Depressive Symptoms in Primary Care: Recognition and Assessment

1
Depressive Symptoms in Primary CareRecognition
and Assessment

• Sudha Prathikanti, MD
• UCSF Department of Psychiatry

2
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

3
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

4
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 gt16
• Carroll (20 questions) mod. depress gt19

5
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)

6
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

7
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

8
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

9
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

10
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/sp
  ecific