Case Finding: Don’t Trust Appearances
For depression, the case-finding approach is preferable to screening the entire practice.5 I no longer trust appearances to recognize depression. While participating in the practice-based study of depression,1 I encountered a hardworking, cheerful female executive who had undergone many diagnostic procedures and who did not at all appear depressed—but she was. She got better after treatment and expressed profound gratitude. Not all severely affected patients present saying, “I’m depressed, please treat me.”
Unexplained somatic complaints
In my practice, one third of depressed patients complain only of a variety of somatic symptoms. I tell medical students, “If you can’t figure out what’s going on in an office encounter within minutes (1 to 3 minutes, depending on the level of training), think depression or alcohol abuse.” This clinical pearl is memorable and mostly accurate; the differential diagnosis can be expanded throughout training.
Stress? Suspect depression
Two thirds of my patients with diagnosed depression allude to “stress,” but often only in a very roundabout manner. So, whenever a patient utters the word “stress” during an office encounter, out comes the PHQ-9. I cannot think of a simpler technique for recognizing depression. In general, it is also well to remember that patients suffering from chronic diseases will have a higher-than-average likelihood of associated depression.
Managing depression should be simple
The management of depression should resemble the management of diabetes: astute case finding (mass screening for diabetes is not recommended), clearly defined diagnosis (blood sugar level), effective treatment (both behavioral and pharmacologic), systematic follow-up, and a quantitative outcome (glycosylated hemoglobin level). Diabetes was formerly managed as an acute illness, since once upon a time it was acceptable just to keep patients out of ketoacidosis. Today we treat diabetes better, and patients do better. Now it is time to do better with depression.
Correspondence
David L. Hahn, MD, MS, Arcand Park Clinic, 3434 East Washington Ave, Madison WI 53704. E-mail: dlhahn@wiscmail.wisc.edu