Capsule Commentary on Waitzfelder et al., Treatment Initiation
for New Episodes of Depression in Primary Care Settings
Hale Thompson, PhD
Department of Psychiatry , Rush University Medical Center, Chicago, IL, USA.
J Gen Intern Med
© Society of General Internal Medicine 2018
he study by Waitzfelder and colleagues provides a unique
opportunity to examine factors associated with initiation
of depression treatment in primary care settings across five
large integrated health systems in five states.
electronic health record data, the findings mostly confirm
documented mental health disparities.
The odds of engaging
in treatment decreased with age and income and for persons of
color, who were also more likely than white patients to choose
psychotherapy over antidepressant medication. Notably, the
odds of initiating treatment were higher for patients who were
screened with the Patient Health Questionnaire (PHQ)-9 than
for those who were not.
In his seminal work, Rose’s Strategy of Preventive Medi-
Sir Geoffrey Rose makes the case for the prevention
paradox when faced with relatively common conditions like
depression. This concept suggests that to achieve the greatest
health benefits for the overall population, each participating
individual derives only a small benefit from an intervention.
Building upon the findings of Waitzfelder and colleagues in
the context of this paradox, medical and epidemiological
research ought to prioritize studies on the effectiveness of
population-level interventions. Evidence-based collaborative
care models employ a systematic use of the PHQ-9 for screen-
ing alongside focused case management, antidepressant med-
ication management, and cognitive behavioral skills-
implementation science could aid in identifying
those mechanisms that help reduce disparities across race,
class, age, and gender. Qualitative inquiries with patients
who are diagnosed with depression but forgo treatment may
generate innovative therapies, social supports, and structural
change that mitigate disparities.
The Affordable Care and Health Information Technology
for Economic and Clinical Health Acts ushered in the capacity
to implement population mental health strategies. The insur-
ance mandate, mental health parity, and widespread uptake of
electronic health records have expanded access to mental
health care. With only 36% of newly diagnosed patients opting
we need to understand how best to utilize these
infrastructures not only for research, but also for interventions
that will systematically reduce the prevalence of depression
and benefit the general population.
Corresponding Author: Hale Thompson, PhD; Department of
Psychiatry Rush University Medical Center, Chicago, IL, USA
Compliance with Ethical Standards:
Conflict of Interest: The author has no conflicts of interest with this
1. Waitzfelder B, Stewart C, Coleman K, et al. Treatment initiation for new
episodes of depression in primary care settings. J Gen Intern Med. 2018.
2. Akincigil A, Matthews E. National rates and patterns of depression
screening in primary care: results from 2012 and 2013. Psychiatry Serv.
2017;(In Advance):1-7. https://doi.org/10.1176/appi.ps.201600096.
3. Rose G. Rose’s Strategy of Preventive Medicine. Second. Oxford: Oxford
University Press; 2008.
4. Thota AB, Sipe TA, Byard GJ, et al. Collaborative Care to Improve the
Management of Depressive Disorders: A Community Guide Systematic
Review and Meta-Analysis. Am J Prev Med. 2012;42(5):525-538. https://
5. Archer J, Bower P, Gilbody S, et al. Collaborative care for depression and
anxiety problems. Cochrane database Syst Rev. 2012;10(10):CD006525.