12 March 2004

Depression's symptoms often physical

Mild-to-moderate depression, by far the most common form of the disease, is easily diagnosed and treated by doctors.

Mild-to-moderate depression, by far the most common form of the disease, is easily diagnosed and treated by doctors.

So, why do only 30 percent of those suffering from depression seek help? Also, why are only half of those accurately diagnosed, and only 20 percent of those people treated appropriately?

Because the headaches, fatigue, and aches and pains that are often the physical manifestations of depression go unrecognized in many primary-care doctors' offices, mental health experts said during a depression workshop in New York City. Add to that the lingering stigma of depression, and a managed-care system that's reluctant to pay for easy access to therapy.

The workshop, sponsored by the University of Michigan Depression Center, focused on ways to better treat a disease that affects approximately 10 percent of the U.S. population, or nearly 20 million people annually, according to the National Institute of Mental Health.

Physical symptoms
A key to diagnosing depression is to know the disease exacts more than a psychological toll -- it has a strong physical component as well. It's often that physical pain that brings patients to their doctors. However, many primary-care doctors don't make the connection between a patient's aches and pains and a possible depression, panel members said.

"Eighty percent of patients with depression come to the doctor with exclusively physical symptoms," said Dr. David L. Dunner, a psychiatrist at the University of Washington in Seattle.

Headache, pain in the back, stomach, joints, muscles or chest, and fatigue are some of the most common physical symptoms that could indicate an underlying depression, he said. Other symptoms are significant appetite and weight changes, difficulty concentrating, feelings of worthlessness and guilt, and suicidal thoughts.

Depression also often has a genetic component -- if some family members suffer from the disease you're more susceptible to it. Depression can also be "episodic," meaning it can come and go.

Finally, while depression can strike early in one's life, it's often not diagnosed until much later when it is harder to treat, panel members said.

"There is so much complexity between the physical and mental symptoms that they're hard to separate," said Dr. Thomas L. Schwenk, a primary-care physician at the University of Michigan at Ann Arbor.

Case study
Melanie Nau is a 38-year-old woman from Ann Arbor who spoke about how her depression, which struck during her mid-20s and went undiagnosed for five years.

"I had insomnia, headaches, jaw pain, chronic fatigue," Nau said. "I was diagnosed with mononucleosis, but I thought, mononucleosis that lasts for four years?"

Finally, another doctor diagnosed her as has having depression, and she has been under successful treatment for about a decade with a combination of medication and therapy.

"When you're suffering, you don't realize what's normal. I felt like an observer in my own life. Now I feel a lot more engaged with my life," said Nau, who is married, has a daughter and works.

The stigma of depression is another roadblock to people getting help, the health professionals said.

"In 25 years of medical practice I've never had a patient who said they were depressed, although thousands have met the criteria. I've had patients say, 'I think I may need Paxil [a common antidepressant]. When I say, 'Oh, you think you might be depressed?' they say, 'Oh, no.' They can never bring themselves to say the word," Schwenk said.

It's not just patients who are uneasy about depression. Doctors, too, are often reluctant to raise the subject with their patients, even though they may be clearly exhibiting signs of the disease.

"Often, the core problem of depression is never asked about. The medical profession isn't tuned into the problem," said Dr. John F. Greden, director of the University of Michigan's Depression Center.

Add to that the constraints of the managed-care system, which often either doesn't cover or limits the number of therapy visits. Then there's the fact that some health plans don't reimburse doctors for a depression diagnosis. Also, the time needed for a proper diagnosis for depression is a luxury unavailable to many rushed primary-care physicians, Greden said.

"The entire system manages to view depression differently from other [health] problems," Schwenk said.

Improving care for depression is a big task, said the experts on the panel. However, even without major changes to the managed-care system, there are still things doctors -- and patients -- can do.

"We try to normalize depression," said Dr. Rollin M. Gallagher, a panelist who directs a pain center at Hahnemann University School of Medicine in Philadelphia. "We imbed questions about depression into standard care. We ask in the beginning of treatment and continue asking."

Schwenk said people who think they might be depressed should talk to their doctor.

"Eighty percent of depression is easily diagnosed and treatable, and the majority of patients who receive treatment for depression receive it from the primary physician," he said.

The most successful treatment is a combination of supportive counseling by the primary-care doctor, medication, and, if possible, arranging for more sophisticated counseling for the patient, he said.

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