October is a great month. Cool nights, leaves turning, and pumpkin-spiced everything.
It is also a month set aside for thinking about our emotional health. If you’re like me, I suspect that shorter days and longer nights are not your preference. As we anticipate the winter ahead, thinking about how we cope with our emotional health makes sense. What this may mean is being willing to be screened for how our mental health is doing.
The importance of early mental health screening is well known. Approximately one-half of mental health conditions start by age 14 and 75% by age 24, per the National Association of Mental Health. Screening and identifying problems early help improve outcomes. Unfortunately, there is an average delay of 11 years between symptoms first appearing and intervention.
In my experience, there can be a lot of resistance to being screened for things like depression. Many are afraid of being labeled and stigmatized. Some, like my parent’s generation, believed these feelings or symptoms were “just life” and a normal reaction to adversity. Patients sometimes believe that depression isn’t a “real” illness but actually some sort of personal flaw. Finally, many are just plain doubtful about the necessity or value of treatment. If you think about it, many symptoms of depression, like guilt, fatigue, and poor self-esteem, can get in the way of seeking help.
Depression is widespread in the United States. Between 2009 and 2012, 8% of people 12 years of age and older reported having depression for over two weeks. Depression is the main diagnosis for 8 million visits to physician offices, clinics, and emergency rooms each year. Depression impacts patients in many ways. They are more than four times more likely to suffer a heart attack than those without depression.
As can be seen, depression is the most common psychiatric disorder in the general population. As a primary care provider for several decades, you quickly learn that patients rarely come in saying, “I’m depressed.” Much more likely, they show up with what we call somatic symptoms. These are things like headaches, back problems, or chronic pain. If we fail to screen for depression, only 50% are identified.
When depression remains untreated, it can lead to a decreased quality of life, worse outcomes with chronic medical conditions like diabetes or health disease, and an increased risk of suicide. Also, the impact of depression extends beyond the individual patient, negatively impacting spouses, employers, and children.
There are known risk factors for depression. These do not mean you will be depressed, but you might be at higher risk. They include prior depression, younger age, family history, childbirth, childhood trauma, recent stressful events, poor social support, lower income, substance use, and dementia.
Being depressed is not just being “down.” It usually means you have symptoms nearly every day for two or more weeks. They can include a down mood, loss of interest in usual things, trouble sleeping, low energy, poor concentration, feeling worthless, or thoughts of suicide.
What about older adults?
Over 80% of people 65 and older have at least one chronic medical condition. Twenty-five percent have four or more. What psychiatrists call “major depression” generally occurs in about 2% of older adults. Unfortunately, some of these symptoms are blamed on other conditions instead of sadness.
In older adults, risk factors for depression include loneliness, loss of function, a new medical diagnosis, helplessness because of racism or ageism, heart attack, medications, chronic pain, and grief because of loss.
Many doctors are choosing to do a two-step screening process to help identify those patients who might be depressed. The more common tools are the PHQ-2 and PHQ-9. PHQ stands for Patient Health Questionnaire. Both PHQ-2 and PHQ-9 are subsets of the longer PHQ screening tool.
For example, the PHQ-2 consists of the following two questions:
- Over the past month, have you felt little interest or pleasure in doing things?
- Over the past month, have you felt down, depressed, or hopeless?
If you responded positively to either or both questions, it does not mean you definitely suffer from depression, just that it would prompt your caregiver to explore further how you are doing.
Depression symptoms lead to a significant burden of disease from both a length of life perspective as well as a quality of life. The impact of depression on total life span exceeds the effects of heart disease, diabetes, high blood pressure, asthma, smoking, and physical inactivity. Also, depression, alongside any of these and other medical conditions, worsens health outcomes.
So, this October, do yourself a favor (or encourage a loved one). Take stock of where you are emotionally, and if there is any question of whether you might be dealing with a mental health issue, like depression or otherwise, talk to your health care provider.
There is real help.
Psychiatry Epidemiol. 2015;50(6):939. Epub 2015 Feb 7