May 2000 • Volume 6 • Number 5
Wayne Blount, M.D., left, listens as Kathy Cronkite answers an audience question following their presentations on depression at AAFP's CME course on women's health. BY SHARON DICKINSON DENT
Scottsdale, Ariz.A physician's perspective
A woman has a 10 percent chance of suffering from depression in any given year and a 20 percent chance in her lifetime. "So if depression isn't one of the top diagnoses in your practice, then you're missing a lot of it," said Wayne Blount, M.D., at AAFP's Primary Care in Women's Health CME course April 5-8.
Blount, family medicine department chair at the University of Tennessee in Memphis, said only about 25 percent of women with depression are getting adequate treatment.
The key to diagnosing depression, he said, starts with having a high index of suspicion. "Watch for the high utilizer," Blount said. Other symptoms that should raise an eyebrow include: fatigue ("The number one reason people go to the family physician's office is fatigue, and the number one cause of fatigue is depression," he said.), headaches that don't go away or keep coming back, sleep complaints, somatic complaints, weight/
appetite disturbances, atypical neurological problems, chronic pain, coronary artery disease and chest pain without coronary artery disease.Such symptoms suggest screening is in order, said Blunt.
Once you have results from the screening, use the criteria for diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The DSM-IV says a patient has depression if she has either anhedonia or loss of interest for most of the day nearly daily for at least two weeks, and at least five of the following symptoms:
- sleep change,
- decreased interest,
- guilt,
- energy change,
- decreased concentration,
- appetite change,
- psychomotor change and
- suicidal ideation.
"If you think your patient is depressed, it is incumbent upon you to ask about suicidal thoughts," Blount said. Ask the patient whether she ever thinks about dying or killing herself, whether she thinks about how she would die, whether she has determined a way to kill herself and whether she could resist the urge to do so.
Treatment for depression is a combination of behavioral counseling and pharmacotherapy, Blount said. "Studies show that behavioral therapy may work alone for mild depression, but medications are needed for moderate and serious depression." That's because patients with more serious depression may not experience the insight and breakthroughs necessary for recovery without the assistance of drugs, he said.
If you do the counseling, Blount suggests using a strategy such as BATHE from the book The 15-Minute Hour by Joseph Lieberman, M.D.:
Background -- What is going on in your life?
Affect -- How are you feeling about that?
Trouble -- What troubles you the most?
Handling -- How are you handling that?
Empathy -- That must be very difficult.
In up to 75 percent of patients with depression, initial medical treatment fails. In that case, keep experimenting with medicines and dosages until you find what works, Blount said. Once you find a drug that seems effective, the patient should take it for at least six months, even if she feels better sooner, he said.
Evidence-based medicine has shown that there are three treatment phases with depression, said Blount. In the acute phase (six to 12 weeks), you should aim for total symptom remission. In the continuation phase (four to nine months), aim to prevent relapse. And in the maintenance phase (more than a year), you want to prevent recurrence.
The six-month success rate is only 65 percent, but aggressive treatment with frequent follow-up improves compliance, remission rates and quality-of-life scores, said Blount. "The more follow-up you do with them, the more you talk with them, the better the outcomes," he said.
FP Report is published by the AAFP News Department.
Copyright © 2000 by American Academy of Family Physicians.
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