Making the Diagnosis of Depression in the Primary Care Setting Steven Cole, MD, Mary Raju, RN, MSN, Glen Oaks, New York

pproximately A 50% of the depressed patients seen in primary care do not receive adequate diag-

nosis or treatment. l-3 Recent studies have ques- tioned the validity of these findings, arguing that many “unrecognized” or “inadequately treated” de- pressions are mild disturbances that remit sponta- neously without the physician’s attention.4s5 While it seems true that recognized depressions do tend to be more severe than unrecognized depressions, lon- gitudinal outcome studies conflrm that even mild de- pressions can persist for long periods of time and are associated with significant impairment in func- tion.6,7 Furthermore, even when depression is diag- nosed and treated in primary care, outcomes in t,he naturalistic setting are not satisfactory: recovery rates for treated depression in primary care approx- imate 50%, compared to about 80% in protocol-driven intervention studies.**’

These findings are hardly new or unfamiliar. Sim- ilar results and recommendations have been replete in the professional literature for decades.‘“-” De- spite years of continuing attention, however, the problem of underdiagnosing depression or anxiety, substance abuse, or somatization persists.

The case for improving recognition and treatment of mental disorders in primary care remains no less compelling than it was 30 years ago: 20-40% of med- ical outpatients suffer from significant mental dis- orders13; these disorders are associated with signifi- cant disability, morbidity, and mortality“‘-‘“; and about half of these patients will receive their only mental health care from their general medical phy- sicians. l7

Why has the goal of achieving adequate recogni- tion and management of depression in primary care been so elusive? Modifying professional behavior re- quires overcoming complex and multifactorial obsta- cles to change. These include pat.ient and physician factors at the clinical level, and administrative and societal issues at a more structural level. In a recent communication, we described 10 barriers to recog- nition and management of ment,al disorders in pri-

ish Medical Center, Glen Oaks, New York.

partment of Psychiatry, HIllsIde HospitalLong Island Jewish Medical Cen-

6A-10s 01996 by Excerpta Medica. Inc. All rights reserved.

mai-y care: the culture of medicine; the stigma of mental illness; the “fallacy of good reasons”; time constraints; administrative and structural problems; financiaI disincentives; somatization; knowledge def- icits; problematic communication skills; and diffl- culty in changing ingrained habits of be:havior.3 So- lutions must be found for all these barriers before primary care physicians will be able to provide truly adequate care of their depressed patients.

Despite these obstacles, several recent develop- ments offer some hope that professional practices may begin changing. The treatment of uncompli- cated mental disorders in primary care is now more feasible than ever before. The development of more precise diagnostic taxonomies, l8 along with assess- ment tools tailored to primary care,13S1g-20 have made evaluation more efficient and pragmatic. The introduction of new psychotropic agents that are safer and easier to prescribe, and better tolerated by patients, has also made primary care manage- ment more reasonable. Finally, these scientific advances, coupled with the new marketplace and managed care demands for clinical and economic efficiency, make the impetus for change more compelling.

In this article we will (I) describe the 10 barriers discussed above and offer possible solutions; (2) present diagnostic criteria for the three t.ypes of de- pressive disorders of most relevance to the primary care physician; (3) discuss problems of differential diagnosis; and (4) describe screening instruments and interviewing strategies for assessing mood dis- orders.

BARRIERS TO RECOGNITION The culture of medicine today is predominantly

“biomedical”; that is, the mind and body are seen as separate entities, and medical problems are viewed as essentially physical and molecular in nature.” Mental problems are associated with stigma, which leads both patients and physicians away from deal- ing with them. Changing culture and stigma will re- quire the widespread acceptance and practical ap- plication of a biopsychosocial model of illness in which psychological and social variables are seen as central elements of the predisposition, onset, course, and outcome of all illnesses (physical or mental).”

The “fallacy of good reasons” leads patients and physicians erroneously to explain away emotional

0002-9343/96/$15X PII SOOO2-9343(96)00395-2

distress as an “understandable” reaction to life stresses or physical illnesses. This misunderstanding leads to misdiagnosis and/or nontreatment of true mental disorders. A more useful way of conceptual- izing mental distress (and associated mental disor- ders) in the context of co-occurring life stress or physical illness would be to view depressive syn- dromes as “dread” complications of life stress or physical illness and deserving of aggressive assess- ment and management in their own right.

Time constraints represent real barriers to diag- nosing and treating depression in primary care. When the average appointment time is 10 minutes, for example, there is precious little time available for assessing, educating, and managing depressive dis- orders. Because mental disorders are also associated with emotional turmoil, physicians tend to avoid ad- dressing them for fear of opening a “Pandora’s box” that cannot be closed within a reasonable period of time. However, primary care physicians who learn the efficient use of good communication skills are actually able to improve the accuracy with which they detect mental disorders, achieve improved clin- ical outcome in patients, and keep their total inter- viewing time with patients unchanged.23 Good communication skills, in addition, can help physi- cians save time by avoiding the “oh, by the way doctor. . . ” question that occurs at the end of 20% of all medical interviewsZ4

Patients with mental disorders in primary care usually present with somatic symptoms that mask their true disorders. This phenomenon of “somati- zation” presents problems for patients and physi- cians alike. Clinicians and patients are concerned about missing serious physical illnesses. Further- more, since patients truly experience pain and other physical symptoms, they understandably do not readily accept a psychiatric explanation for their problems. Physicians need to develop skills to edu- cate patients to understand the physical manifesta- tions of mental disorders.

Administrative and social barriers also interfere with good clinical care of mental disorders in pri- mary care. Patients and physicians may avoid di- agnostic labeling because of realistic fears of em- ployment or insurance discrimination. Legislative remedies may be necessary to reverse these prac- tices and protect individuals with mental disorders.

Financial disincentives also play a role in under- recognition. Many insurance plans reimburse the pri- mary care treatment of mental disorders at lower rates, or not at all. Other plans “carve out,” such dis- orders to other providers. In many cases, these op- erate as effective disincentives to adequate clinical care. Creative economic and clinical formulas must be devised to align financial incentives in such a way

as to maximize good treatment of uncomplicated mental disorders in primary care and to refer com- plicated problems for specialty mental health care.”

Even if all these other barriers are adequ.ately ad- dressed, considerable new knowledge and skill is still required on the part of the primary care physi- cian to assess accurately a patient’s physical prob- lems as well as to explain the relationship of mental disorders to physical symptomatology. Special edu- cational and motivational interventions are also nec- essary to enlist the patient’s cooperation with treat- ment planning.

Finally, ingrained patterns of behavior will need to change. If knowledge and skill barriers, as well as cultural and structural issues, are resolved, physi- cians and patients will simply need to overcome hab- its that emphasize the physical and de-emphasize the psychological in the medical context. Routine screening procedures, regular feedback, repeated educational interventions, and financial incentives can all be utilized in an effort to alter physician be- havior.

TYPES OF DEPRESSION: MAJOR, CHRONIC (DYSTHMIA), AND MINOR

There are three types of depression that should be recognized and managed by the primary care physi- cian. Major depression is the most important be- cause of its associated disability and eminent treat- ability. Chronic depression is also com.mon, but fewer data are available concerning its treatmentz6 Minor depression (adjustment disorder with de- pressed mood, mixed anxiety-depression, and de- pressive disorder not otherwise specified, (etc.) is by far the most common depressive disorder in primary care, but much less is known about its prevalence, associated disability, and treatment.27

Major Depression There are nine cardinal signs and symptoms of ma-

jor depression” (Table I). We have found it useful to group these symptoms into four central hallmarks. In order to reach the threshold for the diagnosis of major depression, patients must have a total of five symptoms over a 2-week period of time, with one being depressed mood or anhedonia.

Depressed mood. Feeling down, sad, or “blue” is the most common and relatively straightforward symptom of depression. While sadness is, a ubiqui- tous feeling and very human experience, the dys- phoric mood of major depression must be present nearly every day, for most of the day, and for at least 2 weeks. Physicians can ask patients directly some- thing like, “Have you been feeling down in the dumps, blue, or sad?”

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TABLE I I Signs and Symptoms of Depression

The diagnosis of major depression requires the patient to have 5 out of the following 9 symptoms. One of the 9 must be either a depressed mood or pervasive loss of interest or pleasure. For a symptom to be counted, it must be present most of the day, nearly every day, for a Z-week period of time.

1. Depressed mood 2. Loss of interest in pleasure 3. Weight loss or gain (or appetite loss or gain) 4. Sleep difficulty 5. Fatigue 6. Psychomotor retardation or agitation 7. Trouble concentrating or indecisiveness 8. Low self-esteem or guilt 9. Thoughts of death or suicidal ideation

Anhedonia. Anhedonia refers to loss of interest or pleasure in living. This is the second hallmark of major depression, and for primary care physicians, the assessment of anhedonia may be the most im- portant intervention that will be made. Since many medical patients feel a stigma associated with men- tal disorders and because depressive illness is often experienced as a physical problem, patients will of- ten deny the presence of a depressed mood. Even for patients who do not deny a depressed mood, they may rely on the “good reasons” argument to explain away a depressed mood because there may be some concurrent life stress or physical problem. For this reason, the presence of anhedonia may be the most valuable diagnostic marker of depressive illness in primary care patients.

In our experience, the single most useful screen- ing and assessment question a primary care physi- cian can ask a patient is something like, “What do you enjoy doing these days?” or “What do you do for fun?” Patients who deny depressed mood often ac- knowledge profound anhedonia, a total or almost to- tal absence of interest or pleasure in their lives. Such an acknowledgment is a valuable clue to the pres- ence of major depression.

Physical symptoms. There are four central phys- ical symptoms of depression: sleep disorder (too much or too little), low energy, poor appetite or weight loss, and psychomotor agitation or retarda- tion. The physical symptoms of depression are im- portant because, when present in depressive illness, they are predictors of good response to antidepres- sant medications. However, in the context of chronic physical illness, they can confound the diagnostic process. ” For example, when a patient has terminal cancer, clinicians do not often know whether to “count” symptoms that may be secondary to the physical illness (e.g., anorexia) toward the five symp- toms needed to confirm the diagnosis of major de- pression. The third revised edition of the American

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Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) used an “etiologic” rule and suggested that clinicians dis- count symptoms judged to be secondary to a con- current physical illness.

Because of the difficulty in making this distinction in clinical practice, DSM-IV switched to an “inclu- sive” approach, allowing clinicians to count all symptoms, regardless of inferred etiology, toward the diagnosis of depression.” We support this ap- proach for its improved clinical utility. In DSM-IV, however, if the entire clinical picture can be best explained as the direct physiologic consequence of a general medical disorder or medication, the mood disorder should be diagnosed as “depression sec- ondary to a general medical condition, or medica- tion.”

Psychological symptoms. There are three psy- chological symptoms of major depression: trouble concentrating or indecisiveness, low self-esteem or guilt, and recurrent thoughts of death or suicidal ide- ation.

Chronic Depression (Dysthymia) Chronic depression, or dysthymia, represents a

condition that is less severe than major depression but is relatively persistent and chronic. P,atients with chronic depression are much more likely than others to experience episodes of major depression. The di- agnosis of dysthymic disorder requires a full 2 years of disorder, with a depressed mood or anhedonia present more days than not. The diagnosis also re- quires the presence of two other symptoms of de- pression on a chronic basis.

Minor Depression Adjustment disorder with depressed mood, mixed

anxiety-depression, and depressive disorder not otherwise specified, may be categorized as minor de- pression. Minor depressions are by far the most com- mon depressive conditions in primary care. This di- agnosis probably represents a very heterogeneous group of patients. The severity of the condition is less than major depression and it is less chronic than dysthymia. Prevalence may be as high as lo-20% of primary care practice. Despite the fact that minor depressions are less severe and less chronic than the other types of depression, they are still. associated with signillcant disability.” Unfortunately, not much scientific data exists to guide treatment interven- tions at this stage of our understanding. The diag- nosis can be made if the patient experiences signif- icant depressive symptomatology th.at impairs function. 18,2o

DIFFERENTIAL DIAGNOSIS In evaluating patients for depressive illnesses, the

primary care physician typically faces some common problems in differential diagnosis. Some physical conditions and medications for physical illnesses can cause depressive symptoms. Many patients with anxiety disorders, personality disorders, substance abuse, or somatoform disorders also present with depressive problems. Finally, patients grieving sig- nificant losses experience depressive symptoms that create diagnostic difficulties.

Depression Secondary to Medical Condition or Medication

Table II lists several general medical conditions and medications used for physical conditions that can cause depressive symptoms. Physicians should maintain a high index of suspicion that undiagnosed physical illness or other medications may be causing depressive symptoms at any point. A careful history and physical exam is therefore necessary to rule out such etiologies.

Other Mental Disorders: Anxiety, Personality, Substance Abuse, or Somatoform Disorders

The careful physician will focus on the signs and symptoms of major depression separately and rule out the diagnosis of depression, whether or not signs and symptoms of other psychiatric disorders are present. Thus, depressive illness can and should be diagnosed, regardless of the presence of other symp- toms or other comorbid general medical or psychi- atric disorders. In current medical practice, compli- cated comorbidities may actually be more common than simple presentations.” The presence of com- orbidities are important to discern, however, be- cause such patients are more difficult to treat and often require complex modifications of management regimens.

Therefore, in order to assess and manage de- pressed patients effectively, primary care physicians must not only be familiar with the diagnostic criteria for depression, but must also have some familiarity with presentations of anxiety, substance abuse, per- sonality disorders, and somatoform disorders.

Anxiety symptoms, and anxiety disorders such as panic, phobias, generalized anxiety disorder, and ob- sessive-compulsive disorder, are common in de- pressed patients. Panic disorder is marked by sud- den, unexpected and overwhelming anxiety attacks accompanied by physical symptoms, such as tachy- cardia, shortness of breath, sweating, gastrointesti- nal distress, tremulousness, and a sense of impend- ing doom. Phobias of being alone, of public speaking, of going out, of being trapped in lines or on elevators,

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4: Medlcatlons and Illnesses Most Commonly Associated

Medical illnesses Carcinoid Carcinomas (pancreas) Cerebrovascular disease (stroke) Collagen-vascular disease Endocrinopathies Lymphomas Parkinson’s disease Pernicious anemia Viral illness

Medications Antihypertensives (reserpine, a-methyldopa, P-blockers) Benzodiazepines Barbiturates Corticosteroids Levo-dopa Psychostimulants (on withdrawal) Analgesics Chemotherapeutic agents

for example, are also common. Obsessions are re- curring thoughts that trouble an individual (like thinking about the impulse to shout out loud in crowded theatres), while compulsions represent re- petitive behaviors that cannot be controlled, like handwashing or repetitive checking of locks on doors. The recognition of anxiety symptoms or dis- orders is important to make in the context of de- pression, because treatment becomes more complex and modifications may be indicated.

Similarly, depression in the context of substance abuse, personality disorder, or somatofolm disor- ders is also much more difficult to manage than un- complicated depression. Patients who abuse alcohol or other chemicals often present to primary care physicians with a myriad of actual and psychogenic physical complaints. In such cases, a focused diag- nostic approach can be helpful. Patients should gen- erally be treated for substance abuse prior to treat- ment of the depressive illness.

Personality disorders represent long-standing pat- terns of coping that are deeply ingrained and quite resistant to change. Patients with dependent, bor- derline, narcissistic, and histrionic personality dis- orders often develop depressive symptoms or ill- nesses at the time of significant stress. A variety of psychotherapies or psychotherapeutic interventions may be recommended for patients with personality disorders, but empirical outcome data are quite lim- ited for most personality disorders. However, phy- sicians should be aware that personality factors in the presence of depression can make effective treat- ment quite difficult.

Finally, many patients with somatoform disorders may develop depression. Somatoform disorders re-

fer t,o a group of conditions (somatization disorder, conversion disorder, hypochondria&, body dys- morphic disorder, and pain disorder) characterized by significant unexplained physical symptoms. About 50% of patients with somatization disorder (the most severe and chronic of the somatoform dis- orders) develop major depression at some point in their lives3” The presence of a comorbid somato- form disorder will complicate the management of de- pressive illness, because the expectations for com- plete resolution of symptoms must be modified. Because patients with somatoform disorders often maintain a psychological “addiction” to some of their symptoms, complete remission should not, be expected.

Grief Grief reactions often present with symptoms sim-

ilar to major depression. The diagnosis of major de- pression can be used if the full depressive syndrome is present 2 months after the loss. Furthermore, the diagnosis of major depression can also be consid- ered if the grieving individual experiences marked impairment in function, has unreasonable feelings of guilt, significant preoccupation with thoughts of death, marked psychomotor retardation, or morbid preoccupation with feelings of worthlessness.““”

SCREENING INSTRUMENTS AND DIAGNOSTIC TOOLS

Several screening instruments have proved useful to primary care physicians in the detection of de- pression. These are generally self-administered by patients and filled out in the waiting room. The Beck Depression Inventory, the Zung ,Depression Scale, and the Center for Epidemiologic&,Studies Depres- sion Inventory (CESD)“’ scale are all short one- or two-page scales that can be completed by the patient and reviewed by the physician at the current visit. Physicians should be clear that these screening tools measure depressive symptoms and are not diagnos- tic tools. Their sensitivity for the detection of de- pressive disorders is high, but their specificity is lower, with many false-positives. Before making a diagnosis of depression, the primary care physician must conf5-m the screening test results in the clinical context of the patient’s presentation. ‘\

Two other diagnostic aids produced by pharma- ceutical companies have recently become available. PRIME-MD (developed by Pfizer-Roerig) consists of a patient-completed screening questionnaire, which, if positive, is followed by a 5- lo-minute, structured diagnostic interview by the physician.‘“14 Similarly, SDDS (developed by Upjohn) also has a two-part ap- proach: a screen followed up by a short directed di- agnostic interview by a trained clinician.‘” Each of

these instruments has the advantage of adding effi- ciency and effectiveness to the assessment process. However, such aids should be seen as helping the physician make a diagnosis and not as replacing the assessment process.

Finally, several primary care organizations re- cently joined with the American Psychia.tric Associ- ation in developing a diagnostic taxonomy for men- tal disorders in primary care (DSM-IV PC).” This manual represents an abbreviated, yet diagnostically compatible version of DSM-lV for use in primary care settings. Different from the screening instruments described above, DSM-IV PC is a rather complete taxonomy and reference guide for primary care phy- sicians treating mental disorders.

INTERVIEWING STRATEGIES Regardless of the sophistication and te8chnology of

diagnostic aids, the key to effective assessment of depression in primary care will always remain the medical interview. The physician-patient relation- ship is the cornerstone of medical care, particularly for the management of mental disorders. The three functions of the interview are all relevant: data-gath- ering strategies, emotional response and rapport-de- velopment interventions, and education and behav- ior management techniques.32

Data Gathering Strategies Open-ended questioning, facilitathn, and sur-

veying. In conducting the interview, the physician must avoid early interruptions and prelmature clo- sure. Part of the reason that the diagnosis of depres- sion is missed rests in the tendency of primay care physicians to reach premature closure concerning patient problems. One study found thalt internists tended to interrupt their patients, on the average, within the first 18 seconds of the interview.‘3 These interruptions served to divert patients from their agenda to the physician’s agenda in such a way that most patients did not get to inform their physicians of all their problems. Allowing patients to complete opening statements may reveal clues helpful for the diagnosis of depression.

The most efficient and effective way for the phy- sician to obtain a complete and accurat.e history is to rely on the use of three specific data-gathering skills: open-ended questioning, facilitation, and SIX-

veying. Open-ended questions, as opposed to closed questions, cannot be answered with one word, or “yes” or “no.” Since the universe of possible patient problems is so large, physicians will be much more efficient by utilizing open-ended questioning at the beginning of an interview. Allowing patients to “tell their own story” gives physicians a better window into problems than a series of closed “yes/no” ques-

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tions. Asking focused open-ended questions inquir- ing into the impact of a patient’s symptoms on his/ her life has been shown to be associated with greater rates of detection of mental disorders.“* Physicians can also improve their detection rates of mental ill- ness by asking questions about the patient’s expec- tations for the visit, such as “Can you tell me what you would like to achieve as a result of this visit?’

Facilitation refers to any intervention by physi- cians that keeps patients talking in a productive manner. Examples of facilitative techniques include such statements as “tell me more about . . . ,” as well as nonverbal expressions of interest, attentive silence, head-nods, and comments like “uh-huh,” or “go on.”

Finally, surveying includes explicit questions by the physician to make sure all the patient’s problems have been brought forth. The prototypical survey question is simply, “What else is bothering you?” For physicians to survey problems requires the repeti- tion of this question until the patient indicates that all problems have been mentioned. We have sug- gested that this surveying activity occur early in the course of the medical interview to ensure that the physician and patient together have time to negotiate the problems that will be addressed in any one par- ticular interview. For example, it is possible that the patient may mention 8 or 10 problems that cannot possibly all be adequately addressed in one short in- terview. In such an event, the physician and patient together can negotiate a prioritization of which prob- lems should be addressed most thoroughly.

Managing the time. While some physicians may have the sense that such approaches lengthen the medical interview, there is clinical and research ev- idence suggesting precisely the opposite. The skillful use of open-ended questioning, facilitation, and sur- veying actually proves more efficient for the elicita- tion of complete data and does not take more time.“3 In fact, such skills may actually save both time and frustration on the physician’s part. For example, up to 20% of all medical interviews are marked by a con- cluding question on the patient’s part such as “Oh, by the way doctor. . . .“‘* These questions are often frustrating and time-consuming for physicians. At times, such questions indicate the real, or most im- portant, underlying reason precipitating the visit to the physician. Surveying techniques utilized early in the interview tend to reduce these end-of-the-inter- view questions and actually save time.

These data-gathering skills are not only more ef- ficient and effective as general interviewing tech- niques but, when utilized routinely, can increase the physician’s detection of mental disorders. A recent Shour training program for primary care physicians demonstrated significant improvement in detection

rates for physicians trained in the use of these skills.23

Responding to Patient Emotion Improving data-collection skills is key for the ade-

quate recognition of depression in primary care. However, data collection is necessary but not suffi- cient for the goal. Depressed patients feel significant emotional turmoil, and physicians often avoid ad- dressing such issues for fear of “opening Pandora’s box.” Physicians fear that discussing deprlessive ill- ness with patients can unleash a torrent of emotional distress as well as anger at the physician for bringing up a mental disorder in any way.

This anxiety on the physician’s part is common, natural, and understandable, given the culture of medicine and the time constraints physicians face. Unfortunately, avoiding emotional issues leaves pa- tients dissatisfied and can lead to missed diagnoses. Is there any solution?

Part of the solution rests in emotional response skills that can be learned. Many, perhaps most, phy- sicians already possess intuitive emotional response skills that “work” for many patients. Dealing with illness, physicians cannot help being confronted on a daily basis with suffering, sadness, and anxiety. Physicians develop habits and skills for dealing with these emotions that often work well. However, be- cause these skills have been individually dleveloped, usually on an intuitive basis, physicians are often un- able to utilize the skills in situations that become complex or difficult for them.

Fortunately, we have found that by developing a few specific emotional response skills, physicians are better able to cope with a patient’s emotional distress in an efficient manner. That is, patients are allowed to vent and express their distress, but phy- sicians can learn techniques to express empathy in a relatively time-efficient manner that helps develop rapport, partnership, and patient satisfaction. Such outcomes facilitate good medical care.

Examples of emotional response skills include re- flection, legitimation, support, partnership, and re- spect3” All these interventions represent statements and not questions. Reflection indicates an interven- tion in which the physician reflects an observed feel- ing state back to the patient. For example, “I can see that this issue is a problem for you,” or “I can see you feel down in the dumps.” Reflective comments usually encourage the patient to vent. A series of em- pathic comments during patients’ expressions of feeling can help solidify the relationship and en- courage partnership for treatment planning. Legiti- mation indicates statements that let thle patient know that his/her experience is normal or under- standable, for example, “I want you to know that

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many people would feel just like you in these cir- cumstances.” Support refers to statements that let the patient know that the physician is ready to offer personal help for the problems discussed. For ex- ample, “I am here to help you with this problem and you can count on me for that.” Partnership state- ments reinforce the doctor-patient relationship and the collaborative nature of interventions: “I plan to listen to the rest of your problems, and after that is completed, you and I together will develop a plan that I believe will help you a great deal.” Finally, re- spect refers to statements that directly praise the pa- tient for positive efforts or accomplishments. For ex- ample, physicians can say something like, “I am impressed with the way you are coping at home and work, despite how badly you feel.”

Educating the Patient Many physicians avoid diagnosing depression be-

cause of the anticipated trouble or hostility they may encounter in trying to explain this disorder to a re- sistant patient. A few specific educational strategies, however, can be very helpful in the process of pa- tient education. When physicians feel more confl- dent in their ability to overcome stigma and resis- tance, they feel more empowered to devote more attention to the diagnosis of depression.

First of all, physicians need to support the pa- tient’s somatic perceptions and experience. Patients who feel pain, fatigue, or bizarre sensations are not lying or pretending. When confronted with a diag- nosis of depression in the context of somatization, many patients will say something like, “You must think this is in my head!” or, “You don’t, believe my pain is real!” The best response for the physician is something like, “Of course I believe your pain is real, and I know you are suffering. However, my history, physical exam, and laboratory studies support my impression that these symptoms do not result from a serious medical condition. I believe you are suffer- ing from a very treatable depressive disorder.”

Finally, it can be helpful for physicians to establish a baseline of information (or misinformation) the pa- tient may have about depression. The physician can ask something like, “What is your understanding of depression?” This question allows physicians to elicit patient attitudes toward depression and gives the physician the opportunity to correct misunder- standings. In the process of education, physicians should take steps to make sure the patient under- stands that depression is a common problem in both men and women, that it is a medical condition (like other medical conditions such as diabetes or hyper- tension), that it is not related to personality weak- ness, and that it is highly treatable.

SUMMARY Making the diagnosis of depression in the primary

care setting represents a challenge and an opportu- nity. With the numerous cultural, administrative, so- cial, and financial obstacles to the assessment and management of mental disorders in primary care, it is a small wonder that so much treatment of depres- sion actually does occur. However, much depression is missed, and even when the diagnosis is not missed, many depressed patients do not receive adequate treatment. This article reviews the different depres- sive conditions of importance that present in pri- mary care, discusses complexities of differential di- agnosis, and underscores the importance of the medical interview itself for eliciting relevant data, developing rapport, and educating the patient about the key issues of importance relevant to the man- agement of depression.

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December 30, 1996 The American Journal of Medicinea Volume 101 (suppl CiAl 6A-17s