In the primary care setting, mental health has become a prominent and emerging concern. At times, depression has often been overlooked and not been a focus of the office visit, especially when patients come in with other organic medical complaints.
Multiple studies have shown that more than 50% of depression cases have been overlooked or missed in the primary care clinic setting1. Generalized Anxiety Disorder has been shown to cause decreased quality of life and impairments in the activities of daily living, and can significantly contribute to high healthcare costs2.
It is important to screen for such psychiatric disorders, especially in those patients who suffer from chronic medical illnesses such as heart disease, diabetes or cancer. Studies have shown that up to 85% of patients with cancer are suffering from concurrent psychiatric disorders or have clinically significant psychological stress3. These mental health disorders are often missed or not diagnosed in up to 50% of these patient groups, which can further impact the trajectory of their cancer treatment. Often times, dealing with such chronic ailments that require multiple medications, each requiring monitoring with frequent blood tests and clinic visits, can be trying on the mind, leading to imbalances to the dopamine and serotonergic pathways.
In our clinic practice setting, a patient screening questionnaire (PHQ) for depression is conducted at each and every visit. The initial screening is done with a two-part questionnaire triaged by the medical assistant. If we find a positive screen, it is up to the clinician’s discretion to further evaluate with either an extended nine-part questionnaire or other forms of screening assessments. The PHQ-2 questionnaire has been found to have a sensitivity of 76% and a specificity of 87 %, which makes it a simple way to screen and recognize depression in the majority of patients4. These simple screening tools allow clinicians to initiate a conversation about mental health issues as part of the medical visit that would have otherwise been bypassed and brushed under the rug.
What has been of concern is the fact that many of these patients do not realize that what they are feeling is some sort of psychiatric disorder, anywhere from mild forms of anxiety to concerning forms of schizoaffective disorders. It does take experience and perception to isolate out these concerning cases and to tactfully approach it with the patient so they would understand and accept that mental health is affecting their quality of life.
In addition, it is important to recognize that certain mood disorders like depression may, in fact, be a symptom of other medical conditions such hypothyroidism, lupus and even certain vitamin deficiencies such as Vitamin B12. Such chronic medical conditions can often worsen if there is an underlying undiagnosed mental health disorder that is not being treated.
The primary care setting is a great way to introduce and open the door to a discussion about mental health, as quite often patients are suffering from some sort of anxiety or depression that has not been officially “labeled” or diagnosed. Using simple diagnostic questionnaires such as the PHQ allows clinicians to quickly identify such mental health concerns and initiate treatment that can improve the patient’s quality of life. Furthermore, breaking down the stigma of being labeled as medically “depressed” or “anxious” is crucial to allow patients to feel comfortable bringing up these concerns to their physician.
- Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Leicester, UK. 2009 Aug;374(9690):609-19. Epub 2009 Jul 27
- Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Boston, Massachusetts. Arch Gen Psychiatry. 2005;62(6):617.
- Holland JC, Andersen B, Breitbart WS, Buchmann LO, Compas B, Deshields TL, Dudley MM, Fleishman S, Fulcher CD, Greenberg DB, Greiner CB, Handzo GF, Hoofring L, Hoover C, Jacobsen PB, Kvale E, Levy MH, Loscalzo MJ, McAllister-Black R, Mechanic KY, Palesh O, Pazar JP, Riba MB, Roper K, Valentine AD, Wagner LI, Zevon MA, McMillian NR, Freedman-Cass DA. Distress management. New York, NY. J Natl Compr Canc Netw. 2013;11(2):190.
- Manea L, Gilbody S, Hewitt C, North A, Plummer F, Richardson R, Thombs BD, Williams B, McMillan D. Identifying depression with the PHQ-2: A diagnostic meta-analysis. J Affect Disord. 2016;203:382. Epub 2016 Jun 6
Michael Park, D.O., graduated with a bachelor’s degree from University of California, Los Angeles, and his Master of Medical Sciences from Drexel University College of Medicine in Philadelphia. He earned his Doctor of Osteopathic Medicine degree from Touro University Nevada College of Osteopathic Medicine. Dr. Park completed his internship and residency in internal medicine at Coney Island Hospital in Brooklyn, New York, where he served as Chief Resident. He is a member of the American Osteopathic Association. He has been practicing at Piedmont Physicians group in Atlanta, GA for the last 7 years as a primary care physician.