Targeting depression: Primary care tips and tools

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Behavioral Health

Targeting depression: Primary care tips and tools

J Fam Pract. 2017 April;66(4):244-249

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References

1. National Institute of Mental Health. Major depression among adults. National Institute of Mental Health Web site. Available at: http://www.nimh.nih.gov/health/statistics/prevalence/major-depression-among-adults.shtml. 2014. Accessed June 22, 2016.

2. Cameron C, Habert J, Anand L, et al. Optimizing the management of depression: primary care experience. Psychiatry Res. 2014;220:S45-S57.

3. Wang PS, Lane M, Olfson M, et al. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:629-640.

4. Schotte CK, Van Den Bossche B, De Doncker D, et al. A biopsychosocial model as a guide for psychoeducation and treatment of depression. Depress Anxiety. 2006;23:312-324.

5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association, 2013:160-161.

6. Sadock BJ, Sadock VA. Kaplan and Sadock’s Synopsis of Psychiatry. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2003:830-834.

7. Fishbain DA, Cutler R, Rosomoff HL, et al. Chronic pain-associated depression: antecedent or consequence of chronic pain? A review. Clin J Pain. 1997;13:116-137.

8. Arroll B, Khin N, Kerse N. Screening for depression in primary care with two verbally asked questions: cross sectional study. BMJ. 2003;327:1144-1146.

9. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606-613.

10. US Preventive Services Task Force. Depression in adults: Screening. US Preventive Services Task Force Web site. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/depression-in-adults-screening. Accessed March 13, 2017.

11. Thombs BD, Ziegelstein RC. Does depression screening improve depression outcomes in primary care? BMJ. 2014;348:g1253.

12. Siu AL, Bibbins-Domingo K, Grossman DC, et al. Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;315:380-387.

13. Sadock BJ, Sadock VA. Kaplan and Sadock’s Synopsis of Psychiatry. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2003:543.

14. Gould MS, Marrocco FA, Kleinman M, et al. Evaluating iatrogenic risk of youth suicide screening programs: a randomized controlled trial. JAMA. 2005;293:1635-1643.

15. Eynan R, Bergmans Y, Antony J, et al. The effects of suicide ideation assessments on urges to self-harm and suicide. Crisis. 2014;35:123-131.

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Depression is the most common mental health complaint in primary care settings; in 2015, an estimated 16.1 million (6.7%) adults in the United States ages 18 or older had at least one depressive episode in the past year.¹ Depression results in significant health, work, and social life impairments,² and comorbid anxiety is highly prevalent in patients with depression.

Primary care physicians see almost twice as many mental health patients as psychiatrists³ due to barriers in behavioral health treatment (such as wait times, cost, and stigma) and the fact that primary care physicians often provide first-line access to behavioral health resources. Depression is caused by biological, psychological, and social factors, and primary care physicians are ideally positioned to develop therapeutic, healing relationships with patients that coincide with the biopsychosocial model of the disease.⁴

This review will provide some useful tips and tools to ensure that these patients get the care they need.

Depression? Or are other factors at play?

Major depressive disorder (MDD) is defined as a clinically significant change in mood that lasts at least 2 weeks.⁵ The main symptoms of MDD include depressed mood and markedly diminished interest or pleasure; additional symptoms may include reduced self-esteem, weight/appetite changes, fatigue or reduced energy, guilt/worthlessness, decreased activity, poor concentration, and suicidal thinking.⁵ To meet the criteria for a diagnosis of MDD, patients must experience symptoms for most of the day, nearly every day. (Dysthymia or persistent depressive disorder is a type of depression that is milder and more chronic than MDD, but does not have as many symptoms as MDD.) The focus of this article will be on MDD.

Shared symptoms with other disorders

Depression often displays some of the same symptoms as bereavement disorder and adjustment disorder, as well as other conditions.

Grief over loss and depressive symptoms circumscribed to a stressor are considered bereavement disorder and adjustment disorder, respectively. These disorders are usually limited to weeks or months as the patient adapts to his/her particular situation.

Organic problems such as nutritional deficiencies and sleep apnea can cause, exacerbate, or mimic depression (TABLE 1⁶). Pain and depression are often associated, in that chronic pain can precipitate or perpetuate depression.⁷

Bipolar disorder consists of both depressive and manic episodes; patients may be misdiagnosed and treated for depression alone.

Substance intoxication or withdrawal can precipitate or perpetuate depression. A period of abstinence of at least one month may be necessary to see if depressive symptoms persist or resolve.

Premenstrual dysphoric disorder is defined as a period of depressed mood that is limited to the final week before the onset of menses and resolves in the week post-menses.

How to make the diagnosis

Inquiring about prolonged feelings of sadness and/or lack of enjoyment in activities is an effective way to begin the screening process for depression.⁸ Screening tools such as the PHQ-9 (TABLE 2⁹), Beck Depression Inventory, Hamilton Rating Scale for Depression, and Geriatric Depression Scale are useful when combined with a clinical interview. Another useful tool is the Mood Disorder Questionnaire, which can help one determine if a patient is suffering from depression or bipolar disorder. It’s available at: http://www.dbsalliance.org/pdfs/MDQ.pdf. (Asking about a history of consecutive days of elevated, expansive, or irritable mood accompanied by increased activity or energy can also provide valuable insight.)

About two-thirds of all patients with depression contemplate suicide and 10% to 15% will attempt suicide.

For its part, the US Preventive Services Task Force recommends screening adults for depression when adequate systems are in place (eg, referrals to settings that can provide necessary care) so as “to assure accurate diagnosis, effective treatment, and follow-up.”^10-12

Assessing severity. Asking about functional impairments at work and at home and with academics and relationships will help determine severity, as will inquiring about a patient’s past or current suicidal thoughts. About two-thirds of all patients with depression contemplate suicide and 10% to 15% will attempt suicide.¹³

There is no evidence that inquiring about thoughts of death or suicide exacerbates suicidal risk.^14,15 Confirming a diagnosis of MDD may require multiple visits, but should not delay treatment.