Detection, Diagnosis, and Treatment
Depression in Primary Care
Purpose and Scope
A depressed (sad) mood is a normal reaction to disappointments or losses. A sad mood is not to be confused with major depressive disorder, one of several forms of clinical depression, which is a serious medical condition with major public health consequences. About 15 percent of the general public will suffer from major depressive disorder sometime in their life, but the disorder will be accurately diagnosed and treated in fewer than one in three. A person with major depressive disorder suffers intense mental, emotional, and physical anguish, and substantial disability. The depression disrupts family, job, and social functioning. Depression worsens the prognosis for other general medical illnesses. The worst consequence of untreated major depressive disorder is suicide.
Depression is viewed by many patients and the lay public as evidence of a character defect or lack of will power. Thus, those with major depressive disorder must endure the additional burden of having an illness that society views as the reflection of an inherent personal weakness or fault. The practitioner should be sensitive to these issues, provide support, and become a patient advocate. In many cases, the diagnosis and treatment of major depressive disorder can be successfully accomplished by primary care practitioners. When psychotherapy is called for, it may be conducted in either a primary care or specialized setting, depending on the availability of a trained, competent therapist. The primary care practitioner should emphasize to the patient, who is already suffering inappropriate guilt, that major depression is a medical condition that can be successfully treated. Guideline Highlights
The following step-wise process can assist primary care practitioners in detecting, diagnosing, and treating major depression.
1. Maintain a high index of suspicion and evaluate risk factors.
Surveys consistently show that 6 to 8 percent of all outpatients in primary care settings have major depressive disorder; women are at particular risk for depression. Although sadness is frequently a presenting sign of depression, not all patients complain of sadness, and many sad patients do not have major depression. Common complaints of patients in primary care settings with major depressive disorder include:
The clinician should be doubly alert to the likelihood of depression in individuals under age 40.
Additional clinical clues that raise the likelihood of a major depressive disorder include:
2. Detect depressive symptoms with a clinical interview.
Major depressive disorder is a syndrome consisting of a constellation of signs and symptoms that are not normal reactions to life's stress. A sad or depressed mood is only one of the several possible signs and symptoms of major depressive disorder. The clinician may find it useful to provide the patient with a written list of depressive symptoms (pages 3 and 4) and ask the patient to indicate any symptoms experienced. This patient self-report can increase the likelihood of detecting major depression.
Diagnostic criteria for major depressive disorder.
For major depressive disorder, at least five of the following symptoms are present during the same time period, and at least one of the first two symptoms must be present. In addition, symptoms must be present most of the day, nearly daily, for at least 2 weeks.
Source: American Psychiatric Association, 1987.
All depressed patients should be assessed for the risk of suicide by direct questioning about suicidal thinking, impulses, and personal history of suicide attempts. Patients are reassured by questions about suicidal thoughts and by education that suicidal thinking is a common symptom of the depression itself and not a sign that the patient is "crazy." lists the risk factors associated with completed suicide.
If suicide is a distinct risk (specific plans, or significant risk factors exist), consult a mental health specialist immediately. The patient may need specialized care or hospitalization.
A small percentage of patients with major depressive disorder have bipolar illness. These patients experience mood cycles with discrete episodes of depression and mania. In between episodes, they may feel perfectly normal.
Diagnostic criteria for mania.
For mania, at least four of the following symptoms, including the first one listed, must be present for a period of at least 1 week.
Source: American Psychiatric Association, 1987.
3. Diagnose the mood disorder using clinical history and interview.
Many patients are aware of only some symptoms and may minimize their disability. Interviewing someone who knows the individual well (a spouse, close friend, or relative) can be extremely valuable in obtaining an accurate picture of the patient's symptoms, degree of disability, and course of illness.
4. Evaluate patients with a complete medical history and physical examination.
The patient's initial complaints should be evaluated thoroughly with a medical review of systems and a physical examination. If no cause or associated factors can be found for the initial presenting medical complaint, diagnose the patient for a primary mood syndrome.
5. Identify and treat potential known causes (if present) of mood disorder.
Approximately 10-15 percent or more of major depressive conditions are caused by general medical illnesses or other conditions Generally, the principle is to treat the associated condition first. If the depression persists after treatment of the associated condition, major depressive disorder should be diagnosed and treated.
Potential associated conditions include:
Too much alcohol, use of illicit drugs, or abuse of prescription medicines can cause or complicate a major depressive episode. In most cases, once the substance has been discontinued, the depression lifts
Depression may be an idiosyncratic side effect of many medications. However, the clinician should be aware that this effect is uncommon and usually occurs within days to weeks of starting the medication. Current evidence clearly implicates only reserpine, glucocorticoids, and anabolic steroids with the de novo development of depression as a potential side effect of the drug. Changing to a different medication often relieves the depression
General medical disorders.
Depression can occur in the presence of another general medical condition (most commonly, autoimmune, neurologic, metabolic, infectious, oncologic, and endocrine disorders, among others). There are several possibilities in such cases:
The general medical disorder biologically causes or triggers a depression; for example, hypothyroidism can be accompanied by depressive symptoms. In this case, treat the general medical disorder first.
The general medical disorder psychologically results in depression; for example, a patient with cancer may become clinically depressed as a reaction to the prognosis, pain, or incapacity, although most patients with cancer do not suffer a major depressive episode. In this case, treat the depression as an independent disorder.
The general medical disorder and the mood disorder are not causally related. In this case, treat the depression.
Other causal nonmood psychiatric disorders.
These generally include eating disorders, obsessive-compulsive disorder, and some cases of panic disorder
When generalized anxiety disorder co-exists with major depression, treatment should be directed toward the major depression first.
If panic disorder is present only during major depressive episodes, the major depression is treated first.
If panic disorder and major depression are both present and the panic disorder has been present without episodes of major depression in the past, the clinician must judge which is the most significant condition (e.g., by family history, the level of current disability attributable to each, and the prior course of illness) and treat that condition
Relationship between major depressive and other current psychiatric disorders.
If a "personality disorder" is suspected, the major depressive disorder is treated first, whenever feasible.
It is important to differentiate a normal grief reaction from depression. A normal grief reaction persists for 2 to 6 months and improves steadily without specific treatment. Most grief reactions do not meet criteria for a major depressive episode. Grief reactions are usually seen by patients as normal and appropriate. While unpleasant, they rarely cause significant and prolonged impairment in work or other functions. Some individuals experience symptoms of depression along with the grief reaction. If the major depressive episode persists for more than 2 months after the loss, a major depressive disorder should be diagnosed and treated.
6. Reevaluate for mood disorders.
If the depression persists after treatment of the associated psychiatric general medical, or substance abuse disorders, the derpession should be diagnosed and treated.
7. Develop a treatment plan with the patient.
If the mood disorder is still present, or if associated conditions do not exist, work with the patient to treat the primary mood disorder.
The objective of treatment is for the patient to reach a sustained asymptomatic state. presents a flow diagram for the treatment of depression. These principles apply no matter what treatment is selected. The essential features of this plan include:
The effectiveness of any treatment rests on a cooperative effort by patient and practitioner. The patient should be told of the diagnosis, prognosis, and treatment options, including costs, duration, and potential side effects. In presenting patient and family education in the clinical management of depression, it is useful to present the following information:
8. Select the most appropriate acute phase treatment.
The aim of acute phase treatment is symptom remission. Treatment of depression in the primary care setting includes:
The choice of treatment modality is based primarily on the history of illness and the severity of the major depressive episode. The following general definitions may be helpful in determining an appropriate treatment:
Scientific evidence indicates that over 50 percent of depressed outpatients who begin treatment with antidepressant medication experience marked improvement or complete remission of their depressive symptoms. Considerations for acute phase treatment with medication are:
Scientific evidence indicates that several forms of short-term psychotherapy (cognitive, interpersonal, or behavioral) are effective in treating most cases of mild or moderate depression. Other types of psychotherapy may also be helpful in the treatment of major depressive disorder, although their efficacy has not been evaluated fully, if at all. In individuals with mild to moderate depressions, time-limited psychotherapies appear equal in efficacy to antidepressant medications.
Considerations for acute phase treatment with psychotherapy alone include:
Psychotherapy requires the availability of an experienced mental health specialist, such as a psychiatrist, psychologist, social worker, psychiatric nurse, or other professional trained in psychotherapy.
Combined treatment (medication plus formal psychotherapy) should be considered in various situations, including:
9. If medication is used, select the type and dose best suited to the patient.
Primary care providers will find it useful to become familiar with one drug with minimal side effects from each of the major classes of antidepressants (Tables 2 and 3).
Medications should be individualized to the patient in order to optimize treatment benefit and lower risk. Factors to be considered include:
Patients at risk of experiencing adverse drug interactions or with other medical illnesses may need lower than recommended dosages. Geriatric patients often require lower dosages of medication, and dosage increments should be made slowly.
Treatment of patients with bipolar disorder while they are in the depressed phase should be done with knowledge of the risk of inducing mania with antidepressant medications. Consultation with a psychiatrist may be considered if there is suspicion of bipolar illness.
Treatment of the patient with psychotic symptoms (hallucinations, delusions) often involves hospitalization, neuroleptics, or electroconvulsive therapy. A consultation or referral to a mental health specialist is recommended.
10. Evaluate treatment response.
Whether medication, psychotherapy, or a combination are used, evaluate the patient's response to treatment.
Adequate response --
Many patients will respond to an adequate trial of the first drug tried.
Inadequate response --
summarizes the steps in managing partial or nonresponse to medication. If inadequate response is a problem, the following steps may be taken:
Add or change to psychotherapy. Patients who cannot tolerate medication or who have only a partial response (with residual cognitive symptoms) in mild to moderate depression may benefit from time-limited psychotherapy
A significant number (50 percent) of patients with mild to moderate forms of depression obtain substantial symptom relief with psychotherapy. Many patients begin to feel the effects of psychotherapy in the first few weeks. Full remission rather than improvement is the objective of treatment. If there is no symptom improvement at all within 6 weeks, the choice of treatment modality should be reevaluated. For patients who improve but who are still symptomatic after 12 weeks, treatment with medication is a strong consideration.
11. Proceed to continuation phase treatment.
Once the patient has responded to acute phase treatment with medication, continuation treatment is indicated. If acute phase psychotherapy alone was effective, continuation treatment with psychotherapy may be useful in selected cases. The aim of continuation treatment is to prevent the return of the most recent depressive episode (a relapse). The following principles apply:
12. Evaluate the need for maintenance phase treatment.
The goal of maintenance treatment is prevention of a recurrence of a major depressive episode. The efficacy of maintenance treatment in preventing a future episode of depression has been clearly demonstrated only with medication. The following principles apply:
Maintenance psychotherapy can be useful in selected situations with recurrent major depressive disorder, such as women who want to become pregnant and bear a child in a drug-free condition or individuals who must be medication-free for a limited time period. Although maintenance psychotherapy has not been shown to prevent recurrence, one study suggests that it may help to delay the onset of the next episode.
13. Seek consultation.
Consult with or referral to a mental health specialist (e.g., psychiatrist, psychologist, psychiatric nurse, social worker) can be useful in the following situations:
The Clinical Practice Guideline on which this Quick Reference Guide for Clinicians is based was developed by an interdisciplinary, non-Federal panel comprised of health care professionals and a consumer representative. Panel members were:
Special consultants to the panel were: Madhukar Trivedi, MD and David Schriger, MD, MPH.
For a description of the guideline development process and information about the sponsoring agency (Agency for Health Care Policy and Research), see the Clinical Practice Guideline, Depression in Primary Care: Volume 1. Detection and Diagnosis (AHCPR Publication No. 93-0550) <p44-d1.html> and Volume 2. Treatment of Major Depression (AHCPR Publication No. 93-0551). <p44-d2.html> To receive additional copies of the Clinical Practice Guideline, Quick Reference Guide for Clinicians (AHCPR Publication No. 93-0552) and a patient booklet (AHCPR Publication No. 93-0553), call toll free 800-358-9295 or write the AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907.
The panel's inferences as to what is optimal patient care are not expected to apply to all patients or situations. Knowledge developed through research can only provide a starting point for approaching a particular patient. Algorithms and flow charts are not applicable in every case. They do, however, provide coarse road maps for managing certain patients. Practitioners must use their own judgment in adapting guidelines to particular patients.
Note: This Quick Reference Guide for Clinicians contains excerpts from the Clinical Practice Guideline, Vols. 1 <p44-d1.html> and <p44-d2.html>. It was not designed to stand on its own. Practitioners should review the Clinical Practice Guideline carefully to become familiar with the diagnosis, differential diagnoses, and treatment options for patients with major depressive disorder and then use the Quick Reference Guide to help them remember the major decision points in diagnosing and treating major depressive disorder. If the information contained in these documents is insufficient to evaluate the condition of a particular patient, the practitioner is advised to seek a consultation.
American Psychiatric Association.
Depression Guideline Panel.
Depression Guideline Panel.
Depression Guideline Panel.
Goodwin FK, Jamison KR.
AHCPR invites comments and suggestions from users for consideration in development and updating of guidelines. Please send written comments to Director, Office of the Forum for Quality and Effectiveness in Health Care, AHCPR, Executive Office Center, Suite 401, 2101 East Jefferson Street, Rockville, MD 20852.
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