All you need to know about depression in primary care

1. Presenter: Dr Vairam
DEPRESSION IN PRIMARY CARE
25/02/2022

2. Presentation Outline
1. Definition
2. Statistics
3. Diagnostic Criteria
4. Importance of Screening for Depression in Primary Care
5. Conditions Than May be Misdiagnosed or Associated With Depression
6. Special Population - Pregnancy
7. Importance of Correct Diagnosis & Treatment
8. Patient selection for screening at Health Clinics
9. Screening Tools used at health clinics
10. Management options available at health clinics
11. Referral criteria
12. Limitations in health clinics

4. Definition
Depression (major depressive disorder) is a common and serious medical illness that negatively
affects how you feel, the way you think and how you act.

5. • Fortunately, it is treatable
• Depression causes feelings of sadness and/or a loss of interest in activities you once enjoyed
• It can lead to a variety of emotional and physical problems and can decrease the ability to
function at work and at home

6. PlusVibes – Platform To Support & Motivate Mental Health and Well Being (2/3/2021)

8. Diagnostic Criteria

9. Diagnosis Criteria

11. Common Mnemonics
@
Depressed mood

12. The Importance of Screening for Depression in
Primary Care

13. Primary care is most often the first contact point for patients with the healthcare system
Depression is a silent illness & patients with depression may not say they are depressed !!
According to the Primary Care Companion to the Journal of Clinical Psychiatry, in primary care,
more than half of outpatient medical visits are for somatic complaints, which are often associated
with depression
Depression can lead to suicide
Medical Point of View

14. A Cross-Sectional Study on Rates of Detection of Mood and Anxiety Disorders in Primary Care
done at 3 Canadian provinces show that :
27.2% patients met criteria for major depressive disorder &
misdiagnosis rates reached 65.9% for major depressive disorder
Therefore, with high prevalence rates and poor detection, there is an obvious need to enhance
diagnostic screening in the primary care setting
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3184591/#:~:text=Misdiagnosis%20rates%20reached%2065.9%25%20for,97.8%25%20for%20social%20anxiety%20disorder.

15. Mental illness creates enormous social and economic costs & is very expansive !!
For instance, expenditures for mental health care (year 2012) in the U.S. cost a whooping $83.6
billion
Much of the economic burden of mental illness is not the cost of care, but the loss of income
In a Broader Aspect

16. Loss of Income
Work Productivity
and Lost Earnings
Family and
Community
Disruption
Health system Youth and the
Criminal Justice
System
School Failure
Providing for and supporting good mental health is a public health issue. Lack of attention to and treatment of mental
illnesses has costs that extend well beyond the individual impacted by the illness. Communities prosper when the mental
health needs of community members are met
https://www.tpchd.org/home/showpublisheddocument/664/636427057087700000

17. Conditions That May Be Misdiagnosed or
Associated With Depression

19. Hypothyroidism
• Hypothyroidism is an endocrine disorder causing a low metabolism due to suppression of hormones
released from the thyroid gland
https://www.researchgate.net/figure/Signs-and-symptoms-of-hypothyroidism-and-depression-Extein-I-Gold-MS-eds-Medical_fig2_24422744

20. Hypothyroidism
Symptoms
Extreme fatigue
Weight gain
Decreased appetite
Muscle aches
Impaired memory
Emotional lability
Dry skin
Cold intolerance
Hair loss
Depression
https://discoverymood.com/blog/common-medical-illnesses-mimic-depression/

21. • TFT is used to diagnose hyper/hypo thyroidism
https://www.myamericannurse.com/primary-hypothyroidism-more-common-than-you-think/

22. Hypercalcemia
• Approximately 90% of cases of hypercalcemia are caused by malignancy or hyperparathyroidism
• Severity of symptoms depend not only on the level of calcium in the blood but how fast this level has
increased over time
https://discoverymood.com/blog/common-medical-illnesses-mimic-depression/
https://www.researchgate.net/figure/Neuropsychiatric-Symptoms-Based-on-Degree-of-Hypercalcemia-a_tbl1_318083440

23. • Can present with lethargy, a low mood, memory loss, and irritability
• High calcium levels —> catalyst for neuronal demise (possibly due to glutaminergic excitotoxicity and
dopaminergic and serotonergic dysfunction)
• Restoration of normal calcium levels or removal of a parathyroid adenoma has been shown to rapidly
resolve neuropsychiatric symptoms
IMPORTANT TO TAKE CORRECTED
CALCIUM LEVEL IN PATIENT
PRESENTING WITH DEPRESSIVE
SYMPTOMS
NEED TO RULE-OUT
MALIGNANCY &
HYPERPARATHYROIDISM
(Prolonged Hypercalcemia)
https://www.hindawi.com/journals/crips/2020/6954036/
CAN CORRECT THE DEPRESSIVE
SYMPTOMS
IF TREATED

24. • Mnemonic used to describe the symptoms related to hypercalcemia is Stones, Bones, Groans and
Psychiatric overtones
https://www.niddk.nih.gov/health-information/endocrine-diseases/primary-hyperparathyroidism

25. • Investigation results suggestive of primary hyperparathyroidism are
Hypercalcemia, Hypophosphatemia, High PTH, Phosphaturia, Hypercalciuria

26. Anemia
ANEMIA
HYPOXIA
Physical, Cognitive, & Mental health symptoms
DEPRESSION
MALNUTRITION
• IDA —> most common type
of anemia
• Iron is involved in many
essential cognition areas,
including CNS enzymes and
proteins, CNS development,
DNA replication and repair,
white matter myelination,
development of
neurotransmitter systems
• Ix: FBC, Iron Study, PBF

27. DIABETES
DIABETES
DEPRESSION
A. managing diabetes can be stressful
B. cause complications and health problems
C. poor lifestyle decisions
D. Affects the ability to perform tasks, communicate and think clearly
https://www.mayoclinic.org/diseases-conditions/diabetes/expert-answers/diabetes-and-depression/faq-20057904
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2292431/

28. Fibromyalgia & Pain
• Fibromyalgia is a common and complex chronic pain disorder that causes widespread pain and tenderness
to touch that may occur body-wide or migrate over the body
• Fibromyalgia is a diagnosis of exclusion and no specific investigation available
• Individuals with fibromyalgia are up to three times more likely to be diagnosed with depression at initial
diagnosis and have a 74% lifetime risk of depression
https://www.psychologytoday.com/us/blog/happiness-is-state-mind/202112/differentiating-fibromyalgia-depression-and-cfs
https://www.healio.com/news/rheumatology/20180313/interrupting-the-fibromyalgia-cycle

29. FIBROMYALGIA
prolonged, chronic, widespread pain
sleep deprivation DEPRESSION
fatigue
unable to function in day-to-day life
Fatigue/decreased energy, loss of appetite, difficulty concentrating, memory impairment, insomnia are
common to both fibromyalgia & depression
Inability to perform exercise which is the
treatment for Fibromyalgia

30. Chronic fatigue syndrome (CFS) also known as myalgic encephalomyelitis (ME)
• Characterised by unexplained extreme fatigue lasting for at least six months in duration that is not explained
by any other underlying medical illness
• Symptoms include non-refreshing sleep, difficulty with memory, focus, and concentration, postural
hypotension, lymphadenopathy, headaches, sore throat, unexplained muscle/joint pain
• Persistent fatigue, painful physical symptoms, sleep disturbances, poor concentration, psychomotor
retardation, and decreased libido are characteristic features of both depression and chronic fatigue
syndrome. As a result, individuals may be misdiagnosed with one another
https://www.psychologytoday.com/us/blog/happiness-is-state-mind/202112/differentiating-fibromyalgia-depression-and-cfs

31. Arthritis
• Arthritis is a chronic condition, the outcome of which is worsened by comorbid depression
• Among patients with rheumatoid arthritis, 65% reported depression (with 37.5% having moderate or severe
depression) - correlated with arthritis-related pain and functional impairment
• Overall health and quality of life were also improved relative to control patients after 12 months of
depression treatment
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2292431/
Pain, Fatigue,
Depressed Mood
(In pt with RA)
Sleep Disturbance
Depression

32. https://www.psychiatrictimes.com/view/behavioral-comorbidities-rheumatoid-arthritis
(eg IL-1 &
TNF-alpha)

33. Stroke
• Patients with a history of MDD were found to be 2.6 times more likely to experience a stroke than individuals
without depressive illness & were also more likely to suffer a fatal stroke
• Individuals with depression who experienced a stroke were 3.4 times more likely to die in the next 10 years
than those who were not depressed
• Functional recovery after a stroke may be accelerated by improvement in depressive symptoms
• Primary care offers home visit, rehabilitation, physiotherapy & screening for depression every clinic visit to
reduce incidents of depression post stroke
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2292431/

34. Heart Disease
• Depression is an independent risk factor for adverse cardiac events in patients without known heart disease
—> among patients with acute coronary syndromes, 15% to 23% have MDD
• Patients with known heart disease, particularly those who develop a heart attack, are at increased risk of
developing new diagnosis of depression
• A 2014 paper by Stewart suggests that early treatment for depression, before the development of
symptomatic cardiovascular disease, could decrease the risk of heart attacks and strokes by almost half
https://uihc.org/health-topics/understanding-link-between-depression-and-heart-disease
https://www.nhlbi.nih.gov/news/2017/heart-disease-and-depression-two-way-relationship
HEART DISEASE
DEPRESSION
KNOWN HEART DISEASE
(particularly those who
develop a heart attack)

35. Special Population -
Pregnancy

36. Major Depressive Disorder in Pregnant and Postpartum Women
• Depression is the most highly prevalent mental health problem in perinatal population
• Around 1 in 10 women suffer from perinatal depression worldwide
• Treating perinatal depression is essential in reducing symptomatology and preventing detrimental
complications to women, children and the family
• The most devastating consequences of perinatal depression and other mental disorders are a higher risk of
suicidal ideation, suicidal attempt or suicide
• Suicide is now one of the leading causes of maternal mortality; while the incidence of maternal death due to
medical and obstetric factors are all decreasing.

37. • Untreated depression in pregnancy is associated with an increased risk to the offsprings
• Postnatal depression may impair the mother-infant relationship, which can lead to poor infant development
and outcomes
Untreated depression in pregnancy
• fetal hyperactivity
• irregular fetal heart rate
• premature delivery
• low birth weight
• increased rates of premature deaths
• increased neonatal intensive care unit
admission
Postnatal depression
• difficult temperament
• attentional, emotional and
behavioral problems in
children and adolescence

38. Clinical Presentation
• According to DSM-5, perinatal depression is MDD with peripartum onset i.e. when symptoms onset occurs
during pregnancy or in the four weeks following delivery
• Postpartum period is defined up to one year, and selfreport measures are used to identify perinatal
depression (DEFINITION of the POSTPARTUM PERIOD 6-8 weeks after delivery)

39. Screening
• Brief screening tools e.g. PHQ-2 and Whooley Questions may be useful in a two-stage screening
• In a 2-stage screening, PHQ-2 may be used followed by Edinburgh Postnatal Depression Scale (EPDS)
• NICE recommends to consider asking Whooley Questions at a woman's first contact at primary care or her
booking visit, and during the early postnatal period. If she responds positively to either questions or there is
clinical concern, consider using EPDS or or PHQ-9 or refer out.
The suggested time-frame for EPDS
screening is shown below:

42. Treatment
• Principles of treatment for perinatal depression must be based on risk-benefit analysis and shared decision
making so that patient can make well-informed decisions on preferred treatment

43. Pre-pregnancy Care (PPC)
• Women in their reproductive age with mental health problems (including MDD) should receive pre-pregnancy
care (PPC) in a nearby health clinic or an obstetric and gynaecology clinic in a hospital, at least three
months prior to conception
• Treatment of pre-existing MDD must be optimised

44. Pharmacotherapy
• In general, antidepressants are effective for perinatal depression based on extrapolation of evidence on
general adults
• SSRIs are more effective than placebo at 4 - 8 weeks for postpartum depression
• SSRIs are the most well-studied antidepressant compared to other antidepressants
• Second-generation antidepressants including SSRI for depression in pregnancy may be associated with
increased risk of some serious harms although the absolute risks of harm appear to be small
• Antidepressants were associated with maternal adverse outcomes in pregnancy;
1. Venlafaxine —> higher chances for preeclampsia
2. SSRI + venlafaxine —>higher chances for vaginal bleeding during pregnancy or postpartum haemorrhage

45. Safety Profile in Breastfeeding
• In general, a relative infant dose (RID) below 10% of the average maternal level of an antidepressant is
considered safe
• RID level for:
• Sertraline and paroxetine had better neonatal safety profile during breastfeeding compared with other
SSRIs/SNRIs
https://www.pillcheck.ca/2019/02/15/which-antidepressants-will-work-best-for-your-post-partum-depression/
Available at Health Clinics

46. Psychosocial Intervention & Psychotherapy
• Showed significantly effective in reducing depressive symptoms compared to control in perinatal depression
• Psychosocial interventions - peer support and non-directive counselling
• Psychotherapy - IPT, CBT and psychodynamic therapy
• A Cochrane systematic review showed that psychosocial or psychological interventions (i.e. intensive,
individualised postpartum home visits provided by public health nurses or midwives; lay (peer)- based
telephone support and IPT) significantly prevented postpartum depression compared with standard care

47. Choice of Treatment
1. Mild-moderate perinatal depression
Most guidelines recommend on psychotherapy as the initial treatment
2. Severe perinatal depression
Most guidelines recommend pharmacotherapy intervention as the initial treatment

48. Importance Of Correct Diagnosis & Treatment

49. Misdiagnosed Mental
Disorder
Wrong
Medication
Worsening
Condition
Emotional Distress
• when they see that treatment
isn’t working
• feelings of guilt or shame
• relationship problems
• eventually discourage them
from seeking the appropriate
treatment
• substance abuse
• suicide
• various negative side effects
• additional stress and anxiety
• worsening the individual’s
condition

50. Who Do We Screen At Health Clinic?

52. • Prevalence of depression in primary care ranged from 6.7% to 14.4%
• Elderly prevalence was between 6.3% and 18%
• Women had higher rates of depression than men
• Prevalence of depression to be 20.7% in postpartum women,
36% in post-stroke patients
19.1% in breast cancer patients

53. What Screening Tools Are Being Used At Health
Clinics?

54. • The primary screening tool used are:
1) Anxiety and Stress Scale (DASS)
2) Saringan Status Kesihatan (Remaja) BSSK - revised 2014
3) Whooley Questions
4) Patient Health Questionnaire-2 (PHQ-2)
• Other screening tools available:
1) Patient Health Questionnaire-9 (PHQ-9)
2) Hamilton Rating Scale for Depression
Whooley Questions:
Sensitivity 96 -99%
Specificity 70 - 78%
The addition of the help question (Do
you need help?) increases the
specificity to 95%

56. Available Management at Health Clinic

58. • Non pharmacotherapy
1. Psychoeducation
2. Counselling by counsellor
3. OT for stress management, Deep breathing technique
• Pharmacological therapy
A. Fluvoxamine (Luvox)
B. Sertraline (Zoloft)
C. Fluoxetine (Prozac)
D. Amitriptyline (Elavil)

59. Psychiatric Referral Criteria

61. Limitations In Health Clinic

62. A. Time constrain - unable to get detailed history
B. Patient overload - TCA may take longer time
C. No psychologist available
D. 2 Counsellors per PKD - long waiting time
E. Inadequate knowledge/training for doctors to diagnose/manage depression -
misdiagnosed/not diagnosed
F. Limited medication options available
G. Stigma of mental illness - patient factor

64. References
1. American psychiatric association
2. Plus Vibes
3. Befrienders
4. DSM 5
5. NCBI
6. Tacoma-pierce country health
department
7. ResearchGate
8. Discover Mood & Anxiety program
9. American nurse.com
10. Hindawi
11. NIH
12. Mayo Clinic
13. The primary care companion
14. Psychology today
15. Helio Rheumatology
16. Psychiatry Times
17. CPG Major depressive disorder 2019
18. Pillcheck