Dr Robert London

Identifying Depression: We Must Do More

Clinical Psychiatry News - Volume 33, Issue 11, Page 25 (November 2005)

National Depression  Screening Day is a great step forward. That's why I agreed to help screen potential patients during the 15th annual event last month at Lutheran Medical Center in New York City. After all, getting more involved in the early detection and prevention of depression  can lead to a solid public health model of care, in which I am a firm believer.

On that day, Oct. 6, I worked with Jack Fitzpatrick, Ph.D., an experienced psychologist, and a younger colleague, Jacqueline Guajardo, Ph.D., in a screening area at Lutheran. We encouraged passersby to fill out the Patient Health Questionnaire (PHQ-2), a two-item screening test. Based on their responses, some were asked to complete the Patient Health Depression Questionnaire (PHQ-9), a nine-item instrument designed to identify depression.

When depression was noted, the person was invited to a private consultation with any of us doing the screening. If it was clear that the person had depression, an appointment was made for further evaluation and possible treatment. I like this approach. First, having people feel comfortable enough to discuss emotional disorders and receive care gets these patients closer to avoiding the pain and suffering that depression can cause.

We all know the pervasiveness of depression. Results of the National Comorbidity Survey Replication showed that 10%-40% of patients have significant depressive symptoms, and half of those patients do not meet the criteria for major depressive disorder based on the DSM-IV (JAMA 2003;289:3095–105). Other studies have found that when formal DSM-IV criteria are used, the prevalence of “minor” depression is about twice that of major depression (Int. J. Psychiatry Med. 1996;26:177–209).

Because our colleagues in primary care often see these patients first, it seems to me that they—whether they be family medicine doctors, internists, or pediatricians—should be able to identify depression first in these patients. Undoubtedly, gynecologists also come across patients with depression. And just as these providers focus on mammography, colonoscopy, and melanoma detection, they should be prepared to identify depression and provide subsequent care, including referrals.

In fact, Iraida Kazachova, D.O., a psychiatrist at Lutheran Medical Center, suggests that a depression screening and even a Mini-Mental State Exam should be part of every physical exam. It would then fall on those of us in mental health to take a strong role in improving awareness of depression when teaching clinicians in residency programs and as part of continuing medical education.

Not only do primary care doctors need the education to address mental disorders, they also need the confidence to do so, and that is often a tall order. Bradford M. Goff, M.D., chairman of psychiatry and behavioral health sciences at Lutheran, suggests that continuing medical education programs provide mental health updates for primary care physicians every 4 or 5 years, just as we do for issues such as infection control. Again, the primary care physician is the most important resource we have in identifying and treating the simple depressions or in referring the more serious ones.

The learning, philosophizing, and action (LPA) technique, which I have advocated in previous columns for various mental health challenges, can be used to help patients conquer depression. Learning about the illness of depression is a straightforward educational process. We can work with patients in philosophizing about its occurrence, as many did in the better part of the 20th century with a myriad of theories.

But most importantly, we can treat depression—often successfully—once we identify it as a genuine medical illness. Screening is only a first step. The action phase combines medication with various forms of behavior therapy.

As in so many other mental illnesses, managed care companies need to take depression seriously. Primary care physicians who spend time on these screenings must get reimbursed. From a broader perspective, depression is costly. The economic loss to employers from employees with depression is estimated at $31 billion per year (JAMA 2003;289:3135–44). Mental health organizations must focus on making the assessment, understanding, and treatment of this often debilitating illness a national priority.

Let me know what you think about depression screening and a possible expanded role for primary care physicians in identifying, treating, and referring patients. I will try to pass your ideas on to my readers.

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