Download depression1 - Sudha Prathikanti

Depressive Symptoms in
Primary Care:
Recognition and Assessment
Sudha Prathikanti, MD
UCSF Department of Psychiatry
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
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
before dying
 50% of suicide completers visit PMD
month before dying
1 wk
1
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 >16
 Carroll (20 questions) mod. depress >19
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)
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
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
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
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
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/specific