Awareness About Depression: Title and subTitle BreakImportant for All Physicians

The articles published in this theme issue of THE JOURNAL were selected (after editorial and peer review) from more than 100 papers submitted in response to a call for papers¹ on depression. These articles not only cover a range of specific aspects of depression, they also highlight a central challenge—depression is a major public health problem that calls for awareness on the part of virtually all physicians.

The scope of major depressive disorder in the United States is addressed by the landmark epidemiological study reported by Kessler et al.² This nationally representative household survey of the 48 contiguous United States conducted in 2001-2002 found that the lifetime prevalence of major depression is 16.2%, and the 12-month prevalence (ie, meeting criteria for major depression in the preceding year) is 6.6% among US adults, usually associated with substantial symptom severity and role impairment. Survey questions regarding treatment indicated that even though 57% of the respondents with 12-month major depressive disorder had received some treatment in the preceding year, less than 25% of those respondents had received treatment meeting criteria for being at least minimally adequate.

The staggering economic costs of untreated or undertreated depression are documented by Stewart et al.³ The authors present 2002 survey results indicating that the lost productive time costs due to depression in the United States amount to an estimated $44 billion per year, not including labor costs associated with disability time or costs related to treatment. Some of the productive time lost by workers with depression was due to absenteeism, but the majority of the cost was explained by decreased performance while at work (presenteeism).

The National Comorbidity Survey Replication by Kessler et al and labor cost survey by Stewart et al were limited to the United States. However, the global scope and impact of depressive illness have been established by previous epidemiological studies reporting that major depression has an annual prevalence varying from about 1% to 6% in community samples around the world.⁴ Furthermore, there is evidence that the worldwide prevalence of depression is increasing over time in younger cohorts.^{2 ,5} The increasing international impact of depression is reflected in the projection by the World Health Organization–supported Global Burden of Disease Study that major depression will become the second leading cause of disability worldwide by 2020 (second only to ischemic heart disease) and the leading cause in developing regions.⁶ This projection highlights the importance of developing and testing high-quality, effective, and culturally appropriate treatments for depression in international settings. The randomized controlled trial by Bolton et al⁷ of the effectiveness of group interpersonal psychotherapy in rural Uganda provides an excellent model of this kind of needed research, including careful attention to informed consent, full involvement of local health care workers and leaders, and use of treatment techniques that can continue to be implemented after the research has ended if those techniques are found to be effective.

The brain imaging study by Bremner et al⁸ provides new information about the neural circuitry of depression and the introduction section of that article provides a useful summary of the evidence that alterations in serotonergic and noradrenergic functions in the brain are involved in depressive illness. Due to the complexity of brain functions underlying mood disorders and the difficulty of identifying and understanding them, "the etiology and pathophysiology of depression have not been precisely defined" as noted by Insel and Charney.⁹ These authors from the US National Institute of Mental Health summarize a strategic plan for mood disorders research that addresses a number of current gaps ranging from the need for better understanding of genetics and brain function to clinical applications of the best knowledge now available.

One of the clinical applications included by Insel and Charney as a priority for research is the development of strategies that will specifically prevent suicide in patients with depression. The topic of depression and suicide among physicians is addressed by Hendin et al¹⁰ who report a consensus statement based on a workshop sponsored by the American Foundation for Suicide Prevention. This article should be of particular interest to physicians and raises some very pointed issues about how physicians deal with or avoid dealing with depression—sometimes with fatal consequences—and the risk it carries for suicide in ourselves and our fellow physicians.

The current evidence regarding effective strategies for improving the management of depression in primary care is addressed in the systematic review by Gilbody et al.¹¹ This is an important clinical problem, since despite the high prevalence and impact of depression, it is commonly not recognized in primary care practice,¹² and treatment for depression in such settings often does not meet evidence-based treatment guidelines for either drug therapy or psychotherapy.^{2 ,11} The US Preventive Services Task Force recently recommended "screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up."¹³ The screening can be as simple as asking 2 questions about mood and anhedonia: "During the past 2 weeks, have you felt down, depressed, or hopeless?" and "During the past 2 weeks, have you felt little interest or pleasure in doing things?"¹³ Positive responses should then trigger a more complete interview for depression symptoms, definitely including a query about thoughts of death or suicide.

If depression is identified, what works to improve outcomes in primary care settings? The review by Gilbody et al found that simple educational strategies were ineffective, while effective strategies used techniques to increase the likelihood of successful drug or psychotherapy treatments, often involving collaboration with psychiatrists and other mental health specialists for treatment or case management.

The challenge for all physicians regarding depression is to learn to recognize it, in themselves as well as in their patients, and to surmount the obstacles against effective treatment. These obstacles include the feelings of hopelessness and worthlessness that are characteristic symptoms of depression, stigma about mental disorders and their treatment, and the institutionalized stigma that limits access to effective treatment for depression and other mental disorders.¹⁴ As indicated by Keller¹⁵ in a thoughtful discussion about defining optimal treatment outcome in depression, full remission should be the goal of treatment, a goal that assumes particular importance in the face of evidence that depression is usually a recurrent or chronic disease.¹⁶ Increasing the ability of physicians to attain that goal for more people who suffer from the multiple impacts of the illness of depression is surely a worthy endeavor for research, clinical practice, and social policy.