A 4-step program for the diagnosis and management of depression

Journal of Family Practice, Dec, 2003 by C. Brendan Montano, Adam Keller Ashton, Dale A. D'Mello, Bezalel Dantz, Jaye Hefner, F. George Leon, Gary A. Matson, James F. Pradko, Norman Sussman, Bertrand Winsberg

The treatment of uncomplicated depression rightly belongs in the realm of primary care. Approximately one third of all patients with depression see a family physician regularly, and 65% to 70% of patients with depression enter treatment by way of primary care. Thus, the primary care medical network also functions as the primary care mental health network. (1) The clinical importance and therapeutic advantages of this situation were highlighted by the US Preventive Services Task Force (USPSTF), which recommends that adult patients be routinely screened for depression in primary care (level of evidence: B). (2) The USPSTF based the recommendation on "good evidence that screening improves the accurate identification of depressed patients in primary care settings and that the treatment of depressed adults in primary care settings decreases clinical morbidity." (2)

* DEPRESSION IN PRIMARY CARE: UNDIAGNOSED AND UNTREATED

Still, evidence indicates that, in primary care, many patients with depression remain either undiagnosed or untreated. Results from a prospective study of 700 patients attending family medicine clinics demonstrated that family physicians recognized clinical depression or anxiety in only 55% of patients who had diagnostic confirmation of these illnesses (as determined by the NIMH Diagnostic Interview Schedule). (3) Furthermore, a literature review aimed at delineating barriers to the diagnosis of depression in primary care concluded that only about 40% to 45% of primary care patients in need of an antidepressant medication actually received one, and that only 25% of patients who were prescribed antidepressants received the adequate dosage or duration of treatment. (4)

* A PRACTICAL MODEL FOR SCREENING AND DIAGNOSIS

Given the high occurrence of depression in primary care patients, clinicians should assume depression in patients who exhibit symptoms or have risk factors until proven otherwise. Therefore, a logical, accessible clinical model for addressing depressive illness in the office setting is needed. Ideally, this protocol should provide the tools and processes necessary to ensure the accurate diagnosis of depression, together with strategies for appropriate and efficacious treatment, and meticulous follow-up. Such a protocol is outlined below, in 4 steps:

* Brief initial screening

* Diagnostic verification

* Formation of a treatment plan

* Follow-up procedures to assess for medication side effects and monitor mood changes.

* STEP 1: SCREENING

While depression is often the core reason for a visit to the family physician's office, the patient may not display overt signs of a mood disorder. A recent study revealed that among 685 patients who visited family health clinics for self-initiated visits, 50% of the 215 patients who had high scores for depression (based on the CES-D scale) initially presented with only somatic symptoms. Another 38% were identified as "facultative somatizers," patients who initially presented with somatic complaints and made somatic attributions. However, when prompted with a direct question, they accepted the possibility of a psychological explanation for their problems. (3)

Preliminary screening requires little time

Screening for depression may best be considered as a vital part of each patient's assessment, regardless of the chief complaint. Physicians may be concerned that screening leaves little time to address somatic complaints; realistically, administration of screening tools requires only a fraction of an office visit's allotted time. Findings that may indicate depression, however, will require additional investigation--as would, for example, an irregular heartbeat.

Strategies for physician time management

During the general risk-assessment screening interview, patients may want to tell more than physicians want to know about mood symptoms; such sharing may be more appropriate with a counselor or psychologist.

Conversational techniques can redirect the interview and manage time. The authors agree that it is acceptable to gently interrupt the patient by saying, "I realize this situation is causing a great deal of pain, and I do think it's important to talk more, but I must ask a few other questions so that we can grasp the full extent of the problem." This allows the physician to gain necessary information in a timely yet considerate fashion. The importance of obtaining concrete information quickly and compassionately, without appearing to dismiss the patient's concerns, highlights the need for a brief but efficacious screening instrument around which to structure the patient interview.

Screening tools to assess depression

Historically, several strategies have been suggested to construct a physician-directed interview and assess depressive symptoms. All consist of screening, confirming, and then quantifying the depression. It is impractical to screen with a complete quantifying instrument, such as the Hamilton Depression Scale (HAM-D). Such tools tend to be labor intensive and are best used in research. The Zung, Beck and PHQ-9 are self-administered depression screening tools that are time-efficient and validated. These may be used to screen for and follow depressed patients in a busy primary care environment.