Overview The clinical practice guideline statements contained in Depression in Primary Care were developed to assist patients and primary care practitioners in the detection and diagnosis of depressive conditions and the treatment of major depressive disorder. This guideline is an abbreviated version of a far larger Depression Guideline Report and is divided into two volumes: this one, Volume 1: Detection and Diagnosis, and its companion volume, Volume 2: Treatment of Major Depression. The Depression Guideline Report contains more than 3,500 relevant references. Detection and Diagnosis systematically reviews the diagnosis of depressive and other mood disorders, according to the current U.S. standard system in Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) (American Psychiatric Association, 1987). The disorders reviewed include both unipolar forms of primary mood disorders (e.g., major depressive disorder, dysthymic disorder), depression not otherwise specified (DNOS), and bipolar forms of primary mood disorders (e.g., bipolar I disorder, bipolar disorder not otherwise specified, cyclothymic disorder). The co-occurrence of depression with other nonmood psychiatric disorders and with other nonpsychiatric medical conditions is also considered, as is depression caused by medications. Finally, the guidelines offer a strategy for making a differential diagnosis of depression, including risk factors and clinical clues, use of laboratory and psychological tests, and ongoing clinical reassessment. A clinical depression or a mood disorder is a syndrome (a constellation of signs and symptoms) that is not a normal reaction to life's difficulties. Mood disorders involve disturbances in emotional, cognitive, behavioral, and somatic regulation. A sad or depressed mood is only one of many signs and symptoms of clinical depression. In fact, the mood disturbance may include apathy, anxiety, or irritability in addition to or instead of sadness; also, the patient's interest or capacity for pleasure or enjoyment may be markedly reduced. Up to one in eight individuals may require treatment for depression during their lifetimes; up to 70 percent of psychiatric hospitalizations are associated with mood disorders. According to data based on a 1980 population base, the total number of cases of major depressive disorder among those 18 or older in a 6-month period is 4.8 million; in addition, over 60 percent of suicides can be attributed to major depressive disorder. Based on 1980 data, mood disorders account for more than 565,000 hospital admissions, 7.4 million hospital days, and 13 million physicians' visits annually. The total cost of mood disorders to society, including indirect costs that result from lost productivity, is estimated to be $16 billion annually. In addition to economic costs, depression can carry great personal costs because of the social stigma associated with diagnosis and treatment of a mental illness. This stigma likely plays a large role in patients' reluctance to seek, accept, and adhere to treatment. Yet, when identified, depression can almost always be treated successfully, either with medication, psychotherapy, or a combination of the two. The potential savings to be derived from the appropriate treatment of persons suffering from depression are socially and economically significant. The high prevalence of depression and the success of available treatments prompted the need to develop a guideline to assist primary care providers (general practitioners, family practitioners, internists, nurse practitioners, registered nurses, mental health nurse specialists, physician assistants, and others) in the diagnosis of depression. The Depression Guideline Panel that prepared these guidelines is composed of experts from various mental health and primary care disciplines and a consumer representative, selected for their range and diversity of expertise. The guidelines are based on systematic literature reviews commissioned by the panel and conducted by experts in numerous areas relevant to depression, with special attention to clinical issues most pertinent to diagnosis and treatment of depression in primary care. Guideline development also included input from a broad range of professional and consumer organizations and individuals. The guidelines have undergone peer review and field review with intended users in clinical sites to evaluate the document both conceptually and operationally. The panel did not review the material used to develop the taxonomy in DSM-III-R. Rather, the panel reviewed the epidemiology of major depressive disorder in community samples and primary care settings and the course, co-occurrence, and co-morbidity of depressive and other medical conditions. Where summary statistics were lacking, but data sets were available, the panel commissioned reanalyses of available data. The panel also reviewed literature on the role of self-reports and clinician ratings as tools for detecting or differentially diagnosing depression. The role of laboratory tests in the differential diagnosis of medical causes of depression was reviewed by using thyroid function testing as an example. Because of the current discrimination against those with depressive and other psychiatric conditions, appropriate diagnosis and treatment may carry a far greater personal cost for patients with depression than for those with other medical conditions. Future efforts should address and seek to overcome the consequences of this stigma through the education of health care providers, patients and their families, and the general population to ensure accurate, early diagnosis and effective, early treatment. 1 Guideline Development Background At least five reports suggest that primary care practitioners underdiagnose and/or undertreat depressive conditions (Gullick and King, 1979; Johnson, 1974; Ketai, 1976; Magruder-Habib, Zung, Feussner, et al., 1989; Popkin and Callies, 1987). In fact, only one-third to one-half of patients with major depressive disorder are properly recognized by primary care and other practitioners. Only about one-third of patients with bipolar disorder are in treatment. The problem of underrecognition is important enough to warrant special attention. Other psychiatric disorders are often accompanied by mood symptoms or formal mood syndromes. That is, patients may suffer concurrently from two psychiatric syndromes. In addition, substance abuse or withdrawal may cause mood symptoms/syndromes-so-called substance-induced mood disorders. Depressive symptoms or full syndromes commonly accompany a variety of other general medical disorders. For example, diabetes, cancer, heart attacks, and stroke are often accompanied by depressive symptoms of sufficient duration and intensity to meet the criteria for specific mood syndromes. Recognized general medical conditions, such as neurologic, metabolic, oncologic, and other illnesses, can biologically cause mood symptoms or formal mood syndromes (i.e., organic or secondary mood disorders). In other cases, mood syndromes may be psychological reactions to the disability or prognosis associated with nonpsychiatric medical conditions. Some prescription medicines used to treat general medical conditions, such as antihypertensive drugs, may also precipitate or maintain depressive symptoms or syndromes, especially in persons with a personal or family history of mood disorders. For these reasons, the Depression Guideline Panel has provided Clinical Practice Guideline: Depression in Primary Care to introduce practitioners to the key features of depressive conditions and, thus, to improve early diagnosis. This guideline, an abbreviated version of a far larger document, is divided into two volumes: this one, Volume 1. Detection and Diagnosis, and its companion, Volume 2. Treatment of Major Depression. The nearly 40 literature reviews conducted for these guidelines identified more than 3,500 relevant references, which are cited in the Guideline Report (roughly 1,200 pages). Only recent reviews and highly salient references are cited here. Definition of Depression The panel defined depression according to the current U.S. standard diagnostic system in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) (American Psychiatric Association, 1987). Given the need to complete this report in a timely fashion, the panel focused on major depressive disorder with some consideration of DNOS. The DSM-III-R system is closely aligned with and easily translated to the International Classification of Diseases, Ninth Edition (ICD-9) system of the World Health Organization (WHO). Both the DSM-III-R and the ICD-9 are undergoing revisions, which are to be completed by the end of 1993. In choosing to use the DSM-III-R, the panel acknowledges the availability of other clinical taxonomies pertinent to the diagnosis of depression in primary care practice and recognizes that the selection of a particular taxonomy can add bias to the guideline. The panel recognizes this limitation, but believes the DSM-III-R to be the best taxonomy available at this time. The panel also recognizes that a variety of clinical conditions may be viewed as mood disorder "equivalents." These include masked depression, chronic pain, chronic fatigue syndrome, somatization disorder, fibromyalgia, and others. The panel commissioned reviews of the literature on these conditions to provide a scientific basis for recognizing and differentiating these conditions from mood disorders. Literature Reviews and Guideline Development Practitioners often confront clinical situations for which direct research data are limited, but for which indirectly relevant data are available. The translation of what is scientifically confirmed or suspected into what is clinically required or recommended requires training, professional judgment, and experience. These guidelines are based on systematic literature reviews conducted by experts in diverse substantive areas relevant to depression, with special attention to the clinical issues most pertinent to the diagnosis and treatment of depression in primary care. To develop principles for diagnosis and treatment of mood syndromes in association with other illnesses, the panel also commissioned reviews of the literature on depression and selected general medical conditions. Where evidence is either lacking or incomplete, this is noted; in these cases, either no guideline has been derived or options are provided, based on logical inference, available data, and panel consensus. When the evidence is reasonably clear, though modest in amount, these findings are noted, and a tentative recommendation is offered. Thus, the guidelines that follow are coded according to the strength of the available evidence as interpreted by the panel: |