Management of depression in the outpatient office

Current practice suggests that primary care physicians are in the best position to identify initially and treat depression in the ambulatory setting. Educating primary care physicians about depression is essential for identifying and adequately caring for depressed patients. Depression is commonly seen and easily treated in primary care settings. A structured, consistent approach to the depressed patient is essential and should include patient education; eliciting information about symptoms; clinical observation about the examination; a history of previous psychiatric episodes; family history of affective disorders; history from relatives, other providers, or other clinics if necessary; aggressive use of medication alone or in combination with psychotherapeutic techniques; and appropriate referral. Depression is associated with significant suffering and disability and increased utilization of health care services. Depressed patients can present with a variety of somatic and cognitive symptoms. Primary care physicians should be alert for denial and minimization of symptoms as well as for the presence of stigmatization. The biologic, psychological, and social aspects of depression should be expanded on as needed according to the patient's illness beliefs. A medical model such as that used for explaining diabetes or coronary artery disease may be useful. Primary care physicians miss the diagnosis of depression in as any as two out of three cases, and when the diagnosis is made, patients are often undertreated and given antidepressants at subtherapeutic dosages and for only short periods of time. Treatment of depression can be extremely satisfying and gratifying for patients and physicians, who need to have a high index of suspicion for depression. All antidepressants have the same efficacy, and the selection is based primarily on their side-effect profile. The new generation of antidepressants are better tolerated, relieve symptoms of depression, improve the quality of life, and probably improve morbidity and mortality. In many cases, depression is chronic and recurrent, and treatment should be long-term to prevent relapses. As with other chronic diseases, if a patient requires treatment that the primary care provider cannot render alone, it needs to be coordinated. In particular, consultants may need to be called in for psychotherapy. Primary care physicians should feel confident that, given enough time and cooperation, they can almost always find a treatment regimen that succeeds in alleviating and perhaps preventing the great suffering and risk occasioned by depression in medically ill ambulatory patients.