The Diagnosis and Management of Depression in The Primary Care Setting
Facts About Depression
Depression is one of the most common conditions seen by primary care physicians second only to hypertension. The point prevalence in the outpatient primary care setting is between 4.8 – 8.6%, and the point prevalence in the inpatient setting is 14.6%. Large scale studies have suggested that 7 – 12% of men will suffer an episode of major depression at one point in their lives, while the percentage for women is more on the order of 20 – 25%. Bipolar disorder is less common than depression (0.4% in men and 1.6% in women over their lifetimes) but has no gender difference. Depression can begin in early adulthood, with a peak onset between ages 20 – 30. Over half the people who experience an episode of major depression are at risk for a relapse and recurrence (Cutler, J. Charon, R. 1999).
Depression costs the United States economy more than 43 million dollars every year in medical treatments and lost work productivity (Kahn, 1999). Globally, depression accounts for 4.4% of the disease burden, which is similar to that of diarrheal diseases and ischemic heart disease (Mann, 2003). 300 million people in the world suffer from depression with 18 million of them in the United States (Harvard Press, 1996).
Depression has a high rate of morbidity and mortality when left untreated. Most patients do not necessarily complain of feeling depressed, but rather that they have a lack of interest or pleasure in activities, may have somatic complaints, or vague unexplained complaints. In one study, 69% of diagnosed depressed patients reported unexplained physical symptoms as their chief complaint (NYCDOH, 2006). Unlike patients with depression in psychiatric inpatient or outpatient care settings, persons suffering from depression in primary care settings often present as “undifferentiated” patients.
Depression is often undiagnosed and untreated, and even when it is diagnosed it is often under treated. Primary care physicians must remain alert to effectively screen for depression in their patients. Barriers to effective screening include inadequate education and training, limited coordination with mental health resources, time constraints, poor systematic follow up, and inadequate reimbursement (NYCDOH, 2006). It is sometimes difficult for primary care providers to determine if a patient is depressed as opposed to experiencing a normal response to the challenges of everyday life. Gender, age, culture, and language of the patient and the physician may create further barriers. Furthermore, persons with mood disorders also may have enormous stigma associated with being mentally ill – and may see it as a sign of weakness, fear the criticism of other people, or be concerned that they will be institutionalized.
Patients who suffer from diabetes, ischemic heart disease, stroke, or lung disorders that have concurrent depression have poorer outcomes than those without depression. Depressed patients have a higher risk of death from heart disease, respiratory disorders, stroke, accidents, and suicide (Mann, 2005). Fifteen percent of patients with severe mood disorders die from suicide. In one study among older patients who committed suicide, 20% visited their primary care physician on the same day as their suicide (NYCDOH, 2006).