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The setting makes a difference

A new take on treating depression

From the July/August 1996 ACP Observer, copyright © 1996 by the American College of Physicians.

By William A. Check, PhD

Because patients suffering from depression who see a primary care physician typically present differently than patients seeking psychiatric care, experts on primary care treatment of depression say generalists need to adopt special approaches to diagnose—and treat—psychiatric illness.

Most studies conclude that major depression is seen in 5% to 10% of primary care patients and that up to a fifth of all patients in primary care exhibit some level of depression, but research still shows internists and family physicians have trouble detecting and then treating depression in their patients. Studies as recent as 1995 found that two-thirds of persons with depression went undetected and untreated.

And some predict that rate may slip further, due to the economic pressures from managed care. Not only are primary care physicians being allotted less time and asked to do more in each patient visit, but they also are being limited in how much—and to whom—they can refer patients with problems like depression.

But by knowing what to look for and being careful not to stigmatize patients, experts say primary care physicians can do a better job of diagnosing depression. And even better news is that once they have made the diagnosis, physicians can choose from increasingly effective weapons to battle depression.

Picking up the signs

To treat depression, however, primary care physicians must first recognize its signs, a challenge for many. "We are the ones who see the most depression and miss the most because it doesn't present as depression but as a patient who says, 'My head [or my stomach] is killing me' or 'I have no energy,' " explained Jerome Marmorstein, MD, assistant clinical professor of medicine at the University of Southern California and an internist in Santa Barbara. "This is a different presentation from psychiatrists, who see people saying, 'I am depressed' or 'I am sad.' "

A recent study directed by Thomas L. Schwenk, MD, chairman of the department of family practice at the University of Michigan School of Medicine, came to similar conclusions. "The key issue that you can pin all of this to," Dr. Schwenk said, "is that depression in primary care does not look like depression in psychiatry. These patients function relatively well, have some physical symptoms like fatigue and sleep disturbance, but have not crossed that threshold of being severely depressed with significant functional loss that clearly labels diagnosis and treatment."

Primary care physicians can detect possible depression by keeping alert for symptoms that don't seem to have a physical cause, the experts say, even if little or no testing has been done. Kurt Kroenke, FACP, associate professor of medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., said that depressed patients often describe multiple physical symptoms. So while patients suffering from coronary artery disease will commonly present with chest pain, he said, patients who present with chest pain associated with depression will often have two, three or more physical complaints.

Additionally, several easy-to-use diagnostic instruments developed during the last five years can also help primary care practitioners increase their pickup rate of depressed patients. Two such tools, PRIME-MD and SDDS-PC, ask patients to answer between five and 26 questions; if the outcome is positive, the patient then replies to additional questions. Such instruments can provide a diagnosis for about half of depressed people, an improvement over the 10% to 12% generally achieved by other survey instruments.

About half of persons who test positive by these tools still complain of depressive symptoms after they see their physicians and are candidates for treatment. Symptoms in the other half typically decrease, suggesting some depression and anxiety can result from patients' physical problems, according to Roger G. Kathol, FACP, professor of internal medicine and psychiatry and director of the medical-psychiatric program at the University of Iowa Hospital and Clinics. "That is one difference between depression seen in a psychiatric clinic and in a primary care clinic," Dr. Kathol said, which is why he recommends primary care physicians wait 10 to 14 days before starting depression medication.

The right attitude

Diagnostic instruments are useful, but having the right attitude toward depression is just as important. "It is not a problem of physicians not knowing what questions to ask, but of not being certain that they are worth asking or not being attuned to the fact that in this patient, depression might be an important area to pursue," said the University of Michigan's Dr. Schwenk. Primary care physicians should be "willing to entertain the diagnosis rather early without obscuring the rest of their medical thinking." He noted that some physicians, unfortunately, are not willing to explore parallel diagnostic tracks.

Dr. Marmorstein from USC said one key to diagnosing depression is to use a rigorous investigation of symptoms to rule out organic disease. "You can't really tell the difference between emotional problems and cancer of the colon just from listening to the patient," he said. If a workup provides no diagnostic findings, he may tell the patient, "Many people have a lot of tension in their life. Anxiety with or without depression can underlie the kind of symptoms that you have."

Bringing the patient to accept a diagnosis of depression can be a challenge, largely because of the stigma attached to mental illness. "It heightens the patient's resistance when the physician says it must be a psychiatric problem only after running into a dead-end with the organic approach," Dr. Schwenk said. As a result, he prefers to raise depression as a possibility early in the process. "I tell the patient that we have to look at all possibilities and one of the likely ones is depression. I make it part of routine medical care," he said. "My experience is that when I do that I get tremendous positive feedback."

Dr. Kroenke's research, however, has found that physicians may actually overestimate the stigma patients attach to a diagnosis of depression. "Although stigmatization is an issue in our society and asking about depression is different from asking about high blood pressure," he said, "in the confines of the doctor's office, more doctors have a fear of asking those questions than patients have of being asked. The majority of patients are not offended by them."

Treatment and referrals

Although convincing reluctant patients to proceed with treatment for depression can be difficult, there is good news: Development of selective serotonin reuptake inhibitors has helped make a major difference in the treatment of depression. Primary care physicians may feel more comfortable prescribing these new drugs because they have fewer side effects than tricyclics, Dr. Kroenke said. But internists should recognize that they are not a cure-all and that many patients respond better to tricyclics or to psychotherapy.

If a course of medication doesn't have the desired effect, primary care physicians should consider referral to a psychiatrist. John G. Costino Jr., DO, a family physician in private practice in North Wildwood, N.J., said he seeks an additional opinion in 15% to 20% of depressed patients. "I am looking both for assistance and a second opinion regarding the underlying diagnosis," he said. "But I may want a therapeutic consultation as well."

Dr. Kroenke said that physicians should think seriously about referring to psychiatrists any patient who is suicidal, displays bipolar disorder or psychotic depression including hallucinations and delusions, and patients for whom you have prescribed antidepressants but who also need to resolve some issues with talk therapy. He estimated about 5% of patients with major depression probably need to be referred.

Collaborative treatment

Working with others, the experts say, can be critical when dealing with depression. As a result, some hospitals and large clinics are adopting a model integrating consulting psychiatrists into the primary care milieu.

At Boston's Massachusetts General Hospital, psychiatrists working in the hospital's primary care psychiatric clinic evaluate and triage patients, conduct short-term monitoring of patients on psychotropic medications and lead therapy groups for patients with chronic medical illnesses. They also give seminars for primary care residents on medical/psychiatric issues and are available to residents and physicians for "curbside consults." Explained Carol Wool, MD, co-director of the clinic and an instructor in psychiatry at Harvard Medical School: "Our hope in this clinic is two-pronged. We want to provide education and enrichment for primary care physicians as well as consultation on their more difficult cases."

In a recently published trial conducted at the University of Washington School of Medicine in Seattle, a similar style of collaborative management of depression was shown to improve adherence to medication and symptoms. (JAMA, 1995; 273:1026-31.) In the study, patients diagnosed as depressed visited the medical school's primary care clinic twice over eight weeks and were given pamphlets and an educational videotape. In addition, they visited a psychiatrist twice in the primary care clinic during the first six to eight weeks to discuss issues like medication side effects.

Nearly 90% of the patients showed up for their psychiatric appointments, which researchers feel is directly linked to the fact that these visits were in the primary care clinic, not a psychiatric office. And while collaborative treatment increased costs about $450 per patient—about $150 of which was for greater medication use due to enhanced compliance—the project cut overall costs. Ongoing studies with this model are evaluating effects on patients' quality of life.

Experts hope that as group practices consolidate, they will adopt this type of collaborative model. As researchers from Seattle discovered, primary care physicians working in this type of environment reported that depression had become a more satisfying illness for them to treat. "Physicians want to get people better," said Wayne Katon, MD, who coordinated the study. "The more depressed people they help get better, the more satisfying it will be for them to treat depression." n

William A. Check, PhD, is a freelance writer living in Wilmette, Ill., who writes on medical and scientific topics.


SSRIs: good first-line agents in primary care

The new class of antidepressant agents, selective serotonin reuptake inhibitors (SSRIs), includes fluoxetine (Prozac), sertraline (Zoloft) and paroxetine (Paxil). Experts on depression advise that while SSRIs may not be more effective than tricyclic antidepressants, they should be considered first-line agents for primary care physicians because of their favorable side-effect profile.

"SSRIs are probably no more effective than the drugs that came out in the 1960s," said Jerome Marmorstein, MD, assistant clinical professor of medicine at the University of Southern California and an internist in Santa Barbara. "But they do have fewer atropine-like side effects, such as orthostatic hypotension and constipation, and are easier to prescribe because they can often be given once a day."

When judging whether these medications are working, the consensus is to give them time. Guidelines from the federal Agency for Health Care Policy and Research (AHCPR) recommend a full six-week trial of medication, and experts say to be patient.

"In my experience," said Steven Woolf, MD, a family physician in Fairfax, Va., "it takes longer than that. And you may need to titrate the dose upwards." (With suicidal patients, of course, more aggressive action, including hospitalization, may be indicated.) Although Dr. Woolf said he uses SSRIs, he said he also finds that a fair number of patients do better on tricyclics, particularly those who have problems sleeping at night.

Kurt Kroenke, FACP, associate professor of medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., warned physicians not to be too quick to overprescribe, particularly with patients suffering from minor symptoms of depression. "Because of time pressures there is probably a risk of overprescribing," he said. "We don't have evidence yet that patients with minor depression respond to antidepressants better than to placebo, only in major depression."

As a result, he said, in more than half of the patients he sees for depression, Dr. Kroenke doesn't prescribe anything at all during the first visit. Symptoms often subside after several visits, he noted.

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