Managed Care - March 2008 - (Page M15) Efficient and Effective Care of Depression In Medical Settings KURT KROENKE, MD Professor of Medicine, Indiana University School of Medicine Research Scientist, Regenstrief Institute “I am no better in mind than in body; both alike are sick and I suffer double hurt.” — Ovid (43 BC–17 AD), in Tristia items: two address the core symptoms of depression (depressed mood, anhedonia) and two the core symptoms of general anxiety disorder (feeling nervous or anxious, constant worrying). For patients who screen positive, the longer Patient Health Questionnaire Nine Symptom Checklist (PHQ-9) and the 7-question Generalized Anxiety Disorder (GAD-7) anxiety scale can be used for diagnostic and treatment monitoring (Spitzer 1999, Spitzer 2006). These instruments are based on criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). P atients with depressive disorders most likely are diagnosed and treated in a primary care setting. Efficient and effective care of these patients, though, is often complicated by the presence of comorbid medical and psychiatric conditions. The nine core symptoms of depressive disorders — • Loss of interest or pleasure (anhedonia) • Depressed mood Barriers to treatment • Feelings of guilt or worthlessness Two barriers to the effective care of de• Thoughts of death or suicide pression are stigma and concerns about • Sleep disturbances suicide. Society tends to view depression • Psychomotor disturbances as a personal failing. Further, people fear • Appetite changes that the label “depression” will diminish • Concentration difficulties their employment prospects and ability to • Feelings of fatigue or low energy obtain health and life insurance. The — are not necessarily equal in terms of stigma of depression has been lessened specificity. To make the diagnosis of desomewhat by the disclosure by numerpression in a patient with complex medious celebrities that they have suffered cal symptoms, it is important that the pafrom depression and received successful tient have at least one or several of the therapy for it, and by educational camdepression-specific symptoms, namely, KURT KROENKE, MD paigns informing the public that depresdepressed mood, anhedonia, guilt, and sion is similar to common medical conditions in that it suicidal thoughts. can be controlled if diagnosed and properly treated. Aside from the depressive phase of bipolar disorder, Primary care physicians often are reluctant to care for there are three types of depression: major, minor, and a patient with depression because of concerns about suidysthymia. A diagnosis of major depression requires the cide. Suicide risk can be assessed by asking a patient this presence of at least 5 of the 9 symptoms; minor depresqualifying question: Have you had thoughts you might be sion, 2 to 4 of the symptoms. The symptoms must be better off dead or of hurting yourself in some way? If the present nearly every day for at least 2 weeks. For a diaganswer is yes, three follow-up questions should be asked: nosis of dysthymia, the symptom count is the same as for (1) Do you have any specific plan of how you might hurt minor depression, but the required chronicity is much yourself? (2) Have you ever tried to hurt or harm yourself longer — more than 2 years. For any of these diagnoses, in the past? (3) How likely is it you will act on these one of the patient’s symptoms must be depressed mood thoughts? If the answers to all three questions are negaor anhedonia. tive, the patient often can be managed in primary care In primary care, the short self-administered questionrather than immediately referred to a psychiatrist. naire known as the PHQ-4 (Table 1, next page) is useful Just as primary care physicians have learned to decide for quickly screening patients for depression and anxiwhether a patient with chest pain can be safely sent home ety (Kroenke, in press). The PHQ-4 consists of four SUPPLEMENT / 2007 MEDICAL DIRECTOR COLLOQUY 15
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