Volume 103, Issue s84

Depression is underdiagnosed in primary care because of several factors, including variances in the clinical presentation of depressive symptoms, as well as comorbid medical, psychiatric, and substance abuse problems. Time constraints imposed by managed care add to the challenge of diagnosis. The current medical system encourages a reliance on somatic symptoms for accurate diagnosis, and tools that measure somatic symptoms, such as the Primary Care Rapid Assessment Scale, may be useful. After diagnosis, the depressed patient may benefit from one of the many new antidepressant modes of therapy and medications in the pipeline. Psychotherapeutic treatment modalities should also be taken into account. These diagnostic and therapeutic options are rapidly becoming available to primary care physicians, who should use them to achieve long-term remission of depressive symptoms.

Depression is common in medically ill patients, and it presents a particular challenge to the primary care physician. Depression may exacerbate cardiovascular disease, diabetes, and irritable bowel syndrome. Also, it may cause a poorer prognosis of each of these disorders. It is therefore recommended that depression screening be incorporated into a treatment plan for all these conditions, because treatment of depressive symptoms will improve patient quality of life and the outcome of other comorbid illness.

The chief complaint of depressed patients in a primary care setting is often not their dysphoric mood. Physical complaints are frequently the presenting symptom. Primary care physicians should include a depressive disorder in the differential diagnosis of patients complaining of multiple somatic symptoms, increase in alcohol or drug use, sleep and sexual dysfunction, or reports of anxiety. In the case of acute onset of depression, the physician should first rule out underlying medical illness or medication side effects as the etiology of the symptoms.