Depression in the Primary Care Clinic

HEALTH: “A state of complete physical, mental, and social well being, and not merely the absence of disease or infirmity.” – World Health Organization, 1948

 

Chronic medical illness and depression have a bidirectional relationship

 

 

Facts

  • Up to 75% of all mental health care is delivered in primary care settings.
  • Primary care providers (PCPs) are usually the first providers a patient encounters
  • Stigma prevents patients from seeking mental health treatment from a mental health provider
  • The shortage of mental health providers increasingly places pressure on Primary Care Providers 
  • There is significant overlap between symptoms of depression and common medical conditions (e.g., pain, fatigue, insomnia, appetite changes).
  • Up to 17% of adults experience one major depressive episode in their lifetime
  • 5%-10% of patients seen in primary care settings meet criteria for major depressive disorder
  • 1 in 4 patients in primary care clinics have sub threshold depression or persistent depressive disorder
  • Untreated depression in medical populations is associated with greater somatic symptom burden, poorer quality of life, and overall worse outcomes
  • Risk for depression increases with number of medical diagnoses
  • Depression is associated with higher rates of health care utilization (Cost of medical care for depressed patients is 50% higher than for non-depressed patients)
  • Depressed patients tend to be less adherent with medical treatment, less productive at work (or unemployed/on leave), and more resistant to medical treatment

Misconceptions

  • Depression is “normal” and “understandable” under certain circumstances and does not require treatment (Depression is not a “normal response” to anything)
  • Normal sadness and depression are the same thing (NOT TRUE)
  • Depression due to acute and/or chronic pain is “understandable” and does not require treatment (NOT TRUE)
  • Pain and other somatic symptoms are uncommon presenting complaints in patients with depression (NOT TRUE)
  • “Antidepressants don’t really work” (NOT TRUE)

 

Screening

Patient Health Questionnaire 2 (PHQ-2)

  1. ‘‘Over the past 2 weeks have you felt down, depressed, or hopeless?”
  2. “Over the past 2 weeks have you felt little interest or pleasure in doing things that normally interest you or bring you happiness?”
  • If yes to either 1 or 2, investigate further…

 

Patient Health Questionnaire 9 (PHQ-9)

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Diagnosis

 

Differential Diagnosis

 

 

Depression Treatment Algorithm

 

Treatment Options

Psychotherapy Options

Cognitive Behavioral Therapy

Interpersonal Psychotherapy

Psychodynamic Psychotherapy

Behavioral Activation

Supportive Psychotherapy

 

Pharmacotherapy Options

Selective Serotonin Reuptake Inhibitors (SSRIs)

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

Bupropion

Mirtazapine

Trazodone

Vortioxetine

Tricyclic Antidepressants (TCAs)

Monoamine Oxidase Inhibitors (MAOIs)

 

 

Antidepressant Tables

 

 

 

 

 

PHQ-9 Tool