Primary Care Update-Depression in
Primary Care
David L. Stewart, MD, MPH, Associate Professor and Chairman, Department of Family and Community
Medicine, University of Maryland School of Medicine
Background, Prevalence
Projections by The World Health Organization report that by 2020 depression will be responsible for
more disability adjusted life years than for all health conditions except ischemic heart disease.1 Yet,
studies show that primary care physicians do not recognize depression in 30-50% of patients who present
to the office depressed. 2 Self- rating scales administered in primary care practices indicate that 15.3 –
22% of all patients seen are depressed. Incidence rates range from 4.8-8.6 % for major depression, 2.13.7% for dysthymia, and 8.4-9.7% for minor depression.3 Primary care physicians may encounter the
whole range of depressive disorders. Studies have shown that 40% of individuals who die from suicide
visited a primary care doctor within one month of their death. 4, 5 The National Comorbidity Survey
Replication or 9090 individuals showed that of the individuals depressed 57.5% also had anxiety
disorders.
Risk Factors
Multiple factors have been associated with the risk of developing depression including: a personal or
family history of anxiety and mood disorders, stress level, history of life trauma, abuse, neglect, or
substance abuse. 6 Risk is also associated with comorbid psychiatric or medical disorders such as mood
disorders or anxiety, stroke, degenerative disorders of the brain, HIV, and other chronic medical
conditions such as diabetes. Anyone can have depression which warrants treatment.
Signs and Symptoms
Patients may state they have lost interest or pleasure in previously enjoyable activities or have a sad or
depressed mood. They may complain of such physical symptoms as change in appetite or weight,
increased or decreased sleep patterns, increased or decreased psychomotor activity, and tiredness. Patients
may also note differences in their ability to concentrate, remember, or make decisions. They may feel
worthless, hopeless or guilty. 7 Anxiety may cause worry, avoidance, sympathetic arousal and physical
symptoms such as chest palpitations, shortness of breath, or gastrointestinal distress. They may have
complaints of body pain, loss of sexual functioning, or loss of sexual desire. There may be inappropriate
use of substances or comorbid substance abuse. Patients may appear sluggish, tearful, or pessimistic, and
often make the physician feel depressed. They may have thoughts of death or suicide.
Diagnosis
Over half of the outpatient visits in primary care are for somatic complaints. Often somatic complains
may be associated with depression which is not diagnosed. Physicians should be aware that patients with
somatic symptoms who are depressed will respond positively to questions about depression if they are
asked. About half of the patients with anxiety will also have depression.8
Effective tools which identify and measure the severity of depression can help busy primary care
physicians identify and follow patients with depression.
The following two screening questions for depression have been shown to have a sensitivity and
specificity of 97% and 67% respectively when tested in a primary care setting on patients who are not
receiving psychotropic drugs.9
1) During the past month have you often been bothered by feeling down, depressed, or hopeless?
2) During the past month, have you often been bothered by little interest or pleasure in doing things?
A single positive answer should trigger a physician to look further at the possibility of depression with the
patient.
The Patient Health Questionnaire (PHQ-9) is a nine item instrument based on the criteria in the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The PHQ-9 can be
self- administered and allows depression to be diagnosed as well as followed for response to prescribed
therapy.10, 11 Other useful instruments to evaluate depression include: The Beck Depression Inventory,
Zung Self-Rating Depression Scale, and the 16 Item Quick Inventory of Depressive Symptomology
(QIDS).
Treatment
Treatment depends upon the degree of depression determined during the assessment and the amount of
distress or dysfunction experienced by the patient. Resources and support available to the patient may
influence the therapeutic approach agreed upon with the physician. All patients should be evaluated for
suicidal potential and hospitalized if warranted.12 A patient with mild depression may only warrant
education, support, exercise, informal counseling. Some patients in this group may require formal referral
for cognitive-behavioral, interpersonal, or problem solving therapy. The standard approach for treating
moderate to severe depression combines antidepressant medication with the above modalities. The
number and types of antidepressants available to be used for treatment is large and continues to grow.
Physician’s selection should consider the patient’s treatment history, potential drug interactions, patient
co-morbidities, and the desired side-effect profile. No test allows a physician to predict a patient’s
response to any antidepressant. Most physicians believe the acute phase of treatment should be 6-10
weeks assessing a patient’s response in 4-6 weeks. After therapeutic trials physicians may change drugs
within or between classes of medication depending on the patient’s response. Possible non-adherence
should be routinely assessed throughout treatment. Even with remission most patients require medication
treatment for 6-9 months. Longer term pharmacotherapy should be considered in patients with severe or
recurrent depression.13 14
Themes To Remember
1) Primary care physicians miss the diagnosis of depression in up to 50% of patients with depression
2) A tool used to screen, diagnosis, and following patients’ response to therapy saves time and
standardizes the approach to patient with depression
3) Always evaluate the potential for suicide
4) Non-pharmacologic and pharmacologic modalities should be used and the patient treated until
remission
5) Follow up for evaluation of progress
6) Long term pharmacologic therapy may be warranted
1
Haden A, Campanini B, eds, The World Health Report 2001-Mental Health: New Understanding, New Hope.
Geneva: World Health Organization; 2001:30.
2
Simon GE, VonKorff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med.
1995;4:99-105.)
3
Health Services/Technology Assessment Text. Table 1: prevalence of depressive illness. In: Guide to Clinical
Preventive Services, 3rd Edition: Recommendations and Systematic Evidence Reviews. Bethesda, Md: National
Library of Medicine. Available at: www.ncbi.nml.nih.gov/books/bv.fcgi?rid=hstat3.table.247.
4
Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review
of the evidence. Am J Psychiatry. 2002; 159:909-916.
5
Pirkis J, Burgess P. Suicide and recency of health care contacts: a systematic review. Br J Psychiatry. 1998;
173:462-474
6
Folstein MF, Folstein SE, McHugh PR. Mini-mental state. A practical method for grading the cognitive stat of
patient for the clinician. J Psychiartr Res. 1975, 12: (3): 189-198.
7
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,
Washington, DC: American Psychiatric Association; 2000
8
Kroenke K. The interface between physical and psychological symptoms. Prim Care Companion J Clin Psychiatry
2003;5(suppl7):11-18
9
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.
10
Lowe B, Kroenke K, Herzog W, Grafe K. Measuring depress outcome with a brief self-report instrument:
sensitivity to change of the Patient Health Questionnaire (PHQ-9). J Affect Disord. 2004;81:61-66.
11
Kroenke K, Spitser RL, Williams JB, The PHQ-9: validity of a briedf depression severity measure. J Gen Intern
Med 20001;16:606-613
12
Fawcett J, Scheftner WA, Fogg L, et al. Time-related predictors of suicide in major affective disorder. Am J
Psychiatry 990;147:1189-1194
13
Rush AJ, Trivedi M, Fava M. Depression,IV: STAR*D treatment trial for depression. Am J Psychiatry
2003;160:237
14
Rush A, Trivedi M, Wisniewski S et al. Acute and longer term outcomes in depressed outpatients requiring one
or several treatment steps: STAR*D report. Am J Psychiatry 2006;163:1905-1907.