In response to the widespread problem of depression in the United States, the Council on Scientific Affairs of the American Medical Association (AMA) has conducted a clinical review on the diagnosis and management of depression. The review appears in the September 1999 issue of the Journal of General Internal Medicine.
Through MEDLINE searches, the AMA council was able to identify scientific articles published in the past 10 years that discuss depression in general medical settings, epidemiology, concomitant conditions, diagnosis, costs, outcomes and treatment. Relevant articles were selected and summarized for inclusion in the report.
Recent findings on the epidemiology, burden, diagnosis, comorbidity and treatment of depression, particularly in general medical settings, are included in the review. The report also outlines barriers to the recognition, diagnosis and management of depression and summarizes efforts that are currently under way to reduce some of these barriers.
Recent Findings on Depression
Depression is a common disorder in the general population. According to the AMA council, about 2 to 4 percent of persons currently suffer from depression, while the general population has about a 20 percent lifetime risk for the development of major depression or dysthymia. The rate of depression among women is two to three times that of men. In the United States, about 75 percent of persons who seek help for depression go to a primary care physician rather than to a mental health professional. Persons who suffer from depression may experience functional impairment, increased risk of suicide, higher health care expenses and losses in productivity. Complaints of sleep disturbance, fatigue and pain are the most common presentations of depression seen by family physicians.
The council points out that depression is known to cause patient suffering, family distress and conflict, impaired cognitive development of young children in cases of postpartum depression and a significantly increased risk of suicide. Recent studies have also found that depression affects patient functioning and economic status. According to the Medical Outcomes Study that is discussed in the report, patients with depression had physical functioning scores that were almost identical to those of patients with advanced coronary artery disease; both groups had lower scores than patients with hypertension, diabetes mellitus and arthritis. The high prevalence, the chronic or relapsing course, the frequent early onset and the impairment in functioning that accompany the disorder led some World Health Organization researchers to conclude that unipolar major depression is the leading cause of disability in the world.
The estimated cost of depression in the United States is $43 billion per year, according to the AMA report. Only 30 percent of this cost is from direct medical care; the rest is from premature death and impaired productivity in the workplace.
Major depression is diagnosed on the basis of a careful clinical interview and mental status examination. According to the AMA council, considerable evidence suggests that such an interview is comparable in sensitivity and specificity to many radiologic and laboratory tests that are commonly used in medicine. The standard diagnostic approach generally includes the use of criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV).
Many screening tools are available to help identify patients who are most likely to be depressed. These tools tend to be fairly sensitive, but not too specific in the recognition of depression. The AMA council notes that the authors of most of the review articles recommended screening the patient when depression is suspected.
Commonly used symptom-oriented, patient self-report screens include the General Health Questionnaire, the Beck Depression Inventory, the Symptom Checklist, the Inventory of Depressive Symptoms and the Zung Depression Scale. If scores are above a predetermined cutoff, patients should have a more comprehensive evaluation for depression. These screening tools are designed to rate the severity of depression.
Two more recent screening tools, the Symptom-Driven Diagnostic System for Primary Care and the Primary Care Evaluation of Mental Disorders, are diagnosis-oriented, patient-administered screens that can be supplemented by a physician-driven diagnostic module if any of the patient screens are positive. These tools screen for several different psychiatric disorders, including major depression.
Depression often accompanies anxiety disorders and substance abuse. The AMA council reports that recent research indicates a relationship between nicotine addiction and depression. High rates of depression and related morbidity are seen in many medical conditions, especially those that affect the central nervous system. The rates of depression that occur in combination with other medical conditions are highlighted in Table 1.
Depression may occur with advancing age. When depression strikes the elderly, it can be especially dangerous and costly if not treated properly. Treatment of depression may also be more complicated in the elderly. In reviewing the literature, the AMA council found that untreated depression in patients who are terminally ill is associated with patient requests for physician assistance in dying.
Barriers to the Optimal Management of Depression
Barriers to the diagnosis and treatment of depression may include stigma; patient somatization and denial; physician knowledge and skill deficits; limited time; lack of availability of physicians and treatments; limitations of third-party coverage; and restrictions on subspecialist, drug and psychotherapeutic care. These barriers are summarized in Table 2.
BARRIERS TO RECOGNITION
With the stigma related to psychiatric illness, many patients are afraid to acknowledge their own emotional distress. Patients often deny or minimize symptoms of depression, rationalize them as related to life stress or the result of other general medical conditions, believe them to be failures of willpower or moral shortcomings, or do not see them as treatable by their physicians. Such attitudes may be reinforced by family or cultural beliefs. Patients may also be afraid to disclose information that might be included in insurance or employment records. This concern is especially true in patients who are diagnosed with psychiatric illness.
Patients themselves are not the only barriers to recognition. The AMA report states that physicians may also be deficient in this area. Some physicians may believe that depression is not a “real” illness. Some feel that depression is a reflection of a personal shortcoming or laziness; therefore, they believe the patient could improve with more effort, willpower or “positive thinking.” Other physicians may doubt the existence of depression as a clinical entity because it has not been confirmed by laboratory or radiologic studies.
Even when attitudes are appropriate, some physicians are unable to properly elicit from the patient the relevant history. Many physicians have a highly focused closed-ended interviewing technique that may prevent patients from bringing up psychosocial issues. Failure to recognize non-verbal cues and to ask follow-up questions when the patient seems distressed may also impede the physician's ability to obtain an appropriate history, according to the council. When physicians fail to offer empathic, supportive comments during the interview, patients may interpret this as a lack of interest or an unwillingness to discuss their concerns.
BARRIERS TO DIAGNOSIS
Physicians may not correctly appraise the willingness of the patient to consider a psychiatric diagnosis. Physicians may not diagnose a psychiatric illness for fear of compromising patient confidentiality or offending the patient or family. Sometimes, physicians may accurately assess that a patient is not ready to accept a diagnosis, so they defer a full assessment decision about the diagnosis.
Other barriers to diagnosis discussed in the report include appropriate diagnostic criteria. When patients meet some but not all of the DSM-IV criteria for major depression, they may not be appropriately diagnosed or treated. Some patients may also experience mixed symptoms of depression and anxiety that fall short of the DSM-IV thresholds for a disorder.
When physicians have inadequate knowledge of depression and its symptoms, this can cause another barrier to diagnosis. Physicians may not be familiar with the diagnostic criteria for depression; therefore, they may not appreciate the differences among transient sadness, bereavement and a clinical illness. Other physicians understand the diagnostic criteria, but fail to appreciate the significance of the illness. Often, they believe that it will resolve spontaneously, that it is understandable in the context of the patient's life or that it does not cause much suffering or dysfunction. Because of this, they may not perform a careful diagnostic assessment.
BARRIERS TO TREATMENT
At times, convincing patients to start treatment is difficult. Some patients may refuse to accept a diagnosis of psychiatric illness; therefore, they will not accept treatment for the disorder. Some patients may be hesitant to begin specific treatments. Some patients are reluctant to take antidepressant medications because they fear “becoming addicted,” “needing a crutch,” taking “mind-control drugs” or for other reasons. Such patients are then likely to mislabel pretreatment symptoms as drug-related after starting antidepressants. Other patients refuse psychotherapy because they believe that it will be too intrusive, complicated, lengthy, expensive or overly focused on experiences from childhood.
When patients begin treatment, some may be dissuaded by unexpected or unpleasant side effects of the medications, delay in sufficient improvement or difficulty in forming an alliance with a psychotherapist. Patients may also be reluctant to visit a mental health subspecialist, even if such services are available.
Patients who initially agree to treatment must follow the treatment plan closely to ensure improvement of the illness. Many patients stop taking their medications within the first month of treatment. According to the AMA council, patient education improves the likelihood of adherence to treatment in patients with depression. This has been proved in almost every study in which it has been examined. The differences between outcomes of adherent and nonadherent patients are considerable, equal to the difference between the use of an active antidepressant and a placebo.
According to the AMA council, too many physicians interpret depression as “appropriate” for the patient's circumstances and not requiring treatment. In some cases, physicians cannot appreciate the duration or severity of a depression and may take an inappropriately expectant approach.
Even when physicians decide that treatment is needed, they may prescribe antidepressants in inadequate dosages or for periods of time that are not of sufficient duration to be effective. When patients report side effects that occur shortly after starting an antidepressant, physicians commonly react by discontinuing the drug, lowering the dosage below the therapeutic range or changing to a different drug. The AMA council warns that this could lead to a series of inadequate drug trials, which may result in multiple side effects but no improvement. If this happens, the patient may decide to stop further treatment.
Other barriers to optimal treatment of depression mentioned in the report include the use of ineffective forms of psychotherapy, inadequate third-party coverage for mental health care, a limited availability of mental health facilities and restrictions placed on the use of newer antidepressants by managed care organizations.
Ways to Reduce Barriers
While a number of programs are under way to reduce barriers to the recognition and management of depression, undertreatment remains a serious problem. Public and professional education efforts, destigmatization and improvement in access to mental health care are all necessary.
Many professional organizations and advocacy groups have publicly recognized the undertreatment of depression and the need to increase public and professional awareness. Attempts have also been made to identify critical skills and knowledge for primary care physicians.
Family physicians play a key role in the treatment of depression. The Commission on Health Care Services of the American Academy of Family Physicians referred to mental health services as “an essential component of comprehensive primary medical care.” A model curriculum for the psychiatric training of family physicians has also been developed.
Resources are available to guide physicians in the management of depression. The primary care version of the DSM-IV can assist physicians in the recognition and diagnosis of depression. The American Psychiatric Association, with input from many medical organizations, has also developed guidelines for the treatment of major depression in adults.