Depression Symptoms Treatment

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Depression is common and can usually be treated effectively. However, in many cases physicians may not recognize depression, especially in its early stages. Because the burden of suffering can be high, including death through suicide, early recognition and treatment are worth while. Such efforts are not as easy as they seem, and evidence of their effectiveness must be evaluated.

All physicians must be sensitive to verbal and nonverbal cues that might reflect an episode of depression. Whether a brief, systematic assessment for undeclared depression should be an integral part of the periodic health examination of asymptomatic patients has yet to be determined.

In 1979 the Canadian Task Force on the Periodic Health Examination stated that there was fair evidence to exclude early systematic assessments of depression from the periodic health examination. In reassessing the situation 10 years later we paid particular attention to the quality of early detection instruments currently available, the evidence of the effectiveness of early detection efforts and the features that impede early detection.

Burden of illness

Community surveys of the prevalence of depression have generated estimates of 3.5% to 27%. Clearly, such estimates are affected by the choice of criteria defining depression, the population studied, the assessment methods and the time frame. Our understanding of the epidemiologic features of depression has improved considerably over the past decade. Carefully performed surveys have suggested that 15% to 30% of adults experience clinically significant depression at some point in their lives. The Epidemiologic Catchment Area Study, a landmark survey involving over 18 000 people, identified a 6-month prevalence rate of 2.2% to 3.5% for major depression. These data are supported by findings from studies in family practice and ambulatory care settings that showed depression ranking high among all conditions encountered.

The lifetime prevalence of depression is roughly twice as high for women as for men. The peak prevalence among women occurs between 35 and 45 years of age. Among men the prevalence increases with age. First-degree relatives of people with depression are more likely to become depressed. In Canada in 1986 suicide accounted for an estimated 97 600 potential life-years lost among males and 25 300 among females, the associated direct and indirect costs being $1.6 billion per year. It has been suggested that identifiable depression is causally related to 60% of suicides.

Is depression being recognized?

Depressed patients may present with various complaints, which makes recognition a challenge, particularly in the early stages of depression. In one review of 400 depressed patients in a primary care setting, only 49% presented with a psychologic complaint. In another primary care study depression went unrecognized in about 50% of patients who presented with nonpsychologic complaints yet who met the standardized clinical criteria for major depression. However, although other studies have confirmed that depression is easily missed, they have suggested that many patients have self-limited mild depression. Many overlooked cases may be identified subsequently; however, these data suggest potential benefit if an effective means of early recognition were available.

Is effective treatment available?

Once recognized most cases of depression can be treated effectively. The mainstays of therapy have been tricyclic and “new-generation” antidepressants and psychotherapy. Tricyclic antidepressants have long been considered to be effective and to decrease somewhat the risk of early relapse. Similar support exists for monoamine oxidase inhibitors, but the potential side effects have limited their use. Psychotherapy, although widely practised and generally accepted as being effective, is more difficult to study, and the results of evaluations are often harder to interpret than those of drug trials. Most reviews of randomized controlled trials and meta-analyses, however, do support the effectiveness of psychotherapy. Combined treatment with antidepressants and psychotherapy may produce better outcomes than either treatment alone.

The use of lithium to treat bipolar disorders and the controversial role of electroconvulsive therapy will not be included in this review.