Major Depression: Screening and Diagnosis in Primary Care

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1 BARRY J. WU, MD, FACP Yale University Major Depression: Screening and Diagnosis in Primary Care Dr Wu is clinical professor of medicine at Yale School of Medicine. He is also associate program director of internal medicine and internal medicine clerkship director at the Hospital of Saint Raphael in New Haven, Conn. ABSTRACT: Major depression is a common illness in primary care that can be under-recognized. The United States Preventive Services Task Force guideline recommends screening for depression in adults when appropriate staff is in place to support depression care and followup. Two questions can be used to screen for depression. It is critical to determine the correct diagnosis to provide the optimal care to intervene in the 10% of patients with major depression at risk to commit suicide. Key words: major depression, unipolar depression Major depression is a common illness that affects 1 in 6 Americans during their lifetime. 1 This disabling condition impacts not only the individual, but also family, friends, and society. The annual cost of depression in the United States is estimated to be $83 billion. 2 Depression is under-recognized and challenging to manage because of relapses and recurrences. Half of patients with a first episode of major depression will have a recurrence, 70% after a second episode and 90% after a third episode. In this 2-part series, I will discuss screening, diagnosing and managing major depression in primary care. Here, I review the current United States Preventive Services Task Force (USPSTF) guideline for screening and the criteria for diagnosing major depression. In a coming issue, I will focus on the initial treatment options for primary care providers in caring for patients with major depression. The series will be case-based and utilize scenarios to answer a series of questions. Our first patient is a 35-year-old single mother who has lost her job and reports that she feels tired, has no appetite, has difficulty in sleeping at night, is more forgetful, and does not enjoy her life. Question 1: How common is major depression in primary care? A. < 5% B. 10% C. 30% D. 50% Answer: B. 10% Patients with multiple somatic complaints are commonly seen in primary care. They should be evaluated for medical conditions, substance abuse, and particular stressors that could contribute to their symptoms. If these have been excluded, consider the possibility of a depressive disorder. This includes major depression, bipolar disorder, minor depression, dysthymia, adjustment disorder with depressed mood, and bereavement. These disorders are clinical diagnoses. They are based on specific symptom-related criteria published in 2000 in the Diagnostic and Statistical Manual of Mental Disorders IV Text Revision december 2011 consultant 897

2 Major Depression: Screening and Diagnosis in Primary Care (DSM-IV-TR). 3 About 10% of outpatients seen by primary care providers meet DSM-IV-TR criteria for major depression; however, only half receive a diagnosis. 4-6 Question 2: What does the current USPSTF guideline state about screening adults for depression? A. Screen all adults B. Screen some patients C. Screen when systems are in place D. Do not screen adults Answer: C. Screen when systems are in place SCREENING The USPSTF guideline for screening for depression in adults was published in The task force s review of the evidence favors screening adults for depression when staff-assisted depression care supports are in place to ensure the accurate diagnosis, effective treatment, and follow-up of patients. It does not support screening in general when no staff is available to help coordinate and provide care for patients with depression. The USPSTF defines staff-supported depression care supports as clinical staff who provide depression care, coordination, case management, or mental health treatment. This can range from a screening nurse in your office to special training for you and your staff or referral to a nurse specialist or behavioral therapist. In 1995, the John D. and Catherine T. MacArthur Foundation organized a multidisciplinary group, including physicians from Harvard University, Duke University, Dartmouth University, and Cornell University, to develop a program to improve primary care management of depression. They created a Three Component Model (3CM) utilizing the USPSTF recommendations, National Institute of Mental Health guidelines, and available evidence to develop a model of care (Figure 1). 8 Instead of the previous model of primary care provider referral to a psychiatrist, this model incorporates a care manager to support communication and follow-up for patients. The MacArthur Initiative on Depression and Primary Care provides practical online tools and resources to help enhance the management of depression in primary care. Patient Patient 898 consultant december 2011 PCP Psych PCP Care Manager Psych Figure 1 The MacArthur Three Component Model of Care (3CM) is shown here. 8 In contrast to the previous model of referral to a psychiatrist (also shown here), 3CM incorporates a care manager to support communication and follow-up for patients. PCP, primary care provider; Psych, psychiatrist. Question 3: How can you screen for major depression? A. Forms filled out by patients B. Asking two questions C. Genetic testing D. A and B Answer: D. A and B Although screening for depression in primary care may one day involve genetic testing, it currently is not a standard of care in practice. There are, however, several tools to screen for depression. Some examples include the Center for Epidemiologic Studies Depression Scale, Beck Depression Inventory, Symptom-Driven Diagnostic System for Primary Care, Medical Outcomes Study depression measure, and Quick Diagnostic Interview Schedule. These case-finding instruments have sensitivities of 89% to 96% and specificities of 51% to 72% for diagnosing major depression. Many of these screening scales have 15 to 30 questions eliciting symptoms of depression, and it can be time-consuming to complete these forms. The

3 Nine Symptom Checklist Over the last 2 weeks, how often have you been bothered by any of the following problems? More than Nearly Not at all Several days half the days every day 1. Little interest or pleasure in doing things Feeling down, depressed, or hopeless Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual? 9. Thoughts that you would be better off dead or of hurting yourself in some way? (For office coding: Total score ) If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult M M M M Scale 5 9: Mild depression 10 14: Moderate depression 15 19: Moderate to severe depression 20: Severe depression From the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD PHQ). The PHQ was developed by Drs Robert L. Spitzer, Janet B. W. Williams, Kurt Kroenke, and colleagues. For research information, contact Dr Spitzer at PRIME-MD is a trademark of Pfizer Inc. Copyright 1999 Pfizer Inc. All rights reserved. Reproduced with permission. Figure 2 The Patient Health Questionnaire 9 (PHQ-9) can be used to screen for depression and to determine its severity. Adapted from Kroenke K et al. J Gen Intern Med december 2011 consultant 899

4 Major Depression: Screening and Diagnosis in Primary Care Table 1 Two-question screening tool for depression During the past month, have you often been bothered by feeling down, depressed, or hopeless? During the past month, have you often been bothered by little interest or pleasure in doing things? Data from Whooley MA et al. J Gen Intern Med Patient Health Questionnaire Nine (PHQ-9) has nine questions and can be filled out by patients (Figure 2). It has been found to be a reliable and valid instrument for screening and defining the severity of depression. 9 A simple two-question casefinding instrument has been studied; positive responses to both questions resulted in a sensitivity of 96% and a specificity of 57% for major depression (Table 1). 10 This may be a convenient way to screen for depression in a busy primary care office. DIAGNOSIS Diagnostic criteria. While it may be helpful to consult a psychiatrist for the diagnosis of major depression, you can make the diagnosis by asking about specific symptoms in the history. Major de pression is a clinical diagnosis based on a set of symptoms. The DSM-IV-TR criteria for diagnosing major depression are based on asking about nine specific symptoms that occur nearly every day over the same 2-week pe- Table 2 Nine symptoms and sample questions for diagnosis of major depression: D Sig E Caps 11 Symptom Question D: Depressed open-ended: How would you describe how you feel? Closed-ended: Have you felt sad, down, or blue? S: Sleep How would you describe your sleep? Have you had trouble sleeping? I: Interest Tell me about the things you enjoy doing? Have you less interest in the things you liked? G: Guilt Tell me about your sense of worth? Have you been feeling guilty? E: Energy How has your energy level been? Have you been feeling more tired than normal? C: Concentration How has your concentration been? Have you had trouble concentrating? A: Appetite How has your appetite or weight changed? Has your appetite or weight changed? P: Psychomotor Tell me about your thinking and coordination? Have you felt slowed down or sped up? S: Suicidal Tell me about your sense of worth? Have you felt like you don t want to live? Major depression = 5 symptoms (one must include depressed mood or loss of interest) for > 2 weeks. 900 consultant december 2011

5 Table 3 Sample questions for bipolar disorders Have you gone through periods in which you felt the opposite of being depressed? Have there been times you felt high? Have there been times you have lots of energy? Have there been times you did not need sleep? Have there been times you thought you could do anything? Have there been times you spent too much money? Have there been times your thoughts went too fast for you to keep up with them? riod and represent a change from previous functioning. The nine symptoms include: Feeling sad or depressed mood. Sleep disturbance. Loss of interest or pleasure in doing things. Inappropriate guilt feelings. Fatigue or loss of energy. Difficulty in concentrating or indecisiveness. Change in appetite or weight (ie, defined as 5% change in body weight in 1 month). Psychomotor retardation or agitation. Recurrent thoughts of death or suicide. Patients with major depression must have at least five of these nine symptoms. One of the symptoms must be a depressed mood or loss of interest or pleasure. One method of remembering these symptoms is an abbreviation for prescribing energy pills to help treat patients with depression or Sign for Energy Capsules or Sig E Caps. Clearly, it is not appropriate to prescribe antidepressants for all patients with depression; however, this can be a helpful tool in remembering the questions to ask to determine the diagnosis. The mnemonic Sig E Caps was devised by Carey Gross, MD, at the Massachusetts General Hospital and refers to eight of the nine symptoms of depression. 11 If we add the letter D, we have D Sig E Caps, all nine symptoms (Table 2). Question 4: How can you distinguish between major depression, bipolar disorder, minor depression, dysthymia, adjustment disorder, and bereavement? A. History B. Physical examination C. Genetic testing D. MRI Answer: A. History Dif ferential diagnosis. The history is essential for primary care practitioners and psychiatrists in distinguishing the various depressive disorders. Major depression is also called unipolar depression. This is important to distinguish from bipolar disorders, in which patients have major depression with episodes of mania (bipolar I disor- Table 4 Differential of depressive disorders Depressive disorder Major depression Minor depression Dysthymia Bipolar disorder type I Bipolar disorder type II Comment Unipolar depression 5 of 9 ( mood/interest) 3 > 2 wk 2-4 of 9 ( mood/interest) 3 > 2 wk Minor depression 3 2 yr Mania Hypomania Adjustment disorder with depressed mood Bereavement Modified from Bostwick JM. Mayo Clin Proc december 2011 consultant 901

6 Major Depression: Screening and Diagnosis in Primary Care Table 5 Suicide risk assessment Suicide/homicidal ideation, intent, plan, or action Access to means and lethality of means Psychotic symptoms/severe anxiety Family history of recent suicide Alcohol and substance abuse 902 consultant december 2011 der) or hypomania (bipolar II disorder). The symptoms of mania and hypomania can be unmasked in patients who are treated for major depression but who actually have bipolar disorder. Patients with bipolar disorders have periods of elevated, expansive, or irritable moods that can be accompanied by inflated selfesteem, grandiosity, decreased need for sleep, pressured speech, racing thoughts, distractibility, psychomotor agitation, or excessive involvement in pleasurable activities that could lead to harm. Some sample questions to ask patients with suspected bipolar disorders are listed in Table 3. Patients with minor depression have two to four of the nine symptoms listed in Table 2 for 2 weeks. This must include either a depressed mood or anhedonia. If these symptoms persist for 2 or more years, dysthymia is diagnosed. Patients receive a diagnosis of adjustment disorder with depressed mood if they have an identifiable stressor, symptoms out of proportion to what is expected, social and occupational impairment lasting up to 6 months, and insufficient criteria to meet the diagnosis of major depression. Bereavement may be diagnosed if patients have symptoms that resemble those of major depression which last less than 2 months and are related to the death of a loved one. It is critical to establish the correct diagnosis in patients with depressed mood because management may not treat the underlying problem and could cause harm (Table 4). Question 5: How common is suicide among patients with major depression? A. < 5% B. 10% C. 30% D. 50% Answer: B. 10% ASSESSMENT OF SUICIDE RISK About 10% of all patients with major depression will eventually commit suicide. Some of the risk factors include prior suicide attempts, hopelessness, living alone, psychotic symptoms, substance abuse, age-specific risk (ie, older white men, young black men), and family history of suicide attempts. Question all depressed patients specifically about thoughts of harm to self or others (Table 5). It is imperative to develop a safe treatment plan, which may range from continued primary care follow-up to immediate emergency department psychiatric referral. n REFERENCES: 1. Kessler RC, Berglund P, Demlar O, et al. The epidemiology of major depressive disorder. JAMA. 2003;289: Donohue JM, Pincus HA. Reducing the societal burden of depression: a review of economic costs, quality of care and effects of treatment. Pharmocoeconomics. 2007;25:7. 3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder, 4th ed, Text Revision. Washington, DC: American Psychiatric Association; Shurman RA, Kramer PD, Mitchell JB. The hidden mental health network. Treatment of mental illness by nonpsychiatrist physicians. Arch Gen Psychiatry. 1985;42: Simon GE, Von Korff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med. 1995;4: Von Korff M, Shapiro S, Burke JD, et al. Anxiety and depression in a primary care clinic. Comparison of Diagnostic Interview Schedule, General Health Questionnaire, and practitioner assessments. Arch Gen Psychiatry. 1997;44: U. S. Preventive Services Task Force. Screening for Depression in Adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2009;151: MacArthur Initiative on Depression in Primary Care website: org/. 9. Kroenke K, Spitzer RL, Williams JB. The PHQ-9 validity of a brief depression severity measure. J Gen Intern Med. 2001;16: Whooley MA, Avins AL, Iranda J, Browner WS. Case-finding instruments for depression: two questions are as good as many. J Gen Intern Med. 1997;12: Brigham and Women s Hospital. Depression: A Guide to Diagnosis and Treatment National Guideline Clearinghouse. Available at Accessed November 17, Bostwick JM. A generalist s guide to treating patients with depression with an emphasis on using side effects to tailor antidepressant therapy. Mayo Clin Proc. 2010;85:

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