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Awareness, diagnosis, and treatment of depression

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Abstract

OBJECTIVES: To review recent findings on the epidemiology, burden, diagnosis, comorbidity, and treatment of depression, particularly in general medical settings; to delineate barriers to the recognition, diagnosis, and optimal management of depression in general medical settings; and to summarize efforts under way to reduce some of these barriers.

DESIGN: Medline serches were conducted to identify scientific articles published during the previous 10 years addressing depression in general medical settings and epidemiology, co-occurring conditions, diagnosis, costs, outcomes, and treatment. Articles relevant to the objective were selected and summarized.

CONCLUSIONS: Depression occurs commonly, causing suffering, functional impairment, increased risk of suicide, added health care costs, and productivity losses. Effective treatments are available both when depression occurs alone and when it co-occurs with general medical illnesses. Many cases of depression seen in general medical settings are suitable for treatment within those settings. About half of all cases of depression in primary care settings are recognized, although subsequent treatments often fall short of existing practice guidelines. When treatments of documented efficacy are used, short-term patient outcomes are generally good. Barriers to diagnosing and treating depression include stigma; patient somatization and denial; physician knowledge and skill deficits; limited time; lack of availability of providers and treatments; limitations of third-party coverage; and restrictions on specialist, drug, and psychotherapeutic care. Public and professional education efforts, destigmatization, and improvement in access to mental health care are all needed to reduce these barriers.

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References

  1. Council on Scientific Affairs, American Medical Association. Informational Reports. Comorbidity; Epidemiology of Depression; Diagnosis of Depression; Treatment of Depression. Presented at the American Medical Association Annual Meeting, Chicago, Ill, June 23–27. 1991.

  2. Robins LW, Helzer JE, Weissman MM, et al. Lifetime prevalence of specific psychiatric disorders in three sites. Arch Gen Psychiatry. 1984;41:949–58.

    PubMed  CAS  Google Scholar 

  3. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51:8–19.

    PubMed  CAS  Google Scholar 

  4. Sansone R, Sansone L. Dysthymic disorder: the chronic depression. Am Fam Physician. 1996;53:2588–94.

    PubMed  CAS  Google Scholar 

  5. Myer J, Weissman MM, Tischler GL, et al. Six-month prevalence of psychiatric disorders in three communities: 1908 to 1982. Arch Gen Psychiatry. 1984;41:959–67.

    Google Scholar 

  6. Montano CB. Recognition and treatment of depression in a primary care setting. J Clin Psychiatry. 1994;55(12, suppl):18–34.

    PubMed  Google Scholar 

  7. Katon W, Schulberg H. Epidemiology of depression in primary care. Gen Hosp Psychiatry. 1992;14:237–47.

    Article  PubMed  CAS  Google Scholar 

  8. Barrett JE, Barrett JA, Oxman TE, et al. The prevalence of psychiatric disorders in a primary care practice. Arch Gen Psychiatry. 1988;45:1100–6.

    PubMed  CAS  Google Scholar 

  9. Schulberg HC, Madonia MJ, Block MR, et al. Major depression in primary care practice: clinical characteristics and treatment implications. Psychosomatics. 1995;36:129–37.

    PubMed  CAS  Google Scholar 

  10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Press; 1994:320–7.

    Google Scholar 

  11. Coghill SR, Caplan GR. Impact of maternal postnatal depression on cognitive development of young children. BMJ. 1986;292:116–7.

    Google Scholar 

  12. Wells KB, Stewart A, Hays RD, et al. The functioning and wellbeing of depressed patients: results from the Medical Outcomes Study. JAMA. 1989;62:914–9.

    Article  Google Scholar 

  13. Murray CJL, Lopez AD, eds. The Global Burden of Disease. Cambridge, Mass: Harvard University Press; 1996:21.

    Google Scholar 

  14. Greenberg PE, Stiglin LE, Finkelstein SN, et al. The economic burden of depression in 1990. J Clin Psychiatry. 1993;54:405–18.

    PubMed  CAS  Google Scholar 

  15. Greenberg PE, Kessler RC, Nells TL, et al. Depression in the workplace: an economic perspective. In: Feighner JP, Boyer WF, eds. Selective Serotonin Uptake Inhibitors: Advances in Basic Research and Clinical Practice. 2nd ed. New York, NY: John Wiley and Sons; 1996.

    Google Scholar 

  16. Callahan CM, Kesterson JO, Tierney WM. Association of symptoms of depression with diagnostic test charges among older adults. Ann Intern Med. 1997;126:426–32.

    PubMed  CAS  Google Scholar 

  17. Henks HJ, Katzelnick DJ, Kobak KA, et al. Medical costs attributed to depression among patients with a history of high medical expenses in a health maintenance organization. Arch Gen Psychiatry. 1996;53:899–904.

    Google Scholar 

  18. Unutzer J, Patrick DL, Simon G, et al. Depressive symptoms and the cost of health services in HMO patients aged 65 and older: a 4-year prospective study. JAMA. 1997;277:1618–23.

    Article  PubMed  CAS  Google Scholar 

  19. Simon GE, VonKorff M, Barlow W. Health care costs of primary care patients with recognized depression. Arch Gen Psychiatry. 1995;52:850–6.

    PubMed  CAS  Google Scholar 

  20. US Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, Md: Williams and Wilkins; 1996.

    Google Scholar 

  21. Periodic Health examination, 1990 update, 2: early detection of depression and prevention of suicide. Can Med Assoc J. 1990;142:1233–8.

    Google Scholar 

  22. Goldberg DP. The Detection of Psychiatric Illness by Questionnaire. London, UK: Oxford University Press; 1972.

    Google Scholar 

  23. Beck AT, Beck RW. Screening depressed patients in family practice: a rapid technic. Postgrad Med. 1972;52:81–5.

    PubMed  CAS  Google Scholar 

  24. Derogatis LR. The SCL-90-R. Baltimore, Md: Clinical Psychometrics Research; 1975.

    Google Scholar 

  25. Rush AJ, Gullion CM, Basco MR, et al. The Inventory of Depressive Symptomatology (IDS): psychometric properties. Psychol Med. 1996;26:477–86.

    Article  PubMed  CAS  Google Scholar 

  26. Zung WKW. A self-rating depression scale. Arch Gen Psychiatry. 1965;12:63–70.

    PubMed  CAS  Google Scholar 

  27. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Measure 1992;7:343–51.

    Google Scholar 

  28. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol. 1986;5:165–73.

    Article  Google Scholar 

  29. Lyness JM, Noel TK, Cox C, et al. Screening for depression in elderly primary care patients. Arch Intern Med. 1997;157:449–54.

    Article  PubMed  CAS  Google Scholar 

  30. Weissman M, Olfson M, Leon AC, et al. Brief diagnostic interviews (SDDS-PC) for multiple mental disorders in primary care. Arch Fam Med. 1995;4:220–7.

    Article  PubMed  CAS  Google Scholar 

  31. Spitzer RL, Williams JBW, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. JAMA. 1994;272:1749–56.

    Article  PubMed  CAS  Google Scholar 

  32. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Primary Care Version. Washington, DC: American Psychiatric Press; 1995.

    Google Scholar 

  33. Wolraich ML, Felice ME, Drotar D, eds. Diagnostic and Statistical Manual for Primary Care, Child and Adolescent Version. Elk Grove Village, Ill: American Academy of Pediatrics; 1996.

    Google Scholar 

  34. Ustun B, Goldberg D, Cooper J, et al. New classification for mental disorders with management guidelines for use in primary care, the ICD-10 PHC chapter 5. Br J Gen Pract. 1995;45:211–5.

    PubMed  CAS  Google Scholar 

  35. Glassman AH. Cigarette smoking: implications for psychiatric illness. Am J Psychiatry. 1993;150:546–51.

    PubMed  CAS  Google Scholar 

  36. Stoudemire A, Fogel BS. Principles of Medical Psychiatry. 2nd ed. Orlando, Fla: Grune & Stratton; 1993.

    Google Scholar 

  37. Rundell JR, Wise MG, eds. American Psychiatric Press Textbook of Consultation-Liaison Psychiatry. Washington, DC: American Psychiatric Press; 1996.

    Google Scholar 

  38. Nesse R, Finlayson R. Management of depression in patients with coexisting medical illness. Am Fam Physician. 1996:53:2123–33.

    Google Scholar 

  39. Caine ED, Lyness JM, Conwell Y. Diagnosis of late-life depression: preliminary studies in primary care settings. Am J Geriatr Psychiatry. 1996;4(suppl):S45–50.

    Google Scholar 

  40. Callahan CM, Hendrie HC, Tierney WM. The recognition and treatment of late-life depression: a view from primary care. Int J Psychiatry Med. 1996;26:155–71.

    Article  PubMed  CAS  Google Scholar 

  41. Covinsky KE, Fortinsky RH, Palmer RM, et al. Relation between symptoms of depression and health status outcomes in acutely ill hospitalized older persons. Ann Intern Med. 1997;126:417–25.

    PubMed  CAS  Google Scholar 

  42. Quill TE. Doctor, I want to die. Will you help me? JAMA. 1993;270:870–3.

    Article  PubMed  CAS  Google Scholar 

  43. Masand PS, Chengappa KNR, Edwards W. Somatic treatments. In: Goldman LS, Wise T, Brody D, eds. Psychiatry for Primary Care Physicians. Chicago, Ill: American Medical Association; 1998:331–64.

    Google Scholar 

  44. Jarrett RB, Rush AJ. Short-term psychotherapy of depressive disorders: current status and future directions. Psychiatry. 1994;57:115–32.

    PubMed  CAS  Google Scholar 

  45. McLean PD, Hakstian AR. Clinical depression: comparative efficacy of outpatient treatments. J Consult Clin Psychol. 1979;47:818–36.

    Article  PubMed  CAS  Google Scholar 

  46. Shea MT, Elkin E, Hirschfeld RMA. Psychotherapeutic treatment of depression. In: Frances AJ, Hales RE, eds. Review of Psychiatry. Washington, DC: American Psychiatric Press; 1988:235–55.

    Google Scholar 

  47. Brodaty H, Andrews G. Brief psychotherapy in family practice: a controlled prospective intervention trial. Br J Psychiatry. 1983;143:11–9.

    PubMed  CAS  Google Scholar 

  48. Mynors-Wallis LM, Gath DH, Lloyd-Thomas AR, et al. Randomised controlled trial comparing problem-solving treatment with amitriptyline and placebo for major depression in primary care. BMJ. 1995;310:441–5.

    PubMed  CAS  Google Scholar 

  49. Clarkin JF, Pilkonis PA, Magruder KM. Psychotherapy of depression: implications for reform of the health care system. Arch Gen Psychiatry. 1996;53:717–23.

    PubMed  CAS  Google Scholar 

  50. Kupfer DJ, Frank E, Perel JM, et al. Five-year outcome for maintenance therapies in recurrent depression. Arch Gen Psychiatry. 1992;49:769–73.

    PubMed  CAS  Google Scholar 

  51. Frank E, Kupfer DJ, Wagner EF, et al. Efficacy of interpersonal psychotherapy as a maintenance treatment of recurrent depression: contributing factors. Arch Gen Psychiatry. 1991;48:1053–9.

    PubMed  CAS  Google Scholar 

  52. Agency for Health Care Policy and Research. Depression in Primary Care. Washington, DC: US Government Printing Office; 1993.

    Google Scholar 

  53. Regier DA, Narrow WE, Rae DS, et al. The de facto US mental and addictive disorders service system: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry. 1993;50:85–94.

    PubMed  CAS  Google Scholar 

  54. Goldberg D. Epidemiology of mental disorders in primary care settings. Epidemiol Rev. 1995;7:182–90.

    Google Scholar 

  55. Wells KB, Hays RD, Burnam A, et al. Detection of depressive disorder for patients receiving prepaid or fee-for-service care: results from the Medical Outcomes Study. JAMA. 1989;262:3298–302.

    Article  PubMed  CAS  Google Scholar 

  56. Wells KB. Depression in medical settings: implications of three health policy studies for consultation-liaison psychiatry. Psychosomatics. 1994;35:279–96.

    PubMed  CAS  Google Scholar 

  57. Badger LW, deGruy FV, Hartman J, et al. Psychosocial interest, medical interviews, and the recognition of depression. Arch Fam Med. 1994;3:899–907.

    Article  PubMed  CAS  Google Scholar 

  58. Robbins JM, Kirmayer LJ, Cathbras P, et al. Physician characteristics and the recognition of depression and anxiety in primary care. Med Care. 1994;32:795–812.

    Article  PubMed  CAS  Google Scholar 

  59. Simon GE, VonKorff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med. 1995;4:99–105.

    Article  PubMed  CAS  Google Scholar 

  60. Tiemens BG, Ormel J, Simon GE. Occurrence, recognition, and outcome of psychological disorders in primary care. Am J Psychiatry. 1996;153:636–44.

    PubMed  CAS  Google Scholar 

  61. Katon W, Gonzales J. A review of randomized trials of psychiatric consultation-liaison studies in primary care. Psychosomatics. 1994;35:268–78.

    PubMed  CAS  Google Scholar 

  62. Schulberg HC, Magruder KM, deGruy F. Major depression in primary medical care practice: research trends and future priorities. Gen Hosp Psychiatry. 1996;18:395–406.

    Article  PubMed  CAS  Google Scholar 

  63. Higgins ES. A review of unrecognized mental illness in primary care. Arch Fam Med. 1994;3:908–17.

    Article  PubMed  CAS  Google Scholar 

  64. Chang G. Wamer V, Weissman MM. Physicians’ recognition of psychiatric disorders in children and adolescents. Am J Dis Child. 1988;142:736–9.

    PubMed  CAS  Google Scholar 

  65. Costello EJ, Edelbrock C, Costello AJ, et al. Psychopathology in pediatric primary care: the new hidden morbidity. Pediatrics. 1988;82:415–24.

    PubMed  CAS  Google Scholar 

  66. Canning EH, Hanser SB, Shade KA, et al. Mental disorders in chronically ill children: parent-child discrepancy and physician identification. Pediatrics. 1992;90:692–6.

    PubMed  CAS  Google Scholar 

  67. Lavigne JV, Binns HJ, Christoffel KK, et al. Behavioral and emotional problems among preschool children in pediatric primary care: prevalence and pediatricians’ recognition. Pediatrics. 1993;91:649–55.

    PubMed  CAS  Google Scholar 

  68. Katon W, Von Korff M, Lin E, et al. Adequacy and duration of antidepressant treatment in primary care. Med Care. 1992;30:67–76.

    Article  PubMed  CAS  Google Scholar 

  69. Wells KB, Sturm R, Sherbourne CD, Meredith LS. Caring for Depression. Cambridge, Mass: Harvard University Press; 1996.

    Google Scholar 

  70. Schulberg HC, Block MR, Madonia MT, et al. The ‘usual’ care of major depression in primary care practice. Arch Fam Med. 1997;6:334–9.

    Article  PubMed  CAS  Google Scholar 

  71. Meredith LS, Wells KB, Kaplan SH. Counseling provided for depression: role of clinician specialty and payment system. Arch Gen Psychiatry. 1996;53:905–12.

    PubMed  CAS  Google Scholar 

  72. Katzelnick DJ, Kobak KA, Greist JH, et al. Effect of primary care treatment of depression on service use by patients with high medical expenditures. Psychiatr Serv. 1997;48:59–64.

    PubMed  CAS  Google Scholar 

  73. Sturm R, Wells KB. How can care for depression become more cost-effective? JAMA. 1995;273:51–8.

    Article  PubMed  CAS  Google Scholar 

  74. Schulberg HC, Block MR, Madonia MJ, et al. Treating major depression in primary care practice. Arch Gen Psychiatry. 1996;53:913–9.

    PubMed  CAS  Google Scholar 

  75. Schulberg HC, Block MR, Madonia MJ, et al. Applicability of clinical pharmacotherapy guidelines for major depression in primary care settings. Arch Fam Med. 1995;4:106–12.

    Article  PubMed  CAS  Google Scholar 

  76. Coulehan JL, Schulberg HC, Block MR, et al. Treating depressed primary care patients improves their physical, mental, and social functioning. Arch Intern Med. 1997;157:1113–20.

    Article  PubMed  CAS  Google Scholar 

  77. Katon W, Robinson P, Von Korff M, et al. A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry. 1996;53:924–32.

    PubMed  CAS  Google Scholar 

  78. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA. 1995;273:1026–31.

    Article  PubMed  CAS  Google Scholar 

  79. Von Korff M, Katon W, Bush T, et al. Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression. Psychosomatic Med. 1998;60:143–9.

    Google Scholar 

  80. Rost K, Smith R, Matthews DB, et al. The deliberate misdiagnosis of major depression in primary care. Arch Fam Med. 1994;3:333–7.

    Article  PubMed  CAS  Google Scholar 

  81. Docherty JP. Barriers to the diagnosis of depression in primary care. J Clin Psychiatry. 1997;58(suppl 1):5–10.

    PubMed  Google Scholar 

  82. Goldman LS. Psychiatry in primary care: possible roles for organized medicine. Psychiatr Ann. 1997;27:425–9.

    Google Scholar 

  83. Cohen-Cole S. The Medical Interview: The Three Function Approach. St. Louis, Mo: Mosby-Yearbook; 1991.

    Google Scholar 

  84. Barsky AJ, Borus JB. Somatization and medicalization in the era of managed care. JAMA. 1995;274:1931–4.

    Article  PubMed  CAS  Google Scholar 

  85. Goldberg D. Detection and assessment of emotional disorders in a primary care setting. Int J Ment Health. 1979;8:30–48.

    Google Scholar 

  86. Eisenberg L. Treating depression and anxiety in primary care: closing the gap between knowledge and practice. N Engl J Med. 1992;326:1080–3.

    Article  PubMed  CAS  Google Scholar 

  87. Tylee AT, Freeling P, Kerry S. Why do general practitioners recognize major depression in one woman patient yet miss it in another? Br J Gen Pract. 1993;43:327–30.

    PubMed  CAS  Google Scholar 

  88. Rollman BL, Block MR, Schulberg HC. Symptoms of major depression and tricyclic side effects in primary care patients. J Gen Intern Med. 1997;12:284–91.

    Article  PubMed  CAS  Google Scholar 

  89. Simon GE, Lin EH, Katon W, et al. Outcomes of “inadequate” antidepressant treatment. J Gen Intern Med. 1995;10:663–70.

    Article  PubMed  CAS  Google Scholar 

  90. Basco MR, Rush AJ. Compliance with pharmacotherapy in mood disorders. Psychiatric Ann. 1995;25:269–70,276,278–9.

    Google Scholar 

  91. Simon GE, VonKorff M, Heiligenstein JH, et al. Initial antidepressant choice in primary care: effectiveness and cost of fluoxetine vs tricyclic antidepressants. JAMA. 1996;275:1897–902.

    Article  PubMed  CAS  Google Scholar 

  92. Sclar D, Robison LM, Skaer TL, et al. Antidepressant pharmacotherapy: economic outcomes in a health maintenance organization. Clin Ther. 1994;16:715–30.

    PubMed  CAS  Google Scholar 

  93. Hirschfield RMA, Keller MB, Panico S, et al. The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. JAMA. 1997;277:333–40.

    Article  Google Scholar 

  94. Cole SA, Sullivan M, Kathol R, et al. A model curriculum for mental disorders and behavioral problems in primary care. Gen Hosp Psychiatry. 1995;17:13–8.

    Article  PubMed  CAS  Google Scholar 

  95. Commission on Health Care Services. White Paper on the Provision of Mental Health Care Services by Family Physicians. Kansas City, Mo: The American Academy of Family Physicians; 1994.

    Google Scholar 

  96. Jones LR, Knopke HJ, Parlour RR, et al. A curriculum for the psychiatric training of family physicians. Gen Hosp Psychiatry. 1981;3:189–98.

    Article  PubMed  CAS  Google Scholar 

  97. American Psychiatric Association Work Group on Major Depressive Disorder. Practice guideline for major depressive disorder in adults. Am J Psychiatry. 1993;150(suppl):1–26.

    Google Scholar 

  98. Brown J, Stewart M, McCracken E, et al. The patient-centered clinical method, II: definition and application. Fam Pract. 1986;3:75–9.

    Article  PubMed  CAS  Google Scholar 

  99. Gask L, Goldberg D. Impact on patient care, satisfaction, and clinical outcome of improving the psychiatric skills of general practitioners. Eur J Psychiatry. 1993;7:203–18.

    Google Scholar 

  100. Regier DA, Hirschfield RMA, Goodwin FK, et al. The NIMH Depression Awareness, Recognition, and Treatment Program: structure, aim, and scientific basis. Am J Psychiatry. 1988;145:1351–7.

    PubMed  CAS  Google Scholar 

  101. Paykel ES, Tylee A, Wright A, et al. The Defeat Depression Campaign: psychiatry in one public arena. Am J Psychiatry. 1997;154(suppl):59–65.

    PubMed  CAS  Google Scholar 

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Address correspondence and reprint requests to Dr. Bresolin: Secretary to the Council on Scientific Affairs, American Medical Association, 515 N. State Street, Chicago, IL 60610.

Members and staff of the Council on Scientific Affairs at the time this report was prepared: Ronald M. Davis, MD, Detroit, Mich (Chair); Joseph A. Riggs, MD, Haddon Fields, NJ (Chair-Elect); Roy D. Altman, MD, Miami, Fla; Hunter C. Champion, New Orleans, La; Scott D. Deitchman, MD, MPH, Decatur, Ga; Myron Genel, MD, New Haven, Conn; John P. Howe III, MD, San Antonio, Tex; Mitchell S. Karlan, MD, Los Angeles, Calif; Mohamed Khaleem Khan, MD, PhD, Boston, Mass; Nancy H. Nielsen, MD, PhD, Buffalo, NY; Michael A. Williams, MD, Baltimore, Md; Donald C. Young, MD, Iowa City, Iowa; Linda B. Bresolin, PhD (CSA Secretary), Barry D. Dickinson, PhD (CSA Assistant Secretary), Chicago, III; Larry S. Goldman, MD (Department of Psychiatry, University of Chicago).

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Goldman, L.S., Nielsen, N.H., Champion, H.C. et al. Awareness, diagnosis, and treatment of depression. J GEN INTERN MED 14, 569–580 (1999). https://doi.org/10.1046/j.1525-1497.1999.03478.x

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