Depression is a serious global health issue. Some 121 million people are affected worldwide, according to 2001 estimates from the WHO, with 1 million committing suicide each year and a further 10 to 20 million attempting to do so.
The prevalence of depression in the general adult population of Singapore is around 5 percent. This figure is lower than in the US but comparable to most developed European countries. The prevalence in developing Asian countries is unclear but is likely to rise, placing an increasing burden on society and healthcare systems.
The WHO, as part of a new program launched on World Mental Health Day 2008, recently called on governments and donors to urgently upscale mental health services and better integrate mental health into primary care. Depression in particular is increasingly treatable, and making an early and effective diagnosis in this setting will lead to considerable improvements in outcome.
Diagnosis
Routine screening for depression is not recommended but should be carried out among those who are at the highest risk. There are several risk factors which GPs should be aware of in order to effectively target these patients.
The presence of multiple medical problems is strongly associated with depression. Chronic but stable conditions such as heart disease, stroke and cancer all place a strain upon patients’ wellbeing, and the coexistence of more than three conditions has been shown to significantly increase depression risk.
The link between depression and diabetes, for example, is well established. Depressed patients often lose the motivation to take their medications, which contributes to a worsening of their diabetes. This can be a two-way process, with the resulting deterioration of blood sugar control affecting the vessels and tissues in the brain, leading to a further worsening of depressive symptoms and an even greater loss of motivation.
GPs should also consider the social factors affecting their patients, as this type of information is invaluable in identifying those who should be screened for depression. Do they live alone? Are they recently divorced or widowed? Is there support from their family? Are they likely to have financial problems?
Once the GP has identified a high-risk patient they can initiate screening with two quick, simple questions: “Have you persistently felt depressed in the last 2 weeks to a month? Have you experienced a loss of interest in your daily activities over this time period?” If the patient answers yes to either of these questions then the physician should move on to try and identify further symptoms. A formal diagnosis can then be established according to the criteria laid out in the relevant guidelines.
There are, however, two major obstacles to initiating this process. The first is shyness on the part of the patient. Asian patients tend to perceive doctors as being primarily concerned with their physical wellbeing and may not expect to discuss mental health issues with them. They are often shy and might find the subject awkward.
Doctors nonetheless have a responsibility to overcome this barrier and broach the subject. This can be done by gradually and tactfully guiding the conversation in the right direction. Ask the patient gently about their mood, how they have been feeling in light of recent problems, and whether there are any other issues they would like to discuss. If they clam up, try not to charge in and pry them open in a single visit. Primary care physicians have the advantage of seeing patients regularly, and introducing the subject in one visit might make it easier to return to at a later date.
The second barrier, however, lies with the doctor, since the process of diagnosing depression can only begin if they are willing to ask these difficult questions. There is sometimes a reluctance to open up Pandora’s Box which, although understandable, needs to be overcome. This fear typically lies in the unknown, so doctors can avoid this by reading around the subject and being prepared for what might follow. Continuing Medical Education courses and workshops are often available to help physicians gain confidence in dealing with these issues, while there is a wide range of useful information available on the internet for further reading (see below).
Once doctors are comfortable with broaching the subject they can also use their intuition to guide them in making an early diagnosis. Depressed patients may seem withdrawn and quieter than usual, or may display a steady deterioration in chronic conditions which were previously well controlled. These signs should all arouse suspicion that the patient is not simply having a bad day and may be in need of help.
Practice Guidelines
Practice guidelines on major depressive disorder are available from the American Psychiatric Association website. The Ministry of Health in Singapore also publishes its own guidelines on depression, most recently in March 2004. These state that a diagnosis can be made when a depressed mood or loss of interest is accompanied by a minimum of four specific symptoms (from a list of eight) over a period of 2 or more weeks.
Depression can be a culturally sensitive issue, and guidelines will need to be applied within the context of the local social environment. The ability to adhere to the various guidelines will also depend heavily on the availability of local resources.
A range of advice and information is also available from the Malaysian Psychiatric Association and the Hong Kong College of Psychiatrists.
Treatment
Once the criteria for diagnosis are fulfilled GPs should move on to discuss treatment with their patients. If the patient is not severely agitated or suicidal then it can be useful to spread this discussion over more than one clinic visit. Start by making them aware that they have a medical condition which goes beyond just experiencing difficulties in life, and let them know that it is treatable and that safe and effective medications are available. This will give the patient time to digest the information, discuss the options with their family and do their own research before committing to a plan of action.
This approach also gives the GP a little more time to review options and prepare for prescribing an antidepressant. Medication access and guidelines will vary by country, but GPs should typically aim to begin with a selective serotonin reuptake inhibitor (SSRI) or a tricyclic antidepressant (TCA) for 4 to 6 weeks and wait to see whether there is a response. Algorithms such as the Texas Implementation of Medication Algorithm (see below) can then be used to guide further decisions around medication use.
Patients may have common misunderstandings about medications which physicians should try to allay. They may fear that the medications are addictive, or they may expect them to provide instantaneous relief. Managing these expectations in advance is important, and can help prevent patients from becoming disappointed or frustrated and stopping their medications.
Close follow-up is also crucial. Guidelines suggest that medication use should continue for 6 months to a year even if the patient shows signs of recovery. Early discontinuation leads to a higher risk of relapse, so it is important to make sure that patients finish their course. Side effects such as gastrointestinal complaints, drowsiness, dry eyes and dry throat will also need to be managed and patients should be warned about these in advance.
Psychotherapy, where available, is also a useful tool for treating depression. Few GPs are trained in psychotherapy themselves, and they should prepare for this eventuality by thoroughly researching the options in the local community and knowing how and where to refer their patients.
Treatment can be augmented by attempting to tackle some of the underlying triggers for depression. Rather than focusing solely on medical issues, GPs should also explore a patient’s psychosocial problems to understand what is troubling them. Community resources and support groups may be on hand to help, and many patients will benefit from further advice and referrals. With patients facing many problems this approach can be time-consuming for GPs, and they may like to plan ahead and deal with these issues one session at a time.
Patients with multiple psychiatric disorders or very complex or refractory depression should generally be referred on to a specialist center, particularly if they show signs of suicidal thoughts or self-harming behavior.
These centers may also offer further training which can help primary care physicians to improve their knowledge of depression. The Institute of Mental Health, for example, offers a partnership program for GPs which seeks to provide continuity of care for stable patients and increase the accessibility of treatment within the community. Participants complete a series of lectures and guided clinical sessions on depression and other mental health disorders, and can subsequently receive case consults and phone advice for difficult cases. Having specialist advice on hand can take some of the pressure off busy GPs, and can help them feel more comfortable discussing depression with their patients.
Conclusion
Depression is becoming easier to treat as our understanding of the condition continues to improve. Medications are safer and more effective than ever before and there is a wide range of information available to guide our clinical decisions. Primary care is an important setting for making an early diagnosis, and physicians should be proactive in screening patients who are at high risk.
Online Resources:
The American Psychiatric Association practice guidelines:
http://www.psych.org/MainMenu/PsychiatricPractice/PracticeGuidelines_1.aspx
The World Psychiatric Association:
http://www.worldpsychiatricassociation.org/
Texas Implementation of Medication Algorithm (TIMA):
http://www.dshs.state.tx.us/mhprograms/disclaimer.shtm
Institute of Mental Health patient information: http://www.imh.com.sg/patient_education/depression.htm
Depression.com:
http://www.depression.com/
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