Because of their established rapport with patients, primary care physicians are in an excellent position to intervene in mild-to-moderate depression and refer patients with more severe symptoms for psychiatric evaluation. The key is to build a solid therapeutic partnership—by communicating interest, respect, support, and empathy for the patient’s emotional situation—before turning to the prescription pad.
The underrecognition and undertreatment of psychiatric illness constitute a major problem in the outpatient medical setting. Multiple reports published during the past 20 years confirm that patients often consult their primary care physicians with complaints that overtly or covertly relate to emotional problems. Studies using standardized testing have estimated the prevalence of psychiatric disorders in primary care patients to be between 20% and 33%. Unfortunately, many primary care physicians are unprepared to manage emotional illness, with the result that perhaps one third to one half of this population do not receive adequate treatment.
While the social stigma attached to a psychiatric diagnosis has lessened considerably in recent years, patients still may mask emotional problems behind a barrage of somatic complaints. For a physician who lacks training in this area, the challenge of correctly identifying the source of the difficulty and establishing a treatment plan that is acceptable to the patient, all within the confines of a short time, can be daunting. Awareness of the criteria for common emotional disorders and familiarity with the actions and side effects of psychoactive drugs are prerequisites for effective management. Perhaps most important, however, is refinement of a skill seldom taught in medical school: how to listen and respond empathetically to the patient.
Social functioning of depressed patients is comparable to—or in most cases, worse than—that of patients with other illnesses. Only advanced coronary artery disease resulted in more disability days than depression, and only arthritis caused more chronic pain. The effects of depression and other serious conditions are additive; for example, the combination of advanced coronary artery disease and depression is associated with twice the reduction in social functioning observed for either condition alone.
The most extreme outcome of depression is, of course, suicide, which can be directly attributed to depression in as many as 60% of cases. The fact that more than 70% of patients who commit suicide visit a physician within two months of their death suggests that clinicians need to become more aware of the risk factors for depression and suicide.
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