Anxiety and depression: a model for assessment and therapy in primary care

Patients who feel anxious and depressed often turn to primary care for initial professional help. However, systematic service evaluations allege poor standards of diagnosis and treatment, resulting in disappointing clinical outcomes. All the same, special educational and quality improvement initiatives have not raised standards significantly. Why this should be so and possible remedies are suggested by this article, on the basis that the empirical evidence base for criticising primary care standards is weaker than commonly acknowledged. Systematic clinical trials are often premised by assumptions that are not relevant to primary care, they tend to select subject populations unrepresentative of those typically seen by general practitioners and results are often compromised by a series of methodological flaws. This article proposes an alternative conceptualisation of anxiety and depression apposite to primary care assessment and therapy. It draws on an emergent evidence base within psychobiology that recognises that these reactions have two adaptive functions. Firstly, they are responses evoked by actual personal adversity, secondly they have the function of prompting communication to self and to others of the need for practical remedial action to be taken independently, or with assistance, to improve the quality of the recovery environment. A table summarises the phased stages of anxiety and depression and lists their adaptive and communicative functions along with some phase-appropriate primary care interventions. This new model of assessment and therapy is offered to stimulate discussion and inspire future research that is appropriate for primary care service improvement