Depression is very common. Women are twice as likely as men to get depressed and have approximately a 20% lifetime prevalence of depression while men have a lifetime prevalence of 10%. Most likely the percentage is higher in a PCC due to the fact that those who are depressed are also more likely to have medical problems, pain, and will request medical treatment.
Risk factors for depression include: a family history of depression, early parental death or loss, early trauma, history of childhood sexual abuse, history of disruptive childhood environments, recent negative stressful events, being female, lower socioeconomic status, separation or divorce, and the absence of a confidant.
Depression, known in the DSM IV as Major Depressive Disorder, is diagnosed through interviewing the patient. Certain symptoms, such as chronic pain, vague complaints such as muscle pain, fatigue, low energy, and head aches might be symptoms that would start to appear in a PCC. In our culture, it is much more acceptable for patients to present with physical pain rather than emotional pain. Emotional pain, or depression, is more ambiguous and difficult to describe. Other tools for diagnosis include how you feel when you see the patient: you might feel an emotional heaviness or you might get a “blah” feeling as you walk in to the exam room. This feeling should not be ignored as it is information about how the patient feels. In Psychiatry, we call this feeling that we get from our patients countertransference. However, some patients will do a very good job of covering up their depressed feelings and may appear fine, unless asked specifically if they have any symptoms of depression. Unfortunately, in the general population, depression is sometimes considered a moral weakness rather than a biological illness that requires treatment. It can be very reassuring to the patient to hear that depression is a real medical illness with biological factors that are beyond their control.
Diagnosis of depression requires only 2 things: an understanding of the symptoms and some time to interview the patient. The symptoms to look for include:
- Depressed mood
- Diminished pleasure in activities (also called anhedonia)
- Change in appetite (could be increased or decreased)
- Change in sleep (could be increased or decreased)
- Psychomotor agitation or retardation
- Fatigue or decreased energy
- Feelings of worthlessness
- Decreased memory or concentration
- Recurrent thoughts of death or suicide
In order to meet criteria for depression, one must have five of the above nine criteria for two weeks or longer.
The first line of treatment for depression is usually an SSRI. There are many to choose from and are more or less equally efficacious. We usually choose an SSRI based on it’s side effect profile in order to make the patient more comfortable. If an SSRI does not work, we might either augment with another agent, such as buproprion, or switch to an SNRI, such as venlafaxine or duloxetine. Some of the atypical neuroleptics have also shown efficacy as augmenting agents for depression. Generally speaking, if a medication helped the patient some but not completely, the next step is to augment. If the first agent did not help the patient at all, the next step is to change the medication to a different class.
Psychotherapy can also be very helpful for depression. Cognitive behavioral therapy (CBT) has been shown to be very effective for the treatment of major depression. The combination of pharmacological treatment together with psychotherapy has repeatedly been shown to be superior to either medication or therapy alone. Therefore, the best form of treatment for a depressed patient is both medication and therapy.
If a patient does not improve after trying one or two antidepressants, it is probably a good idea to involve a psychiatrist in the treatment. Treatment-resistant depression is complicated and usually indicates a medical or psychiatric comorbidity. Though the patient may initially be hesitant to see a psychiatrist, if the patient is severely depressed, they usually welcome the idea of seeing an ‘expert’ to help them feel better.
Joanna Chambers, M.D. is the Residency Training Director and Vice Chair for Education in the Department of Psychiatry at the Indiana University School of Medicine. The statements in this post reflects her own opinions and do not reflect the opinions of the Department of Psychiatry or the School of Medicine.