Medically Ill Patients
Many patients with psychiatric symptoms and diagnoses present to primary-care and medical settings. Their treatment commands considerable interest and controversy in the current fiscally cautious health-care climate. The prevalence, health impact, and cost of depression for medical patients has been well documented ( Barrett et al., 1988; Higgins, 1994). The point prevalence of depression in primary care is estimated at 6-8 percent ( Regier et al., 1993). Untreated, depression produces significant medical health costs, social and vocational disability, and adverse effects on the family ( Weissman et al., 1997; Wells et al., 1989; World Health Organization, 1996). Official guidelines on the treatment of depression in primary-care settings include psychotherapy ( AHCPR guidelines: Depression Guideline Panel, 1993). Recognition and treatment of depression in primary care, evidence for effectiveness of standard approaches, and training of medical personnel to diagnose and treat depression remain scant ( Schulberg et al., 1996; Frasure-Smith et al., 1997).
Yet there has also been increasing interest in the treatment of psychiatric disorders complicating medical conditions. This is based on recognition that depression comorbid with cardiovascular disease ( Frasure-Smith et al., 1993; Musselman, Evans, and Nemeroff, 1998) and other disorders ( Cohen-Cole and Kaufman, 1993) may complicate the course and outcome of the medical condition (e. g., Musselman, Evans, and Nemeroff, 1998; Pratt et al., 1996;