Talking about depression in the family practice setting
Despite the fact that two out of every 10 patients sitting in your waiting room will suffer from depression at some point, this illness remains severely under-diagnosed (≤ 50%) and under-treated by physicians.1 There is, as yet, no blood test available to establish a diagnosis and the illness presents in a variety of ways. Patients are often unable to articulate what is wrong with them, and may be hesitant to talk about it even if they suspect depression because of the stigma still associated with mental illness. So how then, as busy family physicians, can we initiate a dialogue that will help identify patients suffering from depression and steer those who need it towards treatment?
A foundation for trust and openness
Educate all your patients about the signs and symptoms of depression, so that even if they have no concerns at the moment, they become aware of what to watch for in themselves and family members. This information can be shared quickly and will help reassure clients that if depression does become a concern, they can be comfortable talking about it with you.
Despite public awareness campaigns, a lot of stigma and fear still surround mental illness and this may prevent some patients from acknowledging that they need help. It is important to normalize the diagnosis, explain its prevalence (20 percent of Canadians will personally experience a mental illness in their lifetime according to the Canadian Mental Health Association)2 and the fact that it affects people of all ages, educational and income levels, and cultures. This is often eye-opening and reassuring.
It may be important to dispel some urban myths about depression, reassuring patients that a diagnosis does not mean they will be “locked up,” lose their children, be unable to travel, or that their employer will automatically be informed. While these ideas may seem preposterous, there is a lot of misinformation regarding depression that can scare people into suffering in silence.
Simple questionnaires that provide a quick screen for depression can be helpful in identifying behavioural changes, especially if used routinely. Three commonly used questionnaires include the Physical Health Questionnaire (PHQ-9), the Sheehan Disability Scale (SDS) and the Beck Depression Inventory (BDI). These types of questionnaires can help to initiate dialogue and highlight areas that require further exploration. It is important to use them to help with screening only, however, as they may lead to overdiagnosis if responses are not adequately followed up.
We need to be especially vigilant for depression in patients who are undergoing physiologic changes and life events known to increase risk for depression, such as pregnancy, the post-partum period and menopause. Make sure to really investigate complaints that could signal depression during those periods.
Medical illnesses also place people at increased risk. Patients with serious medical conditions such as heart disease and cancer may be encouraged to raise concerns if you point out that untreated depression can actually worsen physical outcomes (i.e. increase mortality post-heart attack).
Be aware of how culture and migration issues can impact the presentation of depression. A diagnosis can be missed because of issues like somatization, or an inability to talk about suicide. Diagnosis can also be missed if depressive symptoms in bereavement or after migration are attributed solely to these experiences. In such cases, a longer evaluation of symptoms such as appetite, sleep and energy changes may be required and the use of open-ended questions may be valuable.
Depression should not be ruled out simply because a patient answers “No” when asked “Are you depressed?” More productive dialogue might start by inquiring about when they last participated in favourite activities. The question “What do you think is happening?” can also initiate an exploration of possible mood disorders contributing to the ailment that brought them to your office.
Recognize that complaints regarding headaches, digestive problems, fatigue, irritability or chronic pain can sometimes indicate depression and may be a patient’s way of saying they are in distress. Use these openings as a way to explore mood symptoms as well.
Depression can look different in men than it does in women and may require other lines of questioning. It can be helpful to ask about changes in the use of unhealthy coping behaviours such as excessive alcohol consumption, reckless behavior such as speeding, escapist or solitarily behaviour through sports or work, and becoming quicker to anger.
Acceptance of treatment
A conversation about the fact that depression is an illness that can be treated and that earlier recognition and diagnosis will help improve outcomes may increase a patient’s willingness to take action. You can describe that there are a number of options within the treatment armamentarium, as clients may have fears about electro-convulsive therapy, or not want to be required to take a medication without being given other options.
In following up suspected depression, encourage patients to talk with family members, or even bring family members to an appointment. An individual may be unaware of how their behaviour has changed and a dialogue with those close to them in the somewhat formal context of a physician visit may give the patient (and you) greater insight.
Brush up on your knowledge and skills! There is no doubt that we need to get better at this. Earlier diagnosis and treatment of depression will help improve outcomes and reduce suffering.
Ronald Epstein et al. “I didn’t know what was wrong:” how people with undiagnosed depression recognize, name and explain their distress. J Gen Internal Med 2010;25(9):954-61
Fast facts about mental illness. Canadian Mental Health Association. www.cmha.ca. Website accessed September 2014.
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