as a chronic disease: a randomized trial of ongoing treatment in primary care. BMJ. 2002;325:934.

[5] - Huibers MJ, Beurskens AJ, Bleijenberg G, van Schayck CP. The effectiveness of psychosocial interventions delivered by general practitioners. Cochrane Database Syts Rev. 2003;2:CD003494.

[6] - Olfson M, Shea S, Feder A, et al. Prevalence of anxiety, depression, and substance use disorders in an urban general medicine practice. Arch Fam Med. 2000;9:876-883.

[7] - Borowsky SJ, Rubenstein LV, Meredith LS, Camp P, Jackson-Triche M, Wells KB. Who is at risk of nondetection of mental health problems in primary care? J Gen Intern Med. 2000;15:381-388.

[8] - Ruiz P. The role of culture in psychiatric care. AM J Psychiatry. 1998;155:1763-1765.

[9] - American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington DC: American Psychiatric Association; 2000.

[10] - Lewis-Fernandez R, Guarnaccia PJ, Martinez IE, Salman E, Schmidt A, Liebowitz M. Comparative phenomenology of ataques de nervios, panic attacks, and panic disorder. Cult Med Psychiatry. 2002;26:199-223.

[11] - Hsu SI. Somatisation among Asian refugees and immigrants as a culturally-shaped illness behaviour. Ann Acad Med Singapore. 1999;28:841-845.

[12] - . National Committee for Quality Assurance. Quality Management and improvement (draft standard). 2001. Available at http://www.ncqa.org/docs/tools/2001%20mco%20dcts.doc Accessed March 31, 2004.

[13] - Gill JM, Dansky BS, Use of an electronic medical record to facilitate screening for depression in primary care. Prim Care Companion J Clin Psychiatry. 2003;5:125-128.

[14] - Rollman BL, Hanusa BH, Lowe HJ, Gilbert T, Kapoor WN, Schulberg HC. A randomized trial using computerized decision support to improve treatment of major depression in primary care. J Gen Intern Med. 2002;17:493-503.

[15] - Zuvekas SH, Banthin JS, Selden Thomas Moore. Mental health parity: what are the gaps in coverage? J Ment Health Policy Econ. 1998;1:135-146.

[16] - . National Committee for Quality Assurance. Managed Behavioral Healthcare Organization Accreditation. Available at: http://www.ncqa.org/Programs/Accreditatoin/MBHO/images/1228_MBHO%20Insert.pdf Accessed March 31, 2004.

[17] - Kane RL, Bartlett J, Potthoff S. Integrating an outcomes information system into managed care for substance abuse. Behav Healthcare Tomorrow. 1994;3:57-61.

[18] - Goldman W, McCulloch J, Sturm R. Costs and use of mental health services before and after managed care. Health Aff (Millwood). 1998;17:40-52.

[19] - Agency for Health Care Policy and Research (AHCPR). Depression in Primary Care. Volume 1. Detection and Diagnosis. Clinical Practice Guideline. 1993. Available at: http://www.mentalhealth.com/bookah/p44-d1a.html#Head0 Accessed March 3, 2004.

[20] - American Psychiatric Association. Practice Guideline for the Treatment of Patients With Major Depression. Available at: http://www.psych.org/psych_pract/treatg/pg/Depressoin2e.book.cfm Accessed January 7, 2004.

[21] - . American Psychiatric Association. Practice Guideline for the Treatment of Patients With Bipolar Disorder (Revision). Available at: http://www.psych.org/psych_pract/treatg/pg/bipoarl_revisebook_index.cfm. Accessed January 7, 2004.

[22] - American Psychiatric Association. Practice Guideline for the Treatment of Patients with Panic Disorder. Available at: http://www.psych.org/psych_pract/treatg/pg/pg_panic.cfm Accessed January 7, 2004.

[23] - Agency for Health Care Policy and Research (AHCPR). Depression in Primary Care. Volume 2. Treatment of Major Depression. Clinical Practice Guideline. 1993. Available at: http://www.mentalhealth.com/bookah/p44-d2a.html#Head0Accessed March 10, 2004.

[24] - Institute for Clinical Systems Improvement. Health Care Guideline: Depression, Major, in Adults in Primary Care. 2003. Available at: http://www.icsi.org/knowledge/ Accessed March 30, 2004.