Depression Overview

Depression is a relatively common mental health issue impacting people across the globe. The CDC (2019) estimates that 1 in 5 adults reportedly experience depressive symptoms. While symptom severity varies amongst individuals, depression continues to be the number one contributor to disability worldwide (WHO, 2020). Primary care physicians are often the first line intervention for those struggling with depression, with about 79% of anti-depressants being prescribed by primary care doctors (Barkil-Oteo, 2013). Physicians face many challenges in effectively identifying and treating mental health disorders, with depression going unrecognized about half the time in primary care settings (APA, 2017). This is often due to time constraints, lack of formal guidance and training on screening tools/ procedures, stigma associated with mental health diagnoses, patient guardedness, and lack of sufficient referral resources (Nollett et al., 2020; Nutting et al., 2002).

Depression Screening Tools

The two commonly used screeners for depression are the Patient Health Questionnaire – 2 (PHQ-2) which is used as an initial measure and, if positive, the Patient Health Questionnaire- 9 (PHQ-9) is then administered. Both measures assess for the various symptoms of depression, with each item carrying a specific numerical value that is then added to determine if symptoms cross the threshold of clinical significance. These tools have been translated into multiple languages and can be accessed at: www.phqscreeners.com

Strategies for Screening

1. When discussing mental health difficulties, it is important to use plain, non-stigmatizing language.

2. As an introduction to the topic, discuss and describe a holistic approach to wellness which includes both mental and physical wellbeing. Explain to patients that everyone is asked the same questions. "We ask everyone the same questions in order to assess all areas of life." Make sure to ask for consent before proceeding with the questions/assessment. "Would it be ok if I proceeded with my questions?"

3. Use open ended questions. "What stressors do you have in your life at the current time and how does this stress impact you?"

4. Reflect back what the patient shared to communicate understanding and validate the patient’s experience. "It sounds like you have a lot of responsibilities and many different things you have to take care of."

5. Assess for symptoms in a conversational tone and normalize the experience "Sometimes when people are really stressed out, the stress can impact their mood, sleep, and other aspects of their life. In the last couple of weeks have you felt [insert depressive symptoms here]?"

6. Assess the patient’s support system and current coping mechanisms to better understand how they manage their various stressors. "How do you deal with the various stressors in your life? Who makes up your support system? What kinds of things do you do to make yourself feel better during moments of high stress?"

7. Ask for consent to offer resources. "Would it be ok if I offered you some information on additional resources of support?"

8. Use non-clinical language to discuss resources – a formal therapy experience is not the only option. "There are different resources available if you feel you could use some support as you continue navigating the various responsibilities in your life. There are online resources, support phone lines, and also therapy which some people find useful, just to have a place where they can unload their stress to an objective person, or to feel like they have someone on their side."

9.  Thank the patient at the end of the assessment and check to see if any important information was missed. "Thank you so much for sharing all of that information. Was there anything with regard to your health and wellness that I didn’t explicitly ask about but that you think I should know?"

Resources for Patients and Physicians

1. NY Project Hope Hotline (1-844-863-9314)

2. NYC WELL–Mental health support (1-888-NYC-WELL)

3. Free digital mental health resources through NYC WELL https://nycwell.cityofnewyork.us/en/covid-19-digital-mental-health-resources/

4. Zencare (directory for finding a therapist in select states) https://www.zencare.co/

5. Psychology Today (directory for finding a therapist across all 50 states and Canada) https://www.psychologytoday.com/us

6. Mount Sinai Outpatient Mental Health Clinics

7. **For physicians only** Physicians Support Line (1-888-409-0141)
   https://www.physiciansupportline.com/

8. COVID Coach App available on the App Store and Google Play

References:

American Psychiatric Association [APA] (2017). Depression Screening Rates in Primary Care Remain Low. Retrieved from: https://www.psychiatry.org/newsroom/news-releases/depression-screening-rates-in-primary-care-remain-low

Barkil-Oteo A. (2013). Collaborative care for depression in primary care: How psychiatry could "troubleshoot" current treatments and practices. The Yale Journal of Biology and Medicine, 86, 139–146.

Centers for Disease Control and Prevention [CDC] (2019). Symptoms of Depression Among Adults: United States, 2019. Retrieved from: https://www.cdc.gov/nchs/products/databriefs/db379.htm#:~:text=During%202019%2C%20approximately%20one%20in,and%202.8%25%20experiencing%20severe%20symptoms.

Nollett, C., Bartlett, R., Man, R., Pickles, T., Ryan, B., Acton, J. (2020). Barriers to integrating routine depression screening into community low vision rehabilitation services: A mixed methods study. BMC Psychiatry, 20, 1-13.

Nutting et al. (2002). Barriers to initiating depression treatment in primary care practice. Journal of General Internal Medicine, 17, 103-111.

World Health Organization [WHO] (2020). Depression. Retrieved from: https://www.who.int/news-room/fact-sheets/detail/depression

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