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MENTAL HEALTH

Noticing the Not-So-Obvious

By Stephen Cornell

Underdiagnosed Depression is a Signigicant Problem

Rich, a 29-year old former truck driver, began to experience frequent headaches in his early 20s. Before long, he was getting them nearly every day.

He had trouble getting to sleep and problems waking up early and not being able to fall back asleep. Even when he slept for long periods—12, 13, 14 hours—he felt exhausted when he got up and continued to feel the same way all day.

It became harder for him to think and to remember things. He'd always had an above average memory, but he found himself forgetting entire conversations within minutes. He got lost in places he was very familiar with, causing him to become frustrated.

When Rich would tell friends and family how he felt, they would downplay his symptoms.

"They'd say, "Of course you're forgetful. You have a lot on your mind," or "Of course you're tired. You're working too hard," he says. "I knew what it felt like to be tired from working all the time, and this wasn't it. I felt awful, all day, every day."

Visits to his family practice doctor's office didn't yield any more results. One doctor did blood tests. Another ordered a magnetic resonance scan. Nobody ever suggested depression as a diagnosis. Not that Rich would have accepted that anyway, without a lot of education.

"If someone had told my symptoms were a result of 'depression," I would have denied it," he says. "I had a job, a family, nice things. What right would I have to be depressed?"

The closest Rich came to a solution was when one physician suggested a one-word diagnosis: stress. With no further explanation the physician told Rich that he might benefit from going to a psychiatrist.

Rich was skeptical. Stress could be the cause of all his symptoms? A psychiatrist?

"Yes" the physician said simply, without offering any clarification. Rich didn't make a psychiatric appointment and went on feeling terrible.

Later, when it finally emerged that there was a long history of clinical depression—even suicide—in Rich's family that was never talked about, he was finally diagnosed and adequately treated. But he's still bitter about the years he spent suffering with his depression.

"It makes me so angry," he says. "I've done a good bit of reading about depression now, although I'm no expert. But it seems to me that I had textbook symptoms of depression, even if I was unable to recognize it myself. Why couldn't any of my health care providers even explore depression as a cause? Or explain it to me further? I didn't get help that I really needed."

Underdiagnosed, Undertreated
According to the National Depressive and Manic-Depressive Association (DMDA), in any given year, 17.5 million Americans have some form of depressive disorder such as major depression, bipolar disorder or dysthymia (chronic, moderate depression). Of all psychiatric illnesses, mood disorders are among the most responsive to treatment—when properly treated, 80% to 90% of people with mood disorders can be helped.

But evidence suggests that depression is grossly underdiagnosed and undertreated. Combined results from four randomized clinical trials of patients with dysthymia, chronic major depression or double depression showed that in samples of more than 1,200 patients, 48% to 67% had never been treated with antidepressant medication despite being ill for a median of 20 years. The range of patients who received adequate treatment (defined as 150 mg of imipramine or its equivalent for at least 4 weeks) was extremely low, ranging from 5% to 26.8%. (Hirschfeld RMA, Keller MB, Panico S, et al. The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. JAMA. 1997;277:333-340).

"There have been so many studies that have shown that people with depression just are not recognized," says Myrna Weissman, PhD, professor of epidemiology and psychiatry at Columbia University College of Physicians and Surgeons in New York. "They are not recognized because they are not asked by health care providers. Or because the patient does not feel comfortable bringing it up themselves."

"Most people with depression don't get picked up (in the primary care setting)," says Don St. John, MA, PA-C, a physician assistant in the Adult Outpatient Psychiatry Department, University of Iowa Hospitals and Clinics in Iowa City, Iowa. "And when they do, most are inadequately treated."

Recognizing Depression
Rarely will patients in primary care present with the simple complaint: "I feel depressed."

The diagnosis of depression is made difficult because patients often present with vague somatic complaints such as headache, chronic back pain or stomach pain. Patients can return to the provider again and again with physical complaints lacking an explicit cause.

"The statistics constantly change, but I would certainly say that in the primary care setting, approximately 60% to 80% of patients has a diagnosable psychiatric disorder while 10% to 20% have an emotional disorder. Among these underdiagnosed disorders, depression and other mood disorders linger," says Marvin S. Kalachman, PA-C, MS, a partner in the Child and Adolescent Behavioral Health Center in Huntsville, Ala. "It wasn't until I got involved in psychiatry that I felt I did better at identifying depression."

Clinicians should look for signs such as sadness, inexplicable changes of weight, changes in sleep habits, guilt, suicidal thoughts and feelings of worthlessness, says Louis Kuritzky, MD, clinical assistant professor at the University of Florida family residence program in Gainesville, Fla.

Diminished libido, crying spells, loss of interest in pleasurable activities and extreme anxiety or irritability can also signal depression, Kalachman says. Ask people what kinds of things they like to do and whether they are still doing them, he says.

"PAs should always ask about mood symptoms," St. John says. "They should always be looking for clues such as the patient not making eye contact or talking slower or having more complaints than usual. One advantage of family practice is that you usually know your patients well."

Patients who present with multiple somatic complaints are more likely to have a depressive disorder. One study showed that 2% of patients who presented with one physical complaint or none at all had a mood disorder, while mood disorders were present in 44% of patients who presented with six to eight physical complaints and 60% of patients who presented with nine or more physical complaints. If no physical explanation exists for the patient's somatic complaints, the association with a mood disorder is even stronger. (Valenstein MV, Klinkman MS. Minor depression. In: Knesper DJ, Riba MB, Schwenk TL, eds. Primary Care Psychiatry. Philadelphia, Pa: WB Saunders Co;1997:95-106).

Several tests exist to evaluate patients for depression. The Beck Depression Inventory and the Geriatric Depression Scale are reliable tests—they are most useful for moderate and severe depression—and can be administered in about 15 or minutes in the office.

Clinicians should consider using the tests as part of their initial examination, Dr. Weissman says. "I think clinicians should add questions about depression as part of the normal screening process," she says. "You take blood pressure. You take a pulse. You should also find out about mood. Patients who come in for repeated office visits should be screened. Patients who look sad should be screened. Patients with a history of depression should be screened."

Changing Ideas
A vague array of symptoms is not the only reason for the underdiagnosis of depression. There still is a problem with the perception of depression as a medical illness, says Lydia Lewis, executive director of the National DMDA and a victim of depression. Despite the fact that evidence has shown that depression is a result of chemical imbalance in the brain, clinicians and the general public still have trouble reconciling mental illness with physical illness.

"Since it can't be measured with a blood test, it's probably not going to be in the forefront of a (clinician's) mind," Lewis says. "But people have to realize depression can be a fatal illness if left untreated. About 15% of patients commit suicide if they do not receive adequate treatment."

Many people, Lewis says, did not take her illness seriously because it was a "mental" illness. "If I had a dollar for every person who said, "Lydia, go on the Stairmaster ...,' she says. "And there's a myth that depression is self-indulgent. People say, "Stop thinking so much about yourself."

"Depression is a physical illness, a malfunction of an organ," she says. "That organ just happens to be the brain."

That knowledge is far from universal, St. John agrees. "In the Midwest, people still believe in pulling yourself up by the bootstraps," he says. "They think, "Put your life together and you'l be fine." They are ashamed to admit that they're depressed. That's one of the reasons people present with somatic complaints. They can talk about back pain. That's OK. They can't say depression."

Attitudes of health care providers also have to change, Dr. Kuritzky says. "Our agenda should not be to treat people because they are sad," Dr. Kuritzky says. "We need to treat depression with the same respect that we treat other chronic illnesses such as hypertension, diabetes and asthma. Suicide is one of the top 10 causes of death in this country, and the suicide rate has doubled over the last 10 years."

Clinicians can be hesitant to make a diagnosis of depression, Dr. Kuritzky says, because of the implications of mental illness. It's much simpler to treat stomach pain or lower back pain than it is to discuss issues of mental health. "Clinicians are sometimes reluctant to open up a can of worms," he says. "If they can diagnose a tension headache, the don't have to go into a long discussion about depression."

Even time constraints in a busy practice can make PAs hesitant to bring up depression. "People just don't ask about mood," he says. "Sometimes you only have 15 minutes with a patient. If you open up a discussion about depression, you can be behind the rest of the day."

Therapy for Depression
Medication and psychotherapy have been found to be equally effective in treating mild depression, and studies are being conducted on the effectiveness of therapy in moderate and severe depression.

Because medications work more quickly, they are usually used for patients with severe depression that presents a risk of suicide. But a combination of drugs and therapy is the preferred treatment for most patients.

Newer antidepressants such as fluoxetine (Prozac), paroxetine (Paxil), fluvoxamine (Luvox) and sertraline (Zoloft) work by inhibiting the reuptake of the neurotransmitter serotonin in the nerve synapse, thereby making serotonin more available. These newer drugs have a much better side effect profile than older antidepressants. Since they all work similarly, Dr. Kuritzky says, the initial medication can be chosen by matching the subtle differences in a medication's effect to the symptoms of a specific patient. If a patient is having trouble sleeping, for instance, one of the SSRIs with a sedating effect, such as Paxil, can be chosen, he says.

Venlafaxine (Effexor) inhibits the reuptake of serotonin and norepinephrine and has proven an effective antidepressant. Nefazodone (Serzone), another newer antidepressant, appears to block a specific serotonin receptor. Bupropion (Wellbutrin) is an effective antidepressant, although its method of action is not clear.

Older antidepressants such as imipramine (Tofranil) and amitriptyline (Elavil) can still be useful, although they generally have somewhat less favorable side effects profiles than the newer drugs, Dr. Kuritzky says. Some people tolerate these older drugs well, and the cost can be a fraction of the expense for newer drugs.

Primary care PAs can be helpful as psychotherapists if they're willing to take the time to talk to the patient, Dr. Kuritzky says. People are very willing to talk to health care providers, he says.

"The clinician is often an unwitting counselor," he says. "It's been documented that in the month before people kill themselves, at least half see their clinicians. People are much more likely to talk to their clinician than to their clergyman."

Stephen Cornell is an assistant editor.