Depression is a Challenging Diagnosis

Jason Thornton, APRN

Depression is a very common disorder that severely limits quality of life. It is challenging to diagnose and also easily explained away as numerous other emotional or temporary conditions. Depression is in fact very difficult to identify and treat for many patients. Likewise, only 10% of primary care patients are treated for known depression. It is further estimated that of the remaining undiagnosed patients, another 30% may meet diagnostic criteria.

Depression - A Challenging Diagnosis

In 2008 the World Health Organization (WHO) ranked depression as the third leading cause of burden of disease worldwide. They also predicted the disease would rank number one in the next decade. About one in five people will experience an episode of depression during their lifetime. Risk factors such as family history, alcoholism, drug abuse, and socioeconomic status increase the prevalence of the disease. In addition, the onset of the global pandemic and its resulting social isolation is likely to increase the risk factor prevalence.

Identifying Depression

Depression effects women twice as often as the rest of the population. Likewise, the first episode of depression is likely to occur between mid-adolescence and the mid-40s as an average age range. The diagnosis of depression also requires the provider to get a thorough history. Patients often need an independent observer, such as their healthcare provider to identify their symptoms. These common symptoms include feeling depressed or down, too much or too little sleep, fatigue, feelings of being worthless or guilt, weight gain/loss, and also losing pleasure in things.

To make a diagnosis of depression, the clinician should inquire how long the symptoms have been present and also inquire about the patient mood. Likewise,the Diagnostic and Statistics Manual, version V (DSM-V) identifies 6 months as a key time interval for chronic depression. In fact, the diagnosis of depression can be made with a minimum of 2 weeks of symptoms. A nine item questionnaire (PHQ-9) can also help make this diagnosis.

Masked Disease

Depression also causes many physical symptoms to become chronic issues. These conditions include low back pain, frequent abdominal discomfort, irritable bowel syndrome, and also chronic arthritis to name a few. The clinical picture also becomes clouded when these additional issues are considered. Providers are also taught to exclude physical illness as the first priority. Indeed, mental illness may be a diagnosis of exclusion. Accordingly, this leads to increased outpatient testing, frequent ED visits, and added prescription medications. These new prescriptions can cause additional side effects and add further confusion. In fact, medical conditions caused by poor mental health can persist for years before depression is considered.

StrokePost-Stroke impairment
Left Frontal Pole Lesions
Heart DiseaseMyocardial Infarction
Post-MI Morbidity
Somatic DisordersChronic Pain
Chronic Fatigue
Musculoskeletal DisordersChronic low back pain
Chronic Arthritis
Neck Pain and disorders
Metabolic DisordersHyperglycemia

Treating Depression

Depression is treated in many ways. There are multiple treatments available. Likewise, they can be combined to treat depression. Patients are often hesitant to see their primary care provider because of the stigma related to depression and rumors about medication. Psychotherapy, sleep hygiene, and also regular diet and exercise are the cornerstones of treatment. In some cases these treatments can also be successful without the use of medications. When pharmacotherapy is needed, several medications can be used. For this reason, It is important to base the medication choice around the patient.

Patient compliance relates to the cost of their medications. Likewise, selective serotonin reuptake inhibitors (SSRIs) are the most common classification of medications that treat depression. Examples of SSRI medications include citalopram, escitalopram, sertraline, and fluoxetine and their prices differ greatly between generic and brand name formats. Providers should also discuss cost of treatment with their patients. Medications should be started at the lowest dose. This dose should be increased accordingly. Medication safety should be explained in detail to the patient prior to starting these agents. In addition, adherance to daily use Is critical for successful therapy.

Counseling Patients

Common side effects include nausea, headache, and even decreased libido. Black box warnings also include increased risk of suicidal thoughts in children, adolescents, and young adults. One of the side effects of antidepressants is worsening depression with suicidal thoughts. Suicidal patients should stop their medications immediately and seek help. Patients should also call their health care provider. While depression is still not fully understood, it remains elusive. The stigma surrounding mental illness prevents It from being a mainstream topic of discussion. Accordingly, Prevention and intervention are important factors for treatment. Prevention and cure are more likely to occur once we fully understand the disease. Until that time comes, the best we can do as providers is to remain vigilant, and keep depression on our differential diagnosis.

Malhi, G. S., & Mann, J. J. (2018). Depression. The Lancet, 392 (10161), 2299-2312. doi:

Goodwin, G, et. al. Dialogues Clin Neurosci. 2006 Jun; 8(2): 259–265.

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