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Years ago the treatment of depression occurred only in the
practice of psychiatrists and psychotherapists. Today, there is a wide
range of mental health professionals who assess and treat depression.
Additionally today, there are many patients being assessed and treated
for depression by primary care providers.
Fueling the increase in the treatment of depression in primary
care has been the managed care protocols which have offered financial
incentives to primary care providers, more and more patients are being
treated in the primary care setting than in specialty psychiatric practices.
Because of the stigma that still surrounds psychiatric illnesses, including
depression, some patients avoiding seeking treatment with a psychiatric
provider. While the trend to treat psychiatric illness in primary care
may allow for more people to be assessed and treated, it is the presentation
of depression in the primary care setting that can be confusing to patients
and clinicians alike.
Depression is a very common serious medical illness; it's
not something that someone makes up "in their heads". It's more
than just feeling "down in the dumps" or "blue" for
a few days. It includes feeling "down" and "low" and
"hopeless" for weeks at a time. A depressive disorder is an
illness that involves the body, mood, and thoughts. It affects the way
a person eats and sleeps, the way one feels about oneself, and the way
one thinks about things. A depressive disorder is not the same as a passing
blue mood. It is not a sign of personal weakness or a condition that can
be willed or wished away. People with a depressive illness cannot merely
"pull themselves together" and get better. Without treatment,
symptoms can last for weeks, months, or years (NIMH, 2005).
According to the National Institute of Mental Health (NIMH)
(2003) approximately 19 million persons in the United States suffer from
depression in any given year. NIMH (1999) reports that nearly twice as
many women (12.0 percent) as men (6.6 percent) suffer from major depressive
disorder each year. These figures translate to 12.4 million women and
6.4 million men in the US.
The lifetime risk for depression is 12.7% for men and 21.3% for women,
meaning that at any point in time, an estimated 340 million people throughout
the world and 19 million people in the US have major depressive disorder
(Greden, 2002). Overall, suicide is the 11th leading cause of death in
the US (CDC, 2002). The National Institute of Mental Health (NIMH) (2002),
reports that suicide was the 8th leading cause of death for males and
the 19th leading cause of death for females in 2000 (Minino, et. al.,
2002). More than four times as many men as women die by suicide (Minino,
et. al., 2002), although women report attempting suicide during their
lifetime about three times as often as men (Weissman, et. al., 1999).
With the high prevalence of depression, many people turn to their primary
care providers to get treatment. According to the Administration for Health
Research and Quality (AHRQ) (2000) more than 25 percent of primary care
patients have a diagnosable mental health disorder (most often anxiety
or depression). Over a decade ago, the US Department of Health and Human
Services (1993), reported that significant depressive symptoms are seen
in up to 36% of all medically ill patients and approximately 10% suffer
from Major Depressive Disorder. Those with stroke, dementia, diabetes,
heart disease, and renal impairment have especially high rates of comorbid
depression.
Depression is a term that is widely used in the medical community, the
psychiatric community and the general population. Unfortunately, each
group (and certainly individuals within each group) defines depression
differently. Often, among the general population, the term depression
is synonymous with sadness, or the "blues". The psychiatric
community utilizes the criteria outlined in the Diagnostic and Statistical
Manual of Psychiatric Disorders, 4th Edition, Text Revised (DSMIV-TR)
(APA, 2000) to make a diagnosis of depression. However, in primary care
the presentation of depression can appear very different than it does
to the psychiatric specialist. Not surprisingly, in primary care settings
patients often present with physical complaints, rather than with overt
emotional or psychiatric symptoms. These patients may be high users of
primary care, or they may be the ones that are labeled "difficult",
at least in part because the primary care provider is addressing the physical
complaints often without recognizing that the underlying cause is depression.
Mandy R. is a 24-year-old who has chronic headaches, back pain and gastro-intestinal
problems. She complains of severe pain and lethargy. The pain keeps her
from being able to concentrate well enough to work; she spends most of
her day lying on the couch in a darkened room. Her husband is becoming
increasingly less supportive of her illness because no cause can be found
for her pain and because no treatment has been effective. Mandy's primary
care provider has tested her for almost every conceivable condition and
results are always negative. A referral was made to a pain specialist,
but this has been only minimally beneficial to Mandy. The primary care
provider is highly frustrated.
Ida J., 58-years-old, was in a severe motor vehicle accident 2 years
ago, wherein she sustained a head injury and was severely burned after
the car burst into flames. She has been through physical rehabilitation
and is healing well. She has been very anxious since the accident, fearing
to stay alone and frequently making appointments with her primary care
provider and she also calls her primary care provider, as well as the
burn specialist, with a variety of seemingly trivial concerns. She has
been prescribed Ativan 0.5mg TID for anxiety, with little relief.
Thomas M. is a 64-year-old man who is recovering from a transurethral
resection of the prostate (TURP). He has not been sleeping well since
the procedure. He has had to be rehospitalized for excessive bleeding
since the original procedure. He is up most of the night, cat naps during
the day. He makes frequent calls to the primary care provider's office
to ask a variety of questions regarding his sleep difficulties as well
as his prognosis. The office staff now dreads his calls, finding it difficult
to get off the phone when he calls.
Laura A. is a 60-year-old woman whose husband of 40 years died suddenly
of a heart attack, 2 years ago. Laura has been distressed, angry, sad,
tearful and anxious since her loss; her moods fluctuate. She complains
to her primary care provider of fatigue and episodic shortness of breath.
Are these people depressed?
© 2003, 2005 NYSNA, all rights reserved.
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