REVIEW ARTICLE
DEPRESSION IN PRIMARY CARE
PART 1: SCREENING AND DIAGNOSIS
Major depressive disorder
Major depressive disorder can be classified as mild, moderate or severe. Mild major depressive disorder refers to a condition where few symptoms present and result in minor impairment in social or occupational functioning. Severe major depressive disorder would have several symptoms and these symptoms markedly interfere with social and occupational functioning. Presence of psychotic features and suicidal ideation or attempts indicates severe major depressive disorder. The clinical features and functional impairment of moderate major depressive disorder fall in between mild and severe.
Adjustment disorder
Adjustment disorder is a common condition with a prevalence between 12-23 per cent and is usually characterised by mild depressive symptoms, anxiety symptoms, traumatic stress symptoms or a combination of these. The commonest is adjustment disorder with depressed mood which is self-limiting, once the stressor is over. If the stressor lasts for several years, there is a risk of developing more serious psychiatric disorder such as major depressive disorder, schizophrenia, schizoaffective disorder, bipolar disorder, alcohol dependence and drug use disorder within five years.13 Among the disorders, major depressive disorder and alcohol dependence are common and the co-morbidity of these two conditions is high. Hence, adjustment disorder may represent a sub-threshold clinical syndrome or a precursor to a more severe psychiatric disorder.13
Table 1. Clinical features of depressive disorders based on DSM-IV-TR11 criteria
| Adjustment disorder with depressed mood | Depressed mood, tearfulness or feelings of hopelessness occurring within 3 months of the onset of the stressor. May present with impairment in social or occupational functioning. |
| Major depressive disorder | Five or more of the following symptoms have been present during the same 2 week period representing a change from previous functioning:
Either (1) or (2) must be present. Melancholic features include loss of pleasure, lack of reactivity to usually pleasurable stimuli, depressed mood and depression regularly worse in the morning, early morning awakening (at least 2 hours before usual time of awakening), marked psychomotor retardation or agitation, significant anorexia or weight loss and excessive or inappropriate guilt. Atypical features include mood reactivity (i.e. mood brightens in response to potential positive events), increase in appetite, weight gain, hypersomnia, leaden paralysis (heavy feelings in arms and legs) and a long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment. |
| Dysthymia | Depressed mood for most of the days for at least a 2-year duration.
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| Bipolar disorder: Most recent episode depressed | Currently fulfils the criteria for major depressive disorder and there has been at least one episode of mania in the past. |
| Postpartum onset | Onset of depressive episode within 4 weeks postpartum. May be associated with psychotic features. |
Depression in children and adolescents
In children and adolescents, depression is frequently unrecognised5 and the presentation varies with age. Preschoolers express feelings of sadness in their behaviour such as apathy, being withdrawn or failure to thrive without any organic cause. School-aged children would display poor academic achievements, low self esteem, somatic complaints, anxiety symptoms and behavioural problems. Adolescents would exhibit more anhedonia, hypersomnia, weight change and substance abuse.5
Depression in elderly
Depression in the elderly can be difficult to detect because some of the symptoms overlap with symptoms of physical illness and at times, the clinical presentation is atypical and vague.14 Another possible reason is our own age-related bias especially among young physicians who often view depression in the elderly as a normal reaction to serious illness or disability,14 e.g. it is understood to feel depressed when an elderly person is sick, which makes the case seem as a ‘normal’ depression rather than ‘clinical’ depression. As a result, no proper assessment would be made.
Other types of depression
DSM-IV-TR mentions other types of depression and these are briefly mentioned below. In dysthymia, there are fewer symptoms than major depressive disorder but the duration is for more than one year for an adolescent and two years for adults. If a patient had at least one episode of mania in the past, and is currently depressed, then the diagnosis of bipolar disorder in depressed phase is made. Diagnosis of postpartum depression is made if the onset of depression is within 4 weeks of postpartum. Clinical features are similar to depression and guilt concerning babies is common.
