Depression Is Still Underrecognized and Undertreated
Alan Gelenberg, MD
I WISH I HAD A DOLLAR for every time I have heard the following comments from senior clinicians: "If I were his age, I'd be depressed too." "Wouldn't you be depressed if you had [fill in name of unfavorable diagnosis]?" However, this response is just a misunderstanding of the pathological nature, potentially severe consequences, and treatability of depression that conspires to keep the condition of at least half of people with depression unrecognized and untreated.
Old age is not for the fainthearted. Loss and suffering are too common. But the human organism is amazingly resilient. As we retain body temperature, blood glucose, and other indices over a wide range of conditions, so we also have an inbuilt capacity to respond and adapt. Psychological wounds (eg, loss of function or loved ones) can be met with compensation and the aid of others. Reinvigoration is the norm.
However, in a large minority of the population, perhaps 10% to 20%,1 stressful life events or undetectable internal perturbations can trigger an episode of depression. Unfortunately, approximately half of people with symptoms of depression do not seek treatment,2 and of those who seek treatment, the conditions of about half are misdiagnosed.3 When the symptoms of depression are untreated or undertreated, people overuse general medical services, have an increased risk of functional and occupational impairment and suicide, and experience symptoms for longer periods. 4
Once in progress, depression typically lasts for 6 months or longer and may become chronic.5 Results from the Medical Outcomes Study showed that the functioning of patients with depression in terms of their physical condition, social relationships, days spent in bed, and freedom from pain was comparable to or worse than that of patients with major chronic medical conditions.6 In fact, only patients with heart conditions had the same degree of functioning as patients with depression. In addition, the effects of depression on functioning and well-being are additive with the effects of coexisting medical conditions.7, 8 For example, depressive symptoms may increase the risk of coronary heart disease among elderly women.9 Greenberg et al10 estimated that the economic burden of depressionincluding both direct costs, such as inpatient care and pharmaceuticals, and indirect costs, such as absenteeism and reduced productivity at work and loss of earnings following suicidein the United States in 1990 was $43.7 billion. Of patients with depression who required hospitalization, as many as 15% committed suicide. 11
As diseases go, depression is relatively easy to treat. Today's antidepressant drugs are generally well tolerated and as effective as medicines used to treat most disorders. About 50% of patients achieve remission after initial treatment with antidepressants.12 Among the half whose symptoms do not respond or who cannot tolerate the first antidepressant, another 50% achieve remission with a different antidepressant. Several forms of brief psychotherapy have been empirically demonstrated to be efficacious in the milder forms of major depressionnotably cognitive behavioral and interpersonal therapies.13, 14 The Agency for Health Care Policy and Research guidelines 15-18 for the treatment of depression have been designed for use by primary care physicians. Many managed care organizations have also devised straightforward and reasonable algorithms and protocols.
Treatment follows diagnosis, which, as every physician knows, demands an index of suspicion. Persisting symptoms of depression must be viewed as pathological and should not be interpreted as a normal response to a difficult life situation. (The latter should remit relatively rapidly and respond to the healing ministrations of loved ones.)
The article by Irwin 19 in this issue demonstrates validity of a simple 10-item scale to diagnose depression in older adults. Its primary use will be in research, but its availability can alert clinicians to the importance of this diagnosis. I hope that future epidemiological studies across the whole life span will find enhanced recognition of the nature and effects of depression by both primary care and specialty physicians. The savings, in both dollars and human suffering, will be considerable and well worth the time and modest added medical expenditures. Eventually, the explosive growth of neuroscience research should enhance current treatments and even one day find the means to prevent mood disorders;however, these disorders will exist for the foreseeable future. Blending the art and science that have always been the twin pillars of medical practice, today's physicians can often help and always comfort.
Alan Gelenberg, MD
Department of Psychiatry
University of Arizona Health Sciences Center
PO Box 245002
Tucson, AZ 85724-5002