A 36-year-old female presents to her primary-care clinician with symptoms of headache, insomnia, low energy, and a feeling of being overwhelmed.
The blood workup is unremarkable but some questioning by the practitioner reveals that for the past several weeks the woman has taken little interest or pleasure in enjoyable activities, has been unable to concentrate on tasks, and has been feeling like a failure.
The patient goes on to state that she has had similar but less intense feelings in the past. The clinician prescribes an antidepressant and refers the woman to a psychiatrist.
This case scenario illustrates two key points:
- The primary-care provider is often the first health-care professional to identify depression in a patient.
- In some cases it is the physical complaints that bring a person to the clinician’s office for a visit that leads to a diagnosis of depression.
Women are more likely than men to see a clinician in order to report symptoms of depression. In certain cultures it is viewed as a sign of weakness for a person to make it known that he or she is experiencing depression, and this is often particularly true for men. Some men forgo seeking help until their depression eventually reaches a critical level, and suicide is attempted or completed.
In some instances males may be less communicative than females regarding their depression. A clinician can attempt to draw in the patient by asking him questions about his normal routine and his activities of daily living, and asking him whether he has noticed a change in himself. The man might also need to be checked for appropriate thyroid function and vitamin B12 level, and for evidence of electrolyte imbalances.
For women, the significant hormonal changes they undergo throughout their lifetime can affect neurotransmitter balance, behavior, and emotional state. Whether related to menstrual cycle, pregnancy, the postpartum period, or menopause, women are often experiencing some type of internal change that has the potential to affect the balance of such depression-related neurotransmitters as serotonin, dopamine, and norepinephrine.
While being female is considered to be a risk factor for depression, being male is regarded as a risk factor for suicide. Females are more likely to have suicide attempts; males more completed suicides. Males tend to use more brutal means, such as firearms or hanging, whereas females often use less violent methods, such as overdose.
Depression and the potential for suicide contribute to higher morbidity and morbidity in the context of other medical illnesses.
The Beck Depression Inventory-II (BDI-II) has been proven effective in detecting depression in primary care, as Yuan-Pang Wang and Clarice Gorenstein reported in the journal Clinics (Sao Paulo) (2013;68:1274-1287) after a systematic review of studies on the instrument’s utility.
The 21-question self-report provides a specific scale for determining whether a person has minimal depression (0-13), mild depression (14-19), moderate depression (20-28), or severe depression (29-63) (Smarr KL and Keefer AL. Arthritis Care & Research. 2011;63[Suppl S11):S454-S466])
But as Wang and Gorenstein noted, although the BDI-II scale helps detect depression in persons with medical conditions, clinicians should seek evidence as to how to interpret the score before using the information to make clinical decisions.
Abimbola Farinde, PhD, PharmD, is a professor at Columbia Southern University in Orange Beach, Ala.