Depression is common, disabling, and often underrecognized in general medical practice. More than 300 million people are affected by depression worldwide. Stigma of mental illness and other psychosocial barriers such as negative expectations often diminish the motivation of individuals with depression to seek care. Even when recognized, depression is often inadequately addressed by practitioners who lack either the time or training to provide timely, effective, evidence-based treatment. Despite evidence that depression is quite treatable, and the widespread availability of evidence-based assessment and treatment guidelines, overall outcomes remain poor.
About 3/4 of patients seeking care for depression are treated in primary care rather than by mental health professionals. This chapter focuses on the core knowledge and skills needed by general medical practitioners to effectively assess and manage major depressive disorder (MDD). We also review other related depressive disorders as updated in the DSM-5 including: disruptive mood dysregulation disorder, persistent depressive disorder (dysthymia), premenstrual dysphoric disorder (PMDD), adjustment disorder with depressed mood, substance/medication-induced depressive disorder, depressive disorder due to another medical condition, bipolar disorder/bipolar depression, and other specified and unspecified depressive disorders.
In diagnosing depression, we emphasize the routine use of brief patient self-assessment tools such as the nine-item Patient Health Questionnaire (PHQ-9). The U.S. Preventive Services Task Force (USPSTF) guidelines recommend screening the general adult population “when adequate systems are in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.” Unfortunately, despite the publication of such screening recommendations, adoption of the use of rating scales by providers has been poor. The national depression screening rate was less than 5% of all adult ambulatory care visits according to the National Ambulatory Medical Care Survey (2005–2015). Increased use of screening and rating instruments in depression should provide pivotal leverage needed to improve outcomes for depression, especially since measurement-based care (MBC) is the new standard in the management of MDD and has been shown to improve clinical outcomes.
DEPRESSIVE DISORDERS: MAJOR DEPRESSION & RELATED CONDITIONS
Major depressive disorder (MDD) is associated with considerable disability, morbidity, and mortality. Epidemiologic studies demonstrate that MDD causes as much or more disability and social and role impairment than other chronic illnesses such as diabetes, arthritis, hypertension, and coronary artery disease. The hallmark of MDD is when five or more of nine cardinal symptoms of depression are present during the same 2-week period with at least one of the symptoms being either depressed mood or loss of interest or pleasure (anhedonia). The symptoms must cause clinically significant distress and not be attributable to the effects of a substance or another medical condition (see Table 26-1).
Table 26-1.Diagnosis of major depression. |Favorite Table|Download (.pdf) Table 26-1. Diagnosis of major depression.
Anhedonia (lack of interest or pleasure in almost all activities)
Sleep disorder (insomnia or hypersomnia)
Appetite loss, weight loss; appetite gain, weight gain...