Difficulties for Depression Recognition in Primary Care

To fight the health disorder, it should be properly recognized first. The patient comes to the primary care with his problems, which might be seemingly unrelated to the clear case of the clinical depression, and unfortunately, the recognition of depression success rate in primary care is statistically less than we would like it to be. For example, 50% of people with major depression, identified by independent screening in Great Britain, were not recognized as depressed by the primary physician. The recognition of depression is particularly difficult in certain patient groups such as the physically ill, or in certain cultures, when depression is not socially accepted diagnosis. Yes, in some cultures it is just "normal" to be sad, but clinical depression is much more than cultural specifics, or normal mood swings.
Depression is Often Unrecognized and Undertreated

Numerous studies indicate that 30-70% of cases of major depression are undiagnosed or undertreated in primary care. While some observers note that physicians are more likely to identify severe depression and to miss only milder forms of the illness, recent studies clearly demonstrated that nearly half of the undetected patients with depression in primary care developed suicidal ideation and 53% continued to meet criteria for major depression one year after the index evaluation.
Physician, patient, and system variables probably account for these disturbing findings. Several theories have been offered, including health services issues, sociocultural barriers, poor consumer education, and insufficient physician knowledge level. Patient denial, cognitive impairment, lacking awareness of depressive symptoms, and inability to articulate symptoms compound the difficulties of detecting depression in primary care. Patient nonadherence, resistance to diagnosis, cultural factors, social forces, subtherapeutic dosages of antidepressants, and low insurance reimbursement rates lead to the inadequate treatment of depression. Many employment, health, disability, and life insurance practices discriminate against individuals with mental illness, thereby reinforcing stigma and adversely affecting their socioeconomic status.

Problems for Depression Recognition

There may be a number of possible reasons for a lack of recognition of depression within primary care, both related to the physicians and the patients. Generally these can be summarized as follows:

Patient factors

  • Patients ignore depression in themselves;
  • When depressed, older adults may complain less of depressed mood and present somatic symptoms which may not be identified by the clinician;
  •  Physical co-morbidity may also make the interpretation of depressive symptoms difficult. Depressed patients may appear demented, and patients with early dementia may present with depression;
  • Fear of the stigma of mental illness;
  • Worry about side effects of medication;
  • Blaming depression on circumstances, regarding it as ‘understandable’;
  •  Older adults may misattribute symptoms of major depression for ‘old age’, ill health or grief;
  • Although depression is more frequent in women, differential reporting of symptoms may lead to depression being under diagnosed in men;
  • In some cultures, depression is not considered as socially acceptable disorder, causing patients to cover up the symptoms for the proper diagnostics.
Practitioner factors

  • Primary care practitioners may lack the necessary skills or confidence to correctly diagnose late-life depression;
  • Primary care physicians have been shown to view depression as a normal response to difficult circumstances, illnesses or life events and depression may be under diagnosed because of dissatisfaction with the types of treatment that can be offered, especially a lack of availability of psychological interventions;
  •  Physicians typically have little time per patient.
Recommendations for Patients

Unfortunately those patients who go unrecognized and untreated after the primary care visit lose the advantage of starting the instant treatment and getting on track to the recovery.

Please, remember that it is your health and your well-being is on stack, and you should do everything possible to help your primary physician in its diagnosis.  Get ready for the conversation, perform several self-checks for depression, if you just suspect that you may have it. Remember, that it is a disorder as any others, and you may significantly improve the quality of your life by accepting it and starting the professional treatment.

Sources and Additional Information:
The Atlas of Depression by David S. Baldwin


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