The physician should consider bereavement and substance abuse as possible causes of depression; bereaved patients who continue to meet criteria for major depression at 2 months often benefit from treatment. By that time, the sadness, poor concentration, and other symptoms associated with normal grief are no longer constant and occur in waves brought on by memories. Conversely, persons also suffering from depression report these symptoms as enduring and autonomous.18
The primary care physician also should inquire about agitation and symptoms of anxiety disorders. These are experienced by 85% of depressed patients; 50% have comorbid anxiety disorders.19-21 Identification of such comorbidity is helpful in determining treatment, evaluating response, and managing patients over the long term. The Prime-MD, available in multiple languages, is also useful for screening for both anxiety and substance abuse, which can complicate both the recognition and treatment of comorbid depression.9
Sexual function is often affected by depression. The physician should inquire about sexual arousal, erection or lubrication, and orgasm during the initial assessment.22 Approximately 50% of women and 40% of men with major depression report sexual-arousal problems, and 15% to 20% report orgasm problems during the month prior to diagnosis.23 Further questioning can assess whether this dysfunction is caused by another disorder (eg, diabetes) or whether it is part of the depressive syndrome. This provides a baseline for later assessment of side effects and treatment effectiveness, and it communicates to the patient that the physician will be attentive to this area. In discussing sexual function with depressed patients, it may be helpful to tell patients that a study of the effectiveness of treatment of depression with selective serotonin reuptake inhibitors (SSRIs) found that patients reported modestly improved sexual function with treatment.24
TABLE 1 Screening for depression
Outpatient adults
Over the past 2 weeks, have you felt down or hopeless?
Over the past 2 weeks have you felt little interest in doing things?
Postpartum women (Edinburgh Postnatal Depression Scale)
1. I have been able to laugh and see the funny side of things
— As much as I always could (0)
— Not quite so much now (1)
— Definitely not so much now (2)
— Not at all (3)
6. Things have been getting on top of me
— Yes, most of the time I haven’t been able to cope at all (3)
— Yes, sometimes I haven’t been coping as well as usual (2)
— No, most of the time I have coped quite well (1)
— No, I have been coping as well as ever (0)
2. I have looked forward with enjoyment to things
— As much as I ever did (0)
— Rather less than I used to (1)
— Definitely less than I used to (2)
— Hardly at all (3)
7. I have been so unhappy that I have had difficulty sleeping
— Yes, most of the time (3)
— Yes, sometimes (2)
— No, not very often (1)
— No, not at all (0)
3. I have blamed myself unnecessarily when things went wrong
— Yes, most of the time (3)
— Yes, some of the time (2)
— Not very often (1)
— No, never (0)
8. I have felt sad or miserable
— Yes, most of the time (3)
— Yes, quite often (2)
— No, not very often (1)
— No, not at all (0)
4. I have been anxious or worried for no good reason
— No, not at all (0)
— Hardly ever (1)
— Yes, sometimes (2)
—Yes, very often (3)
9. I have been so unhappy that I have been crying
— Yes, most of the time (3)
— Yes, quite often (2)
— No, only occasionally (1)
— No, never (0)
5. I have felt scared or panicky for no very good reason
— Yes, quite a lot (3)
— Yes, sometimes (2)
— No, not much (1)
— No, not at all (0)
10. The thought of harming myself has occurred to me
— Yes, quite often (3)
— Sometimes (2)
— Hardly ever (1)
— Never (0)
Reprinted with permission, from Cox JL et al. British Journal of Psychiatry. 1987; 150:782-786.
Management of major depression
The acute management of the patient with major depression includes patient education, shared decision-making regarding a treatment modality, supportive counseling, and treatment-specific counseling.25 Education and counseling should extend over the initial weeks of treatment and be combined with monitoring response, identifying and managing any treatment-emergent side effects, and adjusting medications. Long-term management goals include attaining full remission of symptoms, assisting the patient to return to full functional status, integrating depression care with the treatment of other chronic illnesses, maintaining or tapering pharmacologic treatment, and monitoring for and preventing relapse or recurrence.
Education
Education should help patients understand and accept the diagnosis, reduce any stigma they or their families might attach to major depression, and build increased adherence to subsequent treatment.26 It might be helpful to provide a brief explanation of the biologic basis of depression (including biochemical changes in brain function and “chemical imbalances” of serotonin and other neurotransmitters). Explaining pharmacotherapeutic effects (if medication is desired) as mechanisms to help rebalance brain chemistry further emphasizes the biologic basis of depression and decreases any perceptions that depression is a result of moral or character weakness. This educational message should also stress that antidepressants are not habit-forming or addictive, are not “uppers” or “downers,” and are not tranquilizers. The physician also should convey a positive prognosis but note that several weeks and, possibly, adjustments in treatments, may be required. For patients choosing antidepressants, the McArthur Foundation Initiative has identified 7 key educational messages (Table 2).27
