REVIEW ARTICLE
DEPRESSION IN PRIMARY CARE
PART 1: SCREENING AND DIAGNOSIS
AM Zainab M Med (Psy)
XV Pereira M Psy Med
Drs Zainab Abd Majeed and Xavier Vincent Pereira are Senior Lecturers from the Department of Psychiatry, International Medical University, Seremban, Malaysia
Conflict of interest: none
One of the commonest psychological problems that a clinician would encounter in primary care is depression. The prevalence of depression is high in women, the elderly and those with underlying physical problems or during the postpartum period. The spectrum of clinical presentations is wide and somatic complaints are more common in primary care clinics. Depression may present as a primary disorder and co-morbidity with other psychological problems or physical illnesses is high. A good clinical interview is an important form of assessment and a quick screening of depression can be done with the administration of proper rating scales, such as the Patient Health Questionnaire, Hamilton Depression Rating Scale or Geriatric Depression Scale. Repeated use of the same scale in a patient would help the clinician to monitor the progress objectively.
Key words: Depression, primary care, diagnosis, screening
INTRODUCTION
Depression is a common psychiatric disorder with a reported lifetime prevalence rate between 8-16 per cent.1,2 It is associated with increased healthcare cost and disability.3 In primary care, it is more common in women, with the ratio varying from 1.5:1 to 2.6:1.4 However, recent trends show that the rates of depression are increasing with an earlier age of onset and some narrowing of the sex difference.4 The prevalence in pre-pubertal children is equal in boys and girls and increases to a 2:1 female-to-male ratio in adolescents.5 In Malaysia, a rural survey on psychiatric illness showed that depressive disorders were the commonest psychiatric illnesses identified with a point prevalence rate of 3.6%.6 The prevalence of depression among the elderly, when assessed using rating scales, was reported as 6.3 per cent7 and 13 per cent.8 The prevalence was also noted to be higher in the presence of underlying physical problems and during the post partum period.6
CLINICAL SPECTRUM OF DEPRESSION
The term depression describes dysphoric mood ranging from mild to severe and from transient to persistent.9 It can be differentiated from normal mood changes by the extent of its severity, the symptoms and the duration of the symptoms. The core symptoms of depressive disorder include depressed mood, inability to experience pleasure, a sense of helplessness, hopelessness, guilt and inhibition of behaviour and thinking. Other features that impair the social and occupational functioning include fatigue, anxiety, apathy and sometimes hostility towards self or others. In many patients, somatic symptoms are common; these are changes in sleep (either increased or decreased), appetite (increased or decreased), weight (increased or decreased) and loss of libido.10 Table 1 summarises the Diagnostic and Statistical Manual fourth edition (DSM-IV-TR)11 criteria for different types of depression in adults.
Some people with depression may experience unexplained pain, which is one of the reasons they go to their primary care physicians complaining of physical symptoms (e.g. musculoskeletal pain and fatigue) instead of saying that they are depressed. This is perceived as a more acceptable and less stigmatised reason to seek help. Therefore somatic complaints are ways of communicating any underlying distress.12
