Discovering Depression in Medical Patients: Reasonable Expectations

One fact has been cited almost tiresomely: Primary care clinicians fail to diagnose depression in half of their patients who have the condition. When depression is detected, clinicians provide adequate treatment only half of the time [1-4]. Because 5% to 10% of medical outpatients (and even more inpatients) have major depression, this indictment is alarming. However, it is also a bit too facile. It ignores the barriers that make detection of depression particularly challenging in the medical setting: time, somatization, stigmatization, reimbursement, and comorbid medical conditions.

Most medical outpatient visits last 15 minutes or less [5], whereas visits to a mental health specialist typically last 30 minutes or longer [6]. Moreover, depression is but one, often subtle, on the item agenda in a medical encounter. During this encounter, the clinician must negotiate such competing priorities as acute symptoms, follow-up of chronic medical disorders, prescription refills, review of laboratory test results, and health maintenance. Medical patients with mental disorders typically present with fatigue, insomnia, pain, gastrointestinal symptoms, or other somatic symptoms rather than saying “I'm depressed” or “It must be my nerves” [7]. The presumed stigma of depression often inhibits explicit questioning, particularly if a trusting physician–patient relationship has not yet been established. However, clinicians overestimate patients' resistance; most patients are comfortable discussing psychosocial problems [8] and welcome questions about them [9, 10]. Problems with reimbursement include some insurers' rules that prohibit clinicians who are not mental health specialists from billing for treatment of psychiatric disorders, copayments, and restrictions on the number of visits.

Comorbid …