Prevalence of depressive symptoms in primary care.

BACKGROUND: Depression is one of the most common medical disorders seen in primary care practice. The purpose of this study was to estimate the prevalence of depressive symptoms in primary care patients across the United States, and to describe patient characteristics that may be associated with an increased likelihood of those symptoms. METHODS: Survey data were obtained from a sample of 75,858 patients who visited one of 765 participating primary care physicians for any reason from February 1991 to September 1991. The outcome measurement used was the index score for presence of depressive symptoms on the Zung Self-rating Depression Scale. RESULTS: The overall prevalence of clinically significant depressive symptoms was found to be 20.9%, but the percentage of patients citing depression as a reason for visit (1.2%) was markedly lower. Patients who perceived their health as poor were more likely to have severe depressive symptoms than patients who perceived their health as excellent. Women, those in older age groups, and those with lower levels of education were more likely to have clinically significant depressive symptoms than men, those in younger age groups, and those with higher levels of education. When classified by marital status within each sex, married men and women were the least likely to have clinically significant depressive symptoms. CONCLUSIONS: Clinically significant depressive symptoms are highly prevalent in primary care patients; however, depression is an infrequent patient complaint. There are certain patient characteristics that may cue the physician to consider depression in the differential diagnosis, particularly the patient's self-perception of his or her overall health status. In addition, certain other subsets of patients are at increased risk of depression, such as women, those in older age groups, and those of lower socioeconomic status.

The role of rating scales in the identification and management of the depressed patient in the primary care setting.

The author conducted a review of the literature for reported prevalence of depression in primary care settings. Studies that provided data on both standardized interview and self-ratings were included. Reported prevalences from six studies ranged from 6% to 17%. Based on the results of 904 questionnaires administered at continuing medical education meetings held in 11 cities across the United States, primary care physicians estimated that 14% of their patients have a component of depression. To evaluate the usefulness of patient self-rating depression scales in the family practice setting, studies were reviewed where the patients' physicians were either notified or not notified of the results of a screening in which the Zung Self-Rating Depression Scale was used. In six published studies, results showed that notified physicians were able to increase their ability to recognize depression by 2.5-fold to 25-fold.

The comorbidity of anxiety and depression in general medical patients: a longitudinal study.

In a general medical clinic setting, 880 patients were screened for depression by using the Diagnostic Interview Schedule version of the DSM-III and the Zung Self-Rating Depression Scale (SDS), as well as the Zung Self-Rating Anxiety Scale (SAS). Based on a morbidity cutoff index of 50 on the SDS and a positive DIS for depression, 112 patients (13%) were found to have a depressive disorder. The SDS showed a 97% sensitivity, a 63% specificity, and an 82% correct classification of depressed and nondepressed control patients. Based on the SDS results and SAS results when anxiety was considered present at a moderate severity level, the comorbidity of anxiety and depression was 67%. Depressed patients were followed for 1 year during which time they were retested with the SDS and SAS at five time points (6 weeks and quarterly). Fifty-one patients who met the criterion of a decrease of greater than or equal to 12 points in the SDS index were assigned to the improved group, 23 who met the criterion of an increase of greater than or equal to 12 points were assigned to the worse group, and 36 patients were assigned to the no-change group. Depressed patients who improved showed a significant decrease in anxiety based on SAS change scores; depressed patients who worsened showed a significant increase in their anxiety index. The decrease in the anxiety index of patients in the no-change group was not statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Improving physicians' recognition and treatment of depression in general medical care. Results from a randomized clinical trial.

A randomized clinical trial was performed to assess whether the results of a depression screening instrument, when provided to physicians, could influence their recognition and treatment of depression in a primary care setting. The intervention consisted of randomly informing or not informing physicians of the depression status of 100 patients who screened positively for depression on both the Zung Self-rating Depression Scale (SDS) and a DSM-III screen. For 12 months patients were followed to assess depression status, and medical records were audited to assess depression recognition and treatment. Results show that feedback to physicians of SDS scores of previously unrecognized depressed patients makes a significant difference in greater recognition (56.2% vs. 34.6%) and treatment (56.2% vs. 42.3%) of depression over the 12-month study period. This was especially true for patients with high somatic (P less than 0.05) or low psychologic symptoms of depression (P less than 0.05). These results suggest that routine use of a depression screening instrument can improve physician recognition of depression, with increased initiation of treatment.

Management of general medical patients with symptoms of depression.

This article describes the management of depressive symptoms in a group of ambulatory patients in general medical care during a 1-year period. It also examines patient outcomes by types of management and aggressiveness of treatment. Subjects are 112 male patients longitudinally enrolled in a V.A. General Medical Clinic who screened positively on both the Zung Self-rating Depression Scale and the DSM-III criteria. Medical records were abstracted to obtain information on mental health management. During the follow-up year, 48% of the moderately depressed patients received some form of mental health management compared to 92% of the severely depressed patients. Of the treatment modes, only patients who had a mental health clinic visit and/or psychiatric consultation were significantly more improved than those not so treated--but only at 6 months (p = 0.09) and 9 months (p = 0.02). Actual treatment experience was then classified into three levels based on intensity, duration, and combinations of treatments. Of the three levels, only those patients in the moderately aggressively treated condition were significantly more improved at 3 months (p = 0.02) and at 6 months (p = 0.04) than those in the no-treatment condition.

Prevalence of clinically significant depressive symptoms in black and white patients in family practice settings.

The authors administered the Zung Self-Rating Depression Scale to 764 black and 773 white adult outpatients in primary care settings. There was no significant difference between the races in prevalence of depressive symptoms or distribution of symptom severity levels.

Effect of clorazepate on depressed mood in anxious patients.

A double-blind, placebo-controlled study of clorazepate in the treatment of 189 patients diagnosed with generalized anxiety disorder was conducted to evaluate the efficacy of an anxiolytic on the depressed-mood component of anxiety. Clorazepate-treated patients with concomitant high levels of depressed mood, defined as a score of 60 or above on the Zung Self-Rating Depression Scale (SDS), showed significant improvement of anxiety symptomatology, as measured by the Hamilton Rating Scale for Anxiety and the Zung Self-Rating Anxiety Scale, and of depressed mood, as measured by the SDS, compared with placebo-treated patients (all p values less than .01).

Prevalence of clinically significant anxiety in a family practice setting.

The Zung Self-Rating Anxiety Scale was administered to 739 consecutive patients seen in a family medicine center during a 9-month period. When a morbidity cutoff score of 50 was used, 20% of the patients were found to have clinically significant anxiety symptoms.

Accidental and homicidal death in a psychiatric emergency room population.

To identify potentially preventable mortality other than suicide among psychiatric emergency room patients, the authors compared the rates of accidental and homicidal death among 5,284 consecutive psychiatric emergency room patients with those expected for an age-, sex-, and race-matched sample of the general population. The rate of accidental death was two and one-half times and the rate of homicidal death nearly twice the expected rate for the matched general population. Diagnostic and demographic analyses indicated that increased risk of death from either cause was highest among alcoholics, schizophrenic patients, and males. The implications of the findings for clinical care are discussed.

Validation of four definitions of melancholia by the dexamethasone suppression test.

The authors evaluated four sets of diagnostic criteria, the Newcastle Index, DSM-III, RDC, and the Michigan Diagnostic Index, for the diagnosis of melancholia. Forty-nine depressed inpatients, all of whom met RDC for major depression, also received consensus diagnostic assessment for melancholia. The dexamethasone suppression test (DST) was administered before drug treatment began. Results showed that the sensitivity of the DST ranged from 39% to 48%, specificity from 80% to 100%, and diagnostic confidence from 66% to 100%. All four scales received validation, but DSM-III showed the lowest specificity and predictive value.

Cortisol suppression index: a further evaluation.

The cortisol suppression index (CSI) is the ratio of pre- to postdexamethasone plasma cortisol concentrations. The 8 a.m. CSI was previously found to identify 66% of a sample of psychiatric inpatients with major depression. In the present study, a 4 p.m. CSI identified 71% of psychiatric inpatients with major depression, in contrast to 53% when using DST criteria alone. This finding adds further validation to the CSI. Further studies of the utility of the CSI are suggested to help improve the detection of major depression.

Symptom perception by nonpsychiatric physicians in evaluating for depression.

A questionnaire was constructed and used to assess the perception of symptoms of a depressive disorder by nonpsychiatric physicians in patient evaluations. Results showed that respondents consistently perceived depression as resulting from psychological rather than biological factors. It is suggested that such perception on the part of physicians may hinder consolidation of a patient's symptom complex with the degree of certainty necessary for a diagnostic consideration of depressive disorder.

Classification of depressive disorders: a multiaxial approach.

Classification of depressive disorders can be performed following the Linnaean binomial nomenclature model by defining depression as a genus and the subtypes as species. A medical classification of depressive disorders would need to be jointly inclusive and mutually exclusive between subtypes, and to provide time of onset, severity of illness, pathological process, prognosis, and treatment indications. Etiologic, phenomenologic (clinical, descriptive), statistical, and biological approaches have been used to classify depression. A convergence of these various systems in different combinations has evolved, and a consensus approach using the multiaxial system, such as DSM-III, has advanced psychiatric nomenclature to provide clinical relevance and heuristic possibilities.

Patient compliance with MAO inhibitor therapy.

Exaggerated fears of monoamine oxidase inhibitors (MAOIs) and of their interactions with foods often restrict their use. A review of the literature reveals seven food items most likely to produce a hypertensive crisis in combination with MAOI administration: aged cheeses, smoked or pickled fish, beef or chicken liver, dry fermented sausage, pods of broad beans, brewer's yeast products, and certain alcoholic beverages. Improved understanding of the dietary restrictions, benefits, and mechanism of action of the MAOIs can enhance cooperation with the prescribed treatment program.

Practical aspects of MAO inhibitor therapy.

Instructions for patients regarding the observation of dietary and medication restrictions during MAOI therapy are presented. Principles of physician management of MAOI therapy, including avoidance and management of hypertensive crises and the potential for drug-drug interactions, are briefly reviewed.

Identification and treatment of masked depression in a general medical practice.

The usefulness of the Zung Self-Rating Depression Scale as a screening instrument to uncover masked depression, and the benefits of early identification and treatment with alprazolam, were evaluated in a general medical practice population. There was a 95% scale acceptance by patients and a 12% overall prevalence of depression based on SDS results. Patients who scored in the depressed range on the SDS were, on a randomized basis, either identified immediately to their physicians and treated with alprazolam (N = 21) or identified after 4 weeks (natural history controls, N = 20). Treatment resulted in improvement in 66% of the identified group versus a 35% spontaneous improvement in the control group (p less than .05).

Review of placebo-controlled trials with bupropion.

Results of four multicenter randomized double-blind placebo-controlled studies of the antidepressant efficacy and safety of bupropion are reviewed. Bupropion was superior to placebo on the Hamilton Depression and Anxiety Rating Scales, Clinical Global Impressions-Improvement, and patient self-rating scales (Zung) for depression and anxiety. Overall, the proportion of patients responding to bupropion was typically 60%-70%, compared to approximately 30% for placebo. Drug-placebo differences became apparent at 5 days to 3 weeks after treatment initiation. With respect to subjective side effects, bupropion exhibited a profile very similar to that of placebo. Further, no clinically significant cardiovascular or clinical laboratory changes were noted. Bupropion appears to be an effective broad-spectrum antidepressant with an excellent side effect profile.

A multicenter evaluation of bupropion versus placebo in hospitalized depressed patients.

Bupropion, a new antidepressant with a novel structure and neurochemical profile, was compared to placebo in a three-center evaluation. Seventy-five depressed inpatients, 48 on bupropion and 27 on placebo, participated for up to 28 days. At dosages of 300-600 mg/day, bupropion was significantly more active than placebo in reducing depressive and anxious symptomology, beginning at the 3-week evaluation. Bupropion was particularly efficacious in more severely ill and older patients. Symptoms reflecting cognitive disturbance, somatic anxiety, and psychomotor retardation were most improved; sleep disturbances showed less marked effects. Appetite and diurnal variation were not markedly influenced. Adverse effects were minimal, with no significant cardiovascular or clinical laboratory findings. Three patients developed a skin rash. There was a notable absence of sedative, anticholinergic, and cardiovascular-related side effects. Bupropion has demonstrated antidepressant effects and a spectrum of activity that holds promise for a difficult subgroup: the older depressed patient with retardation and cognitive disturbance.