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OBJECTIVE: To determine primary care physicians' attitudes and practice patterns concerning the diagnosis and treatment of depression in elderly outpatients. DESIGN: Survey of primary care physicians' attitudes using a 22-item questionnaire. Current practice patterns were identified from a computerized medical record system. SETTING: Academic primary care group practice at an urban ambulatory care clinic. PATIENTS/PARTICIPANTS: Thirty-five faculty general internists and 118 resident internal medicine physicians who had cared for 2,759 patients 65 years of age and older in the previous year. MEASUREMENTS AND MAIN RESULTS: Attitudes: Eighty percent of all physicians considered the diagnosis and treatment of depressed elderly patients to be their responsibility. Fifty-five percent of the internists felt confident in accurately diagnosing depression, and 35% felt confident in prescribing antidepressants for this population. Residents reported more difficulties in dealing with depressed elderly patients than did faculty. Practice patterns: Of patients greater than or equal to 65 years old, 8% were prescribed antidepressants, 5.4% had current diagnoses of depression, and 2% were seen for evaluation by psychiatry professionals. Age was negatively correlated with depression diagnosis, antidepressant drug use, and psychiatry evaluation. CONCLUSIONS: Internists in this primary care group practice accept responsibility for the treatment of depressed elderly patients but perceive their clinical skills as inadequate and are frustrated with their practice environment. Interventions aimed at improving the diagnosis and treatment of depressed elderly patients may be more effective if they are able to improve knowledge, attitudes, and the practice environment.