Depression is a common and important problem in the primary care setting. Despite the fact that effective treatments are available, the recognition, management and outcomes of depression in primary care are far from optimal. A variety of approaches to remedy these problems have been evaluated, including: physician education programs; depression screening and feedback; protocol-based treatment by mental health specialists in the primary care setting; and a variety of disease management strategies. Based on this work, we have learned that improving the care and outcomes of depression in primary care requires some or all of the following: a systematic approach to the recognition and assessment of depression; evidence-based decision support; patient education and activation; ongoing monitoring and feedback regarding patient adherence and outcomes; integration of mental health specialists for patients who are not improving as expected; and physician education. However, interventions that include these components have not been sustained or widely disseminated because of the time, energy, commitment and resources that are required. Successful interventions must be low cost, easy to implement, and they must meet the needs of all stakeholders (i.e. payors, providers, patients and behavioral healthcare companies). Innovative programs that take advantage of new technologies have been recently developed to address these challenges, but require further evaluation.