The Effective Management of Mood Disorders in Primary Care - Part II

Click here for Part I

The US Preventive Services Task Force found good evidence that screening improves the accurate identification of depressed patients in primary care settings and that treatment of depressed adults identified in primary care settings decreases clinical morbidity. Trials that have directly evaluated the effect of screening on clinical outcomes have shown mixed results.Small benefits have been observed in studies that simply feed back screening results to clinicians. Larger benefits have been observed in studies in which the communication of screening results is coordinated with effective followup and treatment. The USPSTF concluded the benefits of screening are likely to outweigh any potential harms.

What to look for in a depressed patient

For a number of reasons, patients most likely will not come out and say that they are depressed. Instead, they will present with complaints such as these:

• Constant sleepiness
• A case of the “blahs”
• Malaise
• Headaches
• Vague abdominal or joint pains
• Stress
• Sleep problems
• Sexual dysfunction or loss of sexual interest
• GI complaints (eg, constipation, diarrhea)
• Apathy
• Chronic pain

When looking for these symptoms, listen for certain key phrases that will also tip you off:

• “I think I need hormones.”
• “My husband thinks I need hormones.”
• “My wife made this appointment for me.’
• “I need a checkup (younger males).”
• “Could you prescribe some vitamins for me?”
• “By the way, could you give me something to help me sleep?”
• “How about that erectile dysfunction medication?”
• “I need something for stress.”
• “I think I have hypoglycemia.”
• “I want you to test me for everything.”
• “I don’t know what’s wrong with me.”

Screening toolsUSPSTF recommends a number of screening tests including:

• Beck Depression Inventory
• Zung Self-depression Scale
• Prime MD Patient Health Questionnaire
• Center for Epidemiology Study Depression Screen

"'Asking two simple questions about mood and anhedonia ('Over the past 2 weeks, have you felt down, depressed, or hopeless?' and "Over the past 2 weeks, have you felt little interest or pleasure in doing things?') may be as effective as using longer instruments."

If you want to be a bit less clinical, ask questions such as these:

• “How are things at work?”
• “How are things at home?”
• “Has your stress level increased lately? How are you handling it?”
• “How much are you drinking? Is that more than usual?”
• “What medicines are you taking?”
• “What OTCs and alternative medicines are you taking?”
• “Has anyone in your family suffered emotional or stress-related problems?”
• “Have you had problems like this before?”
• “Who do you have to talk to?”

Depression, of course increases a person’s risk of taking their life. A number of factors can contribute to this, including:

• Hopelessness
• The patient is Caucasian
• The patient is male
• Advanced age
• Living alone
• Substance abuse
• General medical illness
• Psychosis

When it comes to a patient’s risk of taking their own life, there are two more things to which you should give special consideration:

Prior expiration attempts

Of their previous expiration attempts, always ask the patient whether they intended to leave the world. This will give you better insight into how suspicious you should be of expiration risk in future episodes of depression.

Ways and means

When discussing a expiration attempt, have the patient get very specific about what they intend to do. If the patient claims to be committed to jumping off the top of the highest mountain on Catalina Island, but they have no means to get there, that’s a far less alarming situation than that of an old man who lives alone, drinks, and owns a handgun.