General Considerations
The Surgeon General’s Report on Mental Health, issued by former Surgeon General David Satcher, MD, called the nation’s attention to the importance of mental health in overall health. The report cited the commonality of mental illness and the fact that undertreatment of mental illness is an enormous problem fueled by stigma and barriers to access. Several demographic groups were identified as being at particularly high risk for having unmet mental health needs: children and youth, older adults, and members of medically underserved ethnic and racial groups. Because these groups rely largely on the primary care setting for their mental health needs, the report strongly recommended an expanded role for primary care physicians and allied health practitioners in providing mental health services.
Depression is the leading cause of disability (lost years of healthy life) in Western countries at ages 15-44 years old. The estimated annual cost of depression in the US economy is $83 billion, including expenses related to care, absenteeism, reduced productivity on the job, and premature death and suicide. In the United States, the point prevalence and lifetime prevalence of depression are 6.6% and 16.6%, respectively. While depression may occur at any age, the typical age of onset of major depression is 27-35 years and the highest rate of depression exists in adults ages 40-59. Depression is twice as common among women as men. Recent data continue to support the Surgeon General’s Report that blacks and Hispanics with a diagnosis of depression in the previous 12 months are less likely to receive mental health care than their white counterparts (58.9% and 51.8% vs 71.1%).
Depression often coexists with other chronic medical illnesses, particularly in later life. Medical illness and disability —more common in the elderly—are risk factors for depression. Depression diminishes quality of life, leads to nonadherence with self-care (diet, exercise, taking medication as prescribed), increases use of other medical services, is a risk factor for suicide, and is associated with cognitive impairment in older adults. Additionally, major psychosocial risk factors for depression include bereavement, caregiver strain, social isolation, disability, role transitions, and severe medical problems.
Depression is associated with abnormal functioning of the brain and often has a genetic basis. It often goes unrecognized and untreated and can therefore increase morbidity and mortality in populations such as the elderly and ethnically and racially diverse groups with high prevalence of chronic illness. However, depression is treatable and some interventions can significantly reduce its symptomatology and incidence. Depression is often a chronic illness, following a relapsing course. In order to prolong recovery and prevent recurrence, maintenance treatment beyond the acute treatment of the episode is usually medically appropriate, thus making the primary care setting an appropriate medical home for depression care. In addition, many people prefer to be treated in the general medical sector rather than being referred to specialty mental health care.
Prevention
There is increasing interest in early preventive interventions with patients who are at high risk for developing depression in the wake of medical events such as stroke, myocardial infarction, macular degeneration, interferon therapy, and arthritis. Preventive interventions may include psychoeducation about the particular challenges being confronted, stress-coping techniques, the use of problem-solving therapies to help patients cope more effectively with increasing limitations, supporting general health and wellness (good nutrition/ exercise/relaxation), facilitating support of family/friends/ support groups, and protecting sleep quality through better sleep hygiene. Prevention strategies for addressing depression in the elderly have also been shown to be effective in the primary care setting. Over the past decade, it has become clear that antidepressant treatments can have a very favorable impact on the long-term course of depressive illness, particularly in preventing recurrences of disease.
Depression commonly co-occurs with chronic diseases, complicating treatment and worsening chronic disease outcome. Depression is an independent risk factor in the development of cardiovascular diseases (heart disease, stroke). Stroke is also independently associated with depression. Other chronic conditions that frequently co-occur with depression include HIV/AIDS, arthritis, chronic pain syndromes, sickle cell disease, and cancer. (Tables 52-1 and 52-2.) Depression can negatively affect the outcome of the co-occurring condition because it impacts a person’s ability to follow a treatment plan, including adherence to medication or other therapies, diet, and exercise. Screening, diagnosis, and treatment of depression could have an impact on the course and management of chronic diseases
Although approximately one-third of individuals with chronic medical conditions may experience symptoms of depression, individuals with chronic illnesses often overlook symptoms and signs of depression, assuming that feeling “down” or depressed is normal while living with a serious, chronic illness. In addition, because symptoms and signs of depression are frequently masked by other medical conditions, health care providers treating individuals with chronic diseases may not recognize that the underlying cause of depressed mood, decreased energy, sleep changes, or appetite changes is depression. Therefore, a high index of suspicion of depression should be maintained when treating patients who present with symptoms and signs of chronic physical conditions, multiple somatic complaints, or chronic pain complaints. Screening should be utilized in these instances populations with consistent systems in place for diagnosis, treatment, and follow-up. The American Heart Association and the American Psychiatric Association specifically recommend screening for depression in patients with coronary heart disease.
Overall, studies show that disparities exist between whites and racially and ethnically diverse groups in mental health status, in utilization of mental health services, in quality of care and outcome regardless of socioeconomic status in the four major underserved ethnic and racial groups: African Americans, American Indians, Asian Americans, and Hispanics. Risk of mental illness and poor mental health outcomes in diverse and underserved populations is increased due to nonfamilial factors associated with depression (eg, socioeconomic status, environmental factors, access to health care, and higher rates of health disorders). Despite increases in the rate of antidepressant medication use over the past 12 years among all racial and ethnic groups, this increase has been disproportionately higher in whites compared with non-Hispanic blacks.
The increased risk of living in poverty with inadequate access to health care and inadequate treatment, more prevalent in populations of color, may multiply stress and contribute to persistent and recurring episodes of depression. For nonwhite populations, the chronic stress of discrimination and subsequent effects on immune regulation of living as a member of a marginalized racial and ethnic group can also contribute to depression. Because of the independent increased risk of chronic diseases and mental illness in diverse racial and ethnic populations, the impact of mental illness on chronic diseases is increased substantially.
Clinical Findings
The type and level of severity of depression runs along a spectrum, ranging from subclinical varieties to major depression. Major depression typically occurs in episodes, each with a clear beginning and end. After an initial episode, more than 50% will have additional episodes in their lifetime. Among older adults with depression, about half had experienced depression earlier in their life, the other half experience it for the first time after the age of 60.
The American Academy of Family Physicians states that mental health services are an integral component of the continuum of care in the primary care setting. However, the reluctance of individuals to seek care for mental health problems along with a likelihood of somatization of emotional issues pose giant obstacles for mental health care in these settings. Studies report that approximately 40% of patients with major depression do not want or perceive the need for treatment. Only 20%-30% of patients with emotional or psychological issues report these to their primary care physicians, and the most common somatic symptom reported by more than half of patients with major depression was “feeling fatigued, weak, or tired all over.” Recent data suggest a discordance between patients presenting with symptoms of depression and physicians’ appraisal of depression symptoms during primary care visits.
Initial assessment should include a focused psychiatric history and examination and, for older adults, a brief clinical cognitive examination. In addition, a medical history, physical examination, focused neurologic examination, and laboratory studies to rule out physical conditions with similar symptoms are preferred as part of the assessment. It is also important to assess other domains, particularly for older adults, including level of functioning or disability, loss or grief concerns, physical environment, and psychosocial situation.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) classifies depressive disorders into three categories: major depressive disorder, dysthymic disorder, and depressive disorder not otherwise specified. Specific features associated with these disorders are described as follows:
The nine typical symptoms that may appear during a major depressive episode:
- Depressed mood: Feeling sad, low, empty, hopeless, gloomy, or down in the dumps; different from a normal sense of sadness or grief.
- Anhedonia: Inability to enjoy usually pleasurable activities (eg, sex, hobbies, daily routines).
- Change in appetite or weight:
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