Recognition and Management in Primary Care
Robert M. A. Hirschfeld, M.D.
Depression and anxiety frequently co-occur, especially in primary care settings. These co-occurrences manifest themselves in several ways and have different clinical courses. This review was written to help the clinician to identify what is and is not important in the diagnosis and treatment of patients with comorbid depression and anxiety in the primary care setting. The scope of this review is limited to major depression and not other forms of depression such as bipolar depression or dysthymic disorder. Literature was reviewed by 2 methods:
(1) a MEDLINE search (1980–2001) using key words depression, depressive disorders, and anxiety disorders; comorbidity was also searched with individual anxiety diagnoses; and
(2) direct search of psychiatry, primary care, and internal medicine journals over the past 5 years.
The scope and impact of depression and anxiety disorders worldwide are overwhelming. The watershed Global Burden of Disease study found that major depression ranked fourth among all medical illnesses in terms of its disabling impact on the world population. 1,2 The authors
estimated that by the year 2020 depression would be second only to ischemic heart disease. Anxiety disorders rank close behind major depression, contributing additional disability.
The prevalence of depressive and anxiety disorders in primary care settings is high. Between 10% and 20% of adults in any given 12-month period will visit their primary care physician during an episode of mental illness (although frequently not because of the episode). Depression and anxiety disorders contribute to the majority of those visits. If unrecognized and undiagnosed, depression and anxiety disorders contribute to high medical utilization in the primary care setting. Twenty-four percent of high utilizers (the top 10%) have been found to suffer from current major depression and 22%, from an anxiety disorder.
In primary care, presenting complaints for behavioral problems are more likely to be somatic than psychological. Back pain, chest pain, shortness of breath, heart palpitations, problems with sleep or appetite, and fatigue are among the most frequent presenting symptoms.
Although much work still needs to be done to increase awareness of depression and anxiety, the last decade has witnessed enormous progress in both the recognition and management of these disorders, especially in the primary care setting, which has long been recognized as the she is a bad wife and mother. She is no longer interested in sex. Lately, the patient admits that she does not really care that much about anything she has lost all of her interests.