Family Practice Vol. 19, No.

4
Oxford University Press 2002 Printed in Great Britain

Depression in primary care. A nationwide

epidemiological survey
Domenico Berardi, Giuseppe Leggieria, Giuseppe Berti Ceronib,
Paola Ruccic, Antonio Pezzolid, Elisabetta Paltrinierie,
Natalia Grazianf and Giuseppe Ferrari

Berardi D, Leggieri G, Berti Ceroni G, Rucci P, Pezzoli A, Paltrinieri E, Grazian N and Ferrari G.
Depression in primary care. A nationwide epidemiological survey. Family Practice 2002; 19:
397400.
Background. Most epidemiological studies on depression in primary care are conducted at
single sites, and variations in reported prevalence may depend on characteristics of health care
services and other local factors.
Objectives. Our aim was to investigate the prevalence of depression in primary care in Italy
and its association with physical illness, disability and health care utilization.
Methods. This nationwide epidemiological study involved 191 primary care physicians (PCPs)
who assessed during one index week 1896 patients aged 14 and over attending their clinics.
Screening was conducted by using the General Health Questionnaire-12. Probable cases were
assessed by PCPs with the WHO ICD-10 Checklist for Depression and rated for severity of
physical illness.
Results. The prevalence of current depression ranged between 7.8 and 9.0% in the three main
Italian areas, with no significant variations. A linear increase from North to South was observed
for psychological distress, disability and frequency of medical consultation. Depression was
associated with severe, but not with mild or moderate physical illness. Depression was also
associated with disability and accounted for an increased rate of consultation.
Conclusion. Because of the disability associated with depression and of its impact on health
care utilization, guidelines and intervention strategies are needed.
Keywords. Depression, disability, health service utilization, primary health care, physical
co-morbidity.

Introduction prevalence figures, ranging between 3.3 and 15.3%.

Depression represents an important public health
problem in which primary care physicians (PCPs) play
a pivotal role. Most of the epidemiological studies on
depression in primary care were conducted at single
sites.14 The impact of local factors and methodological
differences may limit the comparability among studies
and may partly account for variations in reported
The present nationwide epidemiological survey has been
undertaken by the Italian Society of General Practi-
tioners, in co-operation with the Institute of Psychiatry
of Bologna University, to provide the 1-week prevalence
of depression in primary care in Italy and to analyse the
association of depression with physical illness, disability
and health care utilization.

Received 30 March 2001; Revised 15 October 2001; Accepted

11 March 2002.
Institute of Psychiatry, Bologna University, aItalian Society
of General Practitioners, bVilla Baruzziana Clinic, eMental
Health Department, Local Health Unit, Bologna, dMental
Health Department, Local Health Unit, Bologna Sud,
fNiguarda Hospital, Milano, Italy and cWestern Psychiatric
Institute and Clinic, University of Pittsburgh, Pittsburgh, PA,
USA. Correspondence to Professor Domenico Berardi,
Istituto di Psichiatria, Viale Pepoli, 5, 40123 Bologna, Italy;
E-mail: dberardi@alma.unibo.it
Methods
In each administrative region of Italy, a PCP co-
ordinated 10 colleagues working both in urban and rural
areas and trained them in the use of the instruments.
During an index week, each PCP randomly selected
10 adult patients among those attending the out-patients
department. Patients with cognitive impairment, inability
to read or write or medical illness that would prevent
completion of the interview were excluded (n = 35).

397
398 Family Practicean international journal
Seventy-nine subjects refused to participate. In case of
exclusion or refusal, the next patient was enrolled until
each PCP obtained a total of 10 cases.
Patients gave written informed consent and com-
pleted the General Health Questionnaire-12 (GHQ)5
and the Brief Disability Questionnaire (BDQ)1. The
PCPs assessed severity of physical illness on a 5-point
Likert scale, and recorded psychiatric diagnosis, fre-
quency and reason for consultation using forms adopted
in the WHO PPGHC study.1 Patients scoring >5 on
the GHQ were assessed by the PCPs using the WHO
ICD-10 checklist for depression.6 This consists of
21 symptoms and was used to diagnose a current episode
of depression, according to ICD-10 classification.7
t-test and one-way analysis of variance were used
to compare means of continuous variables among two
or more groups, respectively. Chi-square was used to
compare the frequency of categorical variables among
groups. We adopted a conservative significance level
of alpha = 0.01. Logistic regression was used to analyse
the association between depression and physical illness.
Continuous variables are reported throughout as mean
SD. Data were analysed using SPSS for Windows,
version 6.0.
Results
The study was conducted in 18 of the 20 Italian regions.
The two smallest regions, Valle dAosta and Molise,
did not participate because of difficulties in recruiting
a sufficient number of PCPs. Out of the 198 PCPs who
were asked to participate, 191 completed the study
(72 from the North, 41 from the central region and 77
from the South). Most PCPs (130) came from urban
areas with .15 000 inhabitants, and 61 practised in rural
areas. Most physicians were male (n = 161), and their
mean age was 42.9 years. All were established physicians
with an average of 14 years of practice and ~1500
patients on their list.
Demographic and clinical characteristics of the
sample are shown in Table 1. The overall prevalence of
current depression was 8.4% [95% confidence interval
(CI) 7.29.6] and the severity of the index episode was
mild in 57.5% of cases, moderate in 36.3% and severe in
6.2%. There was no difference in prevalence of depres-
sion between the North (9.0%, 6.911.1), the central
region (7.8%, 5.210.4) and the South (8.3%, 6.310.3).
Severity of physical illness, as rated by the PCPs, was
not associated with depression in bivariate analyses.
Then, we analysed the relationship between physical
illness and depression adjusted for gender and age
(1459 versus >60 years), using a logistic regression
model. In this model, female gender [odds ratio (OR) =
2.1, 95% CI 1.43.2] and severe physical illness versus
no illness (OR = 2.3, 95% CI 1.04.9) were significantly
associated with current depression. Disability and
frequency of medical consultation were significantly
higher in patients with depression than in those not
depressed (Table 2).
Discussion
The present study is the first national survey on
depressive disorders in primary care in Italy, and one of
the few ever published in the literature. The overall
prevalence of ICD-10 current depression was 8.4%. This
estimate is rather stable throughout the country, and can
be considered as a reliable proxy for the morbidity that
Italian PCPs observe in their current practice. Moreover,
it is in line with the worldwide prevalence of 10.4%
reported in the WHO PPGHC Study,1 using the same
diagnostic criteria. Previous single-site Italian studies
indicated a lower prevalence of depression (4.7% in
Verona1 and 3.3% in Bologna2). These lower figures may
depend on the fact that the studies were conducted in
two wealthy north-eastern towns, with well-developed
public psychiatric services and with a long-standing
collaboration between psychiatry and primary care.
Physical co-morbidity of depressive disorders in
primary care has been investigated extensively, but
results are still controversial. Previous studies1,2 found a
weak association between physical illness and psychiatric
disorders, suggesting that in primary care psychiatric
disorders are in most cases independent of physical ill
health. However, studies focused on subsamples of PCP
patients with physical illness consistently observed
psychiatric co-morbidity.8 The results of the present
study show that a relationship between physical illness
and current depression exists, but is limited to cases with
severe physical illness, while mild and moderate physical
illness is not associated with a higher prevalence of depres-
sion. Co-morbid patients, who deserve special attention
and integrated treatment from PCPs, are, however,
a small minority of the cases of depression seen by our
PCPs (6%). The majority (94%) of patients with depres-
sion are not affected by severe physical illnesses and, in
these cases, the depressive disorder represents the main
health problem.
As reported in a number of studies,1,9 depression was
associated with significant disability. Although depres-
sion is mild in most cases, the proportion of depressed
patients with significant disability was ~3-fold that among
patients without depression. Depression also accounted
for an increased frequency of medical consultations.10
Our study showed that 27.7% of patients with current
depression were frequent PCP attenders, as compared
with 12.8% of the non-depressed patients. These data
underline the importance of proper management of
this disorder in primary care. Somatic presentation may
hinder recognition and management of depression in
primary care. Only 41% of depressed patients presented
with psychological distress or family problems, while the
 TABLE 1 Demographic and clinical characteristics of the sample

Demographic characteristics
Gender n (%) Age n (%) Marital status n (%) Education n (%) Working status n (%)

Males 652 (34.5%) ,18 13 (0.7%) Single 393 (20.9%) Primary school 114 (6.5%) Housewife 468 (26.9%)
not completed
Females 1239 (65.5%) 1824 154 (8.3%) Married 1242 (66.0%) Primary school 548 (31.5%) Retired 443 (25.4%)
(5 years)
Unavailable 5 2544 621 (33.5%) Divorced/ 58 (3.1%) Secondary school 477 (27.4%) Employed 682 (39.2%)
separated (8 years)
4564 613 (33.1%) Widowed 188 (10.0%) High school 504 (28.9%) Unemployed 69 (4.0%)
.64 453 (24.4%) (unavailable) (15) University 98 (5.6%) Student 79 (4.5%)
(unavailable) 42 (unavailable) (155) (unavailable) (155)

Clinical characteristics
GHQ n (%) Disability (BDQ) n (%) Frequency of consultation n (%) Severity of physical illness n (%)

02 1088 (57.4%) None (,5) 1123 (59.5%) Less than once a month 1062 (57.1%) No symptoms 477 (25.5%)
3, 4 364 (19.2%) Mild (57) 311 (16.5%) About once a month 530 (28.5%) Some symptoms without disease 378 (20.2%)
512 444 (23.4%) Moderate (813) 301 (16.0%) More than once a month 267 (14.4%) Mild 551 (29.4%)
Epidemiological survey of depression in primary care

Severe (1424) 151 (8.0%) (unavailable) (37) Moderate 397 (21.2%)

Missing (10) Severe 70 (3.7%)
(unavailable) (23)
399
400 Family Practicean international journal

TABLE 2 Disability, frequency of and reason for consultation by diagnostic status

Non-cases Depressed
(1736) (160)

Disability (BDQ) 2 = 163.6; P , 0.001

None (,5) 62.8% 23.9%
Mild (57) 16.3% 18.2%
Moderate (813) 14.9% 27.0%
Severe (1424) 5.9% 30.8%
Frequency of consultation 2 = 39.1; P , 0.001
Less than once a month 59.1% 35.8%
About once a month 27.8% 36.5%
More than once a month 13.1% 27.7%
Reason for consultation (multiple answers)
Physical disease 54.3% 50.0% NS
Pain 16.0% 18.8% NS
Psychological distress/family problems 9.2% 41.3% 2 = 143.1; P , 0.001
Administrative reasons 27.9% 22.5% NS

rest of the sample did not complain overtly about
psychological problems. Our results suggest that, in the
absence of serious illness, an increased number of visits
may represent an indicator of depression, whatever the
reason for consultation.
Some methodological limitations in our study must be
acknowledged. We did not include a sample of GHQ-12
low scorers, which might have led to an underestimation
of the prevalence of depression. Characteristics of
patients who refused to participate in the study were
not recorded. Also, PCPs were not selected randomly,
but were enrolled on the basis of their willingness to
participate, which might reflect their interest in and
sensitivity to psychological problems.
In conclusion, the relevance of depression observed
in the present study calls for health policies addressing
this problem. We believe that large studies such as the
present one can improve the knowledge and may con-
tribute to modify the attitude of PCPs who provide care
for patients with depression.
Acknowledgements
We thank Paolo Carbonatto, Mauro Pigni, Mauro
Bertoluzza, Marcello Zancan, Romano Paduano,
Alberto Gianmarini Barsanti, Giuseppe Landini,
Giancarlo Rasconi, Mario Vichi, Luigi Milani,
Damiano Volpone, Pasqualino Lalli, Nicola Tarallo,
Gaetano Piccinocchi, Salvatore Moretti, Cosimo Nume,
Gennaro Gadaleta Cardarola, Antonio Pompeo
Coviello, Bruno Cristiano, Francesco Anello,
Sebastiano Romano, Antonio Pinna, Tiziano Scarponi,
Alessandro Rossi and Emilio Angioli for study co-
ordination. This project was carried out with the support
of the Italian Society of General Practitioners and the
commitment of the participating PCPs. The study was
funded by an Eli-Lilly grant.
References
1 stn TB, Sartorius N. Mental Illness in General Health Care:
An International Study. Chichester: John Wiley, 1995: 323334.
2 Berardi D, Berti Ceroni G, Leggieri G, Rucci P, Ustun B, Ferrari G.
Mental, physical and functional status in primary care
attenders. Int J Psychiatry Med 1999; 29: 133148.
3 Katon W, Schulberg H. Epidemiology of depression in primary care.
Gen Hosp Psychiatry 1992; 14: 237247.
4 Spitzer RL, Williams JBW, Kroenke K et al. Utility of a new
procedure for diagnosing mental disorders in primary care: the
PRIME-MD 1000 study. J Am Med Assoc 1994; 272: 17491756.
5 Goldberg DP, Williams P. A Users Guide to the General Health
Questionnaire: GHQ. NFER-Nelson: Windsor (UK), 1988.
6 Janca A, Ustun TB, Early TS, Sartorius N. The ICD-10 symptom
checklist. A comparison to the ICD-10 classification of mental
and behavioral disorders. Soc Psychiatry Psychiatr Epidemiol
7
1993; 28: 239242.
World Health Organization. International Classification of Diseases
(10th version). Geneva: WHO.
8 Kisely SR, Goldberg DP. Physical and psychiatric comorbidity in
general practice. Br J Psychiatry 1996; 169: 236242.
9 Wells KB, Stewart A, Hays RD et al. The functioning and well-being
of depressed patients. Results from the medical outcomes study.
J Am Med Assoc 1989; 262: 914919.
10 Johnson J, Weissman MM, Klerman GL. Service utilization and
social morbidity associated with depressive symptoms in the
community. J Am Med Assoc 1992; 267: 14781483.