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To this point, from Chapters 1, 2, 3, you have learned about the frequent physical symptom presentation of mental health problems in medical settings. And you have heard about the overarching treatment model, the Mental Health Care Model (MHCM), that guides treatment of all mental disorders. We now begin to provide the details, especially of medications, for the first of the three mental health problems medical clinicians will need to address in the future—depression.

The theme of this book is that all physicians require competence with common mental health problems, such as depression, not to the level of becoming psychiatrists but equivalent to their competence with, for example hypertension, asthma, or diabetes.1 Given the shortage of psychiatrists,2 many believe that medical physicians can provide effective treatment for “treatment-responsive” depression, which we will define for you later in this chapter.3

This chapter provides you with tools to recognize and manage depression in its many forms.


Depression is the leading cause of disease burden, work disability, and death by suicide worldwide and, yet, most patients go untreated.4,5 An estimated 350 million people are affected. In the United States, approximately 7% of the population has depression, a rate that is even higher in females and young people.6 One in every 5 women and 1 in every 10 men are affected, and the prevalence increases with each successive birth cohort and progressively with older age, affecting 9% of the elderly living in the community, and 25% of those living in institutions. Among older adults, the presence of depression also is associated with increased chronic disease burden 10 years later.7 The economic impact in the United States is estimated at $210 billion per year.8 There are additional personal costs to families,9 and research demonstrates that effective treatment can save over $5 for every $1 spent on treatment.10

Indeed, treatment has been demonstrated to be very effective in multiple clinical trials, including a recent meta-analysis.11 Not only do antidepressants help for psychological symptoms, but they also have been demonstrated to improve medical outcomes, for example improved survival following an acute coronary syndrome.12 Risk factors for depression include economic poverty, being single, a history of abuse (emotional, physical, or sexual), and a family history of depression. Recent data indicate that severe affective disturbances during adolescence are associated with increased premature mortality—indicating the need for early intervention.13

Depressive disorders have been recognized since antiquity. In Hippocratic writings, melancholia (black bile) was attributed to disrupted humoral balance. In the 1960s, the amine hypothesis emerged following the discovery of antidepressant medications. Depressed patients had lower levels of urinary metabolites of the indoleamine serotonin and the catecholamine norepinephrine. In the 1980s, it was observed that depressed patients displayed aberrant hypothalamic-pituitary-adrenal (HPA) function: they had ...

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