Depression as a General Medical Problem

Modern psychiatry in the NIS is currently undergoing reforms aimed at democratizing psychiatric care and making it more affordable and accessible to the public. Yet at the same time, such reforms are impossible within the narrow framework of the available mental health services. There is an obvious need for interaction between the mental health and general healthcare systems, specifically in terms of integrating the diagnosis and treatment of certain types of psychiatric care into primary healthcare settings-first of all, into territorial outpatient clinics (polyclinics). One promising area for such an integration is depression.

Depression can well be considered a general medical, rather than purely psychiatric, problem. This is due to the specific nature of the clinical manifestations of depression, which heavily affect various somatic functions-sleep, general activity, and physical fitness-while mental activities themselves may remain relatively intact for a long time. It is therefore reasonable for various specialists to participate in the diagnosis and treatment of depression, as well as in the prevention of its severe, chronic, and disabling forms.

Depression in its various clinical versions is now considered a key cause of decreased working ability. In terms of years lost from a full-fledged life, depressive disorders outstrip all other mental diseases-including Alzheimer's, alcoholism, and schizophrenia.¹ Depression currently ranks fourth among all diseases, and is expected to rank second after ischemic heart disease by 2020.²

Rates of depression vary widely depending on the criteria used. For the population of the former Soviet Union, the rate of 0.5 percent³ was found for severe depression, although it reflects a rather narrow diagnostic range. And while our understanding of depression has begun to change and its diagnostic range has been expanded, the disease is still on the rise worldwide.

Research carried out in the United States with the use of the Diagnostic and Statistical Manual of Mental Disorders-known as DSM-IIIR-criteria^{4, 5} has revealed a very high percentage (9.5-11.3 percent) of people suffering from various affective disorders-including depression-with a frequency of at least one depressive episode during a given year. That rate may be much higher with the addition of the so-called disorders of the depressive spectrum, namely some forms of pathologic compulsion, some cases of alcohol/psychoactive substance abuse, some somatoform or initial phases of psychosomatic disorders, and numerous conditions generally classified as neuroses. The rate of depression is especially high among patients of primary care facilities. According to a multi-center study conducted in 12 countries, about 10 percent of patient visits to general practitioners are associated with depression.⁶ However, general practitioners (internists) recognize depressive disorders only in 10-30 percent of these cases. In turn, untimely and inadequate therapy exaggerates the relevant somatic disease (where it accompanies the depression) and renders the depressive state chronic.

The key diagnostic category for depressive disorders is termed a "depressive episode" (F 32 according to ICD-10 or 296.2, "major depressive disorder, single episode," according to DSM-IV). Diagnosis of a depressive episode is based on a low mood and decreased interests and energy, in combination with a number of cognitive and vegetative symptoms that persist for at least two weeks (see Table 1). Similar signs are identified with "recurrent" depression and with depressive episodes related to bipolar affective disorder. The latter shows itself as alternating depression with manic or hypomanic periods (increase in mood and general activity). Less severely manifested depressive symptoms are usually identified with "dysthymia" (relatively light chronic depression), mixed depressive and anxiety episodes, as well as symptomatic forms of depression that evolve from serious somatic diseases and organic brain lesions (see Table 2).

Existing prejudices and concerns about stigmatization often prevent people with depressive disorders from going to mental health institutions where they could gain access to the most experienced practitioners who have all the necessary methods to diagnose and treat depression at their disposal. Fortunately, with changes in the system of care for patients suffering from depression in their common non-psychotic forms, the condition can be treated by general healthcare institutions, in particular, by territorial polyclinics. This has become possible with the appearance of new antidepressants that have few serious side effects, or "behavioral toxicity." It is the frequent negative effects of traditional tricyclic antidepressants-primarily sedation, dry mouth, urinary retention, cardiac arrythmias, disordered fine coordination of movements, and hampered intellectual activity, which limit the opportunities for social functioning-that prevent them from being used outside of psychiatric institution outpatient services. Modern antidepressants, such as selective seratonin re-uptake inhibitors (SSRIs), have far fewer side effects and can, therefore, be widely used in outpatient practice. Outpatient treatment also allows a more flexible combination of pharmacotherapy and psychotherapeutic methods, which themselves are not necessarily sufficient to overcome depression. Yet treatment of depression at a polyclinic should not be the prerogative of a single specialist such as a general practitioner or psychiatrist. This goal can be most successfully achieved with professional interaction among various specialists, as well as health education programs for physicians, nurses, patients, and the public in general.

The experience in some countries shows that health education programs among general practitioners and an increase of their awareness of depressive disorders and therapies can substantially reduce the number of unnecessary procedures and laboratory examinations-as well as inadequate therapeutic prescriptions-while expanding specific therapy with antidepressants. As a result, the frequency of referrals to hospitals, both general somatic and psychiatric, is also decreased.

A New Model for Treating Individuals with Depression

In 1997 the Moscow Research Institute of Psychiatry of the Russian Ministry of Health, and in cooperation with the US National Institute of Mental Health in Bethesda, Maryland, began developing a research and practical program called "Recognition and Treatment of Depression in Primary Health Care Settings." This program is providing Russia with a new approach to the organization of consultancy and treatment services for patients with depression outside of traditional psychiatric institutions such as hospitals and dispensaries-namely, at regional polyclinics. Currently being implemented at several territorial polyclinics in Moscow, Dubna, Yaroslavl, Tomsk, and Tula, the main goal of the program is to reduce the risk of disability, or limited working ability, due to depression.

The following objectives have been set for the program under the above goal:

1. Screen the population of people who apply to polyclinics, to identify patients with affective disorders (including subdepressive and anxiety disorders) and diagnostically evaluate the disorders revealed.
2. Develop and test a model of interaction among various specialists (such as therapists, other internists, psychiatrists, clinical psychologists, and nurses) in the process of caring for patients with depressive disorders at a polyclinic.
3. Develop methodological approaches to the diagnosis of depressions and other affective disorders in patients of polyclinics, and choose safe methods of treatment suitable for use in this category of patients.
4. Implement health education programs and develop information materials for physicians, nurses, patients, and their relatives.

1. Screening of depressive disorders among patients of a polyclinic (based on a special questionnaire).
2. Clinical diagnosis of depressive disorders in accordance with the ICD-10 criteria.
3. Selection of patients for referral to depression therapy based on the minimum expression of 15 scores according to Hamilton's depression scale and absence of any contraindications against polyclinic therapy.
4. Pharmacotherapy of depression: monotherapy with a selected antidepressant (during at least one month); if there is no effect, change of antidepressant, followed by psychotherapy or combined therapy.
5. Clinical evaluation of the therapeutic effect.
6. Continued observation for two months upon completion of the main course of therapy to evaluate functional and symptomatic change.

Based on the data collected to date, one can claim a high identification rate of both affective disorders (some half of those who apply to polyclinics) and clinical forms of depression themselves (about 25 percent, with some 15-20 percent of the applicants having a clinical evaluation of depression that warranted the prescription of antidepressants).

It is important to note a substantially higher positive treatment response rate for depression with polyclinic therapy-perhaps due to the moderate expression and lack of complications-as compared with those forms of depression that psychiatrists usually deal with at mental health institutions. While positive treatment response does not exceed 80 percent for regular patients of a psychiatric hospital, significant reduction of depression symptoms or full remission is observed in more than 90 percent of outpatients of primary care settings.

In addition to the direct effect of therapy on depression, there are certainly humanitarian reasons for providing patients suffering with depression timely and adequate services in the most accessible, familiar, and non-stigmatic environment possible.

References

1. C. J. L. Murray and A. D. Lopez, eds., The Global Burden of Disease, Summary (Harvard School of Public Health, Cambridge, Mass., 1996).
2. R. Desjarlais, et al., World Mental Health: Problems and Priorities in Low-Income Countries (Oxford University Press, New York, New York, 1995).
3. E.B. Panicheva, "A population-specific study of periodical endogenous psychoses," J. of Neuropathological Psychiatry 82(4), 557-65 (1982)
4. D.A. Regier et al., "The de facto US mental and addictive disorders service system: Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services," Arch. Gen. Psychiat. 50, 85-94 (1993).
5. R.C. Kessler et al., "Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States," Arch. Gen. Psychiat. 51, 8-19 (1994).
6. T.B. Ustun and N. Sartorius, eds., Mental Illness in General Health Care: International Study (John Wiley and Sons Ltd., Chichester, 1995).

Valery N. Krasnov, MD, professor, is the director of the Moscow Research Institute of Psychiatry of the Russian Ministry of Health and president of the Russian Society of Psychiatrists.