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More and more, primary-care providers (PCPs) are encountering patients with depression and its numerous manifestations. In fact, depression is the fourth most common presenting complaint at primary-care offices and affects approximately one of every 10 primary-care patients.1 Even after the diagnosis has been made, choosing the appropriate treatment for each patient can be challenging. Pharmacotherapy is often the initial treatment choice for depression in a primary-care setting. Up to 70% of patients respond to their first drug trial.2 In general, selective serotonin reuptake inhibitors (SSRIs) are well-tolerated and not lethal in overdose, making them a popular candidate for first-line treatment. But when patients fail to respond to SSRIs, clinicians often struggle with choosing the next step.

This discussion will touch on the ways to optimize success by individualizing treatment based on depressive symptoms and subtypes. Treatment recommendations are still evolving. While nearly all the studies cited are well-designed randomized controlled trials (RCTs), most involve small numbers of patients, are short in duration, and have not been replicated sufficiently. Some of the treatment indications discussed remain off-label.

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How common is depression?

An estimated 5% of U.S. adults suffer from depression annually. On an individual basis, the lifetime risk of having a mood disorder exceeds 20%.3 Women are twice as likely to suffer from depression as men.4 Even so, depression is probably an even larger problem than statistics indicate. In the absence of systematic screening, up to 50% of patients with depression are thought to go undiagnosed.5 As many as 15% of individuals with untreated depression will complete suicide.1

Identifying depressed patients

To diagnose depression, one must first be able to recognize it. Patients with vague complaints should always be screened for depression.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) defines a major depressive episode as depressed mood or loss of interest for most of the day, every day, for the past two weeks. Additionally, five of the following seven symptoms should be present: changes in appetite or weight, sleep disturbances, psychomotor disturbance, fatigue or low energy, thoughts of worthlessness or inappropriate guilt, impaired concentration, recurrent thoughts of death/suicide.

The mnemonic “SIGECAPS” can serve as a reminder of key areas to investigate when screening for depression—Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor Activity (increased or decreased), and Suicide.

Another valuable screening tool is a simple set of two questions: (1) Have you ever been bothered by feeling down, depressed, or hopeless? (2) Have you ever been bothered by little interest or pleasure in doing things?6

Additionally, the physical appearance of depressed patients may provide a clue to screen for depression. Reluctance to make eye contact, slowed speech or movement, and poor hygiene can all be physical manifestations and/or indicators of depression.

Identifying different types of depression

The manifestations of depression differ between patients. Identifying the features of your patients’ depression will help you manage it. The DSM-IV divides depression into two categories: unipolar and bipolar. They are differentiated primarily by the absence or presence of mania or hypomania (Table 1).

The DSM-IV recognizes two other types of mood disorders outside these categories: substance-induced mood disorder and mood disorder due to a general medical condition. However, there are many other types of depression. Some, such as adjustment disorder with depressed mood and schizoaffective depressive type, are found elsewhere in the DSM-IV. Others are listed in the manual’s appendix and are proposed for future study and categorization (i.e., post-psychotic depressive disorder of schizophrenia, premenstrual dysphoric disorder, minor depressive disorder, recurrent brief depressive disorder, mixed anxiety-depressive disorder, and depressive personality disorder).

The categorization of depression is complex. Categories are separated by symptoms, time frames, and severity. However, the underlying biological mechanism for depression may be similar among categories. Treating depression may be better served by focusing on symptoms or features that identify a specific subtype, such as catatonic, melancholic, atypical, seasonal, or hormonal depression.