Depressive Symptoms in Primary Care: Recognition and Assessment Sudha Prathikanti, MD UCSF Department of Psychiatry

Primary Care Statistics Depressive symptoms the most common outpatient medical problem Depression 10-25% vs HTN 6% On average, medical resident should encounter at least 1 patient with depressive symptoms each clinic day Not all depressive symptoms lead to MDD, but all require some management

Costs of Untreated MDD Untreated depressed patients use 2-3 times more medical services (e.g MD visits) Untreated depressed patients spend more time in bed than those with chronic medical probs like IDDM, arthritis, COPD, GI disease Risk of suicide (6% to 15% lifetime risk)  25% of suicide completers visit PMD 1 wk before dying  50% of suicide completers visit PMD 1 month before dying

Recognition of Depressive Sx Maintain high index of suspicion Evaluate somatic complaints  By type  By number Look for irritability/behavior change Use screening questionnaires  Beck (21 questions) mod. depress >16  Carroll (20 questions) mod. depress >19

Assessing Severity of Depressive Symptoms Increased severity correlates with increased risk of threshold psychiatric disorder Triage of symptom severity  PAT : pt needs assurance & talk  PAM : pt needs more assessment & management  PIT : pt needs immediate treatment (usually psychiatry consult)

Assessing Severity 1) Level of Overall Distress  Ask patient to quantify on scale of 1-10  Use screening questionnaire PAT : lower distress PAM : moderate distress PIT : higher distress

Assessing Severity 2) Identifiable Stressor (not always present)  Acute  Major (death, divorce)  Minor (fender-bender, job deadline)  Chronic  Major (ongoing illness, marital conflict)  Minor (noisy neighbor, long commute) PAT: distress commensurate with stressor, shows adaptation over time PAM: disproportionate distress, difficulty adapting PIT : disproportionate distress, unsafe adapting

Assessing Severity 3) Functional Impairment  Social withdrawal  Impaired job performance  Impaired parenting  Relational difficulties  Self-care problems PAT: less social, longer time to complete tasks PAM: impaired parenting/job performance PIT: self-care/self-preservation becomes issue

Assessing Severity 4) Duration of Symptoms  Days  Weeks (2)  Months (2-3)  Years (2) PAT: mostly days PAM: mostly 2 weeks to 2-3 months PIT: mostly days, but any of above

Assessing Severity 5) Always ask about Suicidal Ideation (esp if psychosis or substance abuse present)  Active vs. passive  Persistent vs. fleeting  Intractable vs. distractable  Specific vs. vague  Means vs. no means  Impulse to enact vs. no impulse  Actual attempt vs. no attempt PAT: no suicidal ideation PAM: may be present, but usually passive/fleeting PIT: present, and active/persistent/intractable/specific