Clinical depression is an illness that envelops lives and shrouds them in shadow. Depression makes everything worse—diabetes, blood pressure, sleep, pain, relationships, jobs—and it’s prevalent in primary care. In safety-net settings, as many as 4 out of 10 patients in our waiting rooms may be struggling with it at any one time.
Primary care providers know this—and depression screening and treatment has advanced to become a hallmark of many high-functioning primary care systems. In spite of these efforts, though, many patients don’t receive the treatment they need, and languish in solitude unnecessarily.
Why is it that depression is so hard to treat in primary care?
1. Depression is an internalizing illness.
In psychiatry, especially child and adolescent psychiatry, we often divide maladies into internalizing and externalizing disorders of behavior. Externalizing behavioral illnesses are easy to spot—the kid with ADHD who can’t sit still in a classroom and is always interrupting, causing a scene, or the person with schizophrenia and prominent auditory hallucinations actively responding to stimuli from within. Internalizing illnesses carry a different burden—they’re less disruptive on the surface. The insidious silence of depression simply slips by under our radar. Persons with depression often actually speak less, slower, and softer. Many studies have shown that without routine screening for depression we miss it. Depression, by its very nature, is hard to see.
2. Depressed patients don’t come to clinic.
In fact, depressed patients don’t go anywhere. Depression leaches motivation, energy and sleep—and consequently it’s hard to make it to work, or soccer games, or graduation ceremonies. In primary care systems we rely on follow-up appointments to drive forward health and wellness agendas with patients. Do an experiment: take a look at the problem list of the last 10 no-shows you’ve had. You’re likely to find that those with depression disproportionately account for your populations of no-shows or late cancellations, if you’ve been lucky enough to identify the depression in the first place.
3. Patients don’t complain of depression.
In one recent study of almost 200 women with clinical depression in a University-based safety-net clinic, only 11% had a psychiatric chief complaint, and less than half even mentioned psychiatric concerns during their visit.1 Patients with depression are more likely to present with chronic pain concerns, headaches, problems with fatigue and concentration, and vague illnesses that are challenging to characterize and frequently result in diagnostic workups that are often unfruitful and the bane of primary care. It’s certainly not to say that everyone with these concerns is depressed, but it definitely makes it harder to treat.
4. We are afraid to ask.
With 15 patients to see in a half-day, addressing more than 2 or 3 problems in any one visit is impossible. We’re constantly checking our watches, trying to stay on time, and trying to respect the time of everyone else on our schedule. Opening up a Pandora’s box of emotions coupled to a bird’s nest of psychosocial complexities seems like it would take time that we don’t have, and frankly, sometimes it does. Once the box is opened, there’s the possibility and need to discuss suicidal ideation, which many primary care physicians feel ill-equipped to handle. To compound the issue, we don’t want to send the message that their complaints are “just in their head”—further reducing the chances that we ask any loaded questions at all. This is stigma incarnate.
The truth is that asking about suicidal ideation does not increase a person’s suicide risk—and it’s the only way to identify emergency treatment resources necessary for a potentially life-threatening condition. We wouldn’t let a blood pressure of 185/110 mm Hg walk out of our clinic without assessing or at least asking about signs of end-organ damage. The same should be true of thoughts of death and depression. And if we knew that a specific subtype of diabetes made it much more refractory to treatment, led to worse diabetic outcomes across the board, and was an independent risk factor for myocardial infarction, we’d screen in a second. We should make sure to take out of the equation our own fears about addressing depression.
5. Depression is seen as being overwhelmingly subjective.
Depending on how you ask the questions, we perceive that we can easily coach someone into checking off the DSM-5 criteria for Major Depressive Disorder. “You’ve been having trouble sleeping lately, right? And your mood’s been down,” etc. . . . These are obviously leading questions, but the point remains. There’s no hemoglobin A1c or blood pressure reading for depression; we don’t have a measure for depression that can be seen as truly objective or that’s beyond the realm of subjective interpretation. So it’s hard to know if diagnoses are accurate or treatments are working beyond the provider and the patient’s prevailing mood du jour.
In spite of this perception, there are validated measures that are free to use, simple to administer, and reliable. They correlate extremely well with structured diagnostic interviews. In fact, you can hand them to patients to take on their own. The Patient Health Questionnaire 9 (PHQ9) has arisen as the gold-standard measure of de
pression for adults in primary care settings. It can both screen and help diagnose Major Depressive Disorder as well as track treatment course over time. It may still be subjective, but measuring the burden of disease is essential to tracking treatments over time, and in my experience, it’s enormously beneficial from the standpoints of clinical treatment and patient education. I can’t imagine managing diabetes without the hemoglobin A1c—and I can’t imagine managing depression without the PHQ9. It’s just that vital, and the closest thing we have to objectifying the illness.
Even in the face of all these limitations, successful identification and treatment of depression is possible in primary care settings. Emerging, evidence-based collaborative care models for behavioral health integration, such as the IMPACT model from the University of Washington, supercharge depression management in primary care and save money while also improving patient and provider satisfaction at the same time. Depression in primary care doesn’t have to be hard to manage, and with the right tools and knowledge at our disposal, it can be some of the most gratifying work we do.
Cerimele JM, Vanderlip ER, Croicu C, et al. Presenting symptoms of women with depression in an obstectrics and gynecology setting. Obstet Gynecol. 2013;122:313-318. doi: 10.1097/AOG.0b013e31829999ee