Treatment delivery and guidelines in primary care

Because depressive illness is so prevalent, the majority of patients are managed in primary care, without recourse to specialist services. Primary care management is seen to fall short of the standards set in secondary care, but unfortunately there is as yet relatively little evidence from primary care to guide management in this distinctive patient population. Guidelines have been introduced as a means of quality management, and their value in improving care has been assessed in trials. To date, the benefits of the implementation of guidelines have been marginal at best. By contrast, strategies which improve the access of patients to specialist services do seem to be beneficial. There is also evidence that such strategies may be associated with 'cost-offset'. Choice of antidepressant medication for maximum cost benefit should also be informed by an evidence base, which is beginning to be accumulated. Further research on this topic in the primary care context is still needed.