Epidemiology of Depression in Primary Care Wayne Katon, M.D. and Herbert Schulberg,

Abstract: Major depressive disorder has been recently found to be associated with high medical utilization azzd more fzozctional impairment than most chronic medical illnesses. Major depression is a common illness among persons in the community, in ambulatory medical clinics, and in inpatient medical care. Studies have estimated that major depression OCCUYS in 2%-4% of persons in the community, in 5%-10% of primary care patients, and lo%-14% of nzedical inpatients. In each setting there are two to three times as many persons with depressiue symptoms that fall short ofmajor depression criteria. Recent studies have found that in one-third to one-half of patients with major depression, the symptoms persist over a 6month to one-year period. The majority of longitudinal studies have determizzed that severity of initial depressive symptoms and the presence of a conzorbid medical illness were predictors of persistence of depression.

Introduction Multiple community studies utilizing structured psychiatric interviews and sizable samples have demonstrated that 2%-4% of people suffer from major depression [1,2]. This disorder is associated with more functional disability than most chronic medical illness [3] and the increased reporting of medically unexplained somatic symptoms [4]. Not surprisingly, seriously depressed individuals have been found to utilize health care services three times as often as nondepressed controls [5]. Over the course of time, over half of community residents with major depression are seen in a primary

Division of Consultation-Liaison, Department of Psychiatry and Behavioral Sciences, University of Washington Medical School, Seattle, Washington (WK), and Western Psychiatric Institute, University ofPittsburgh, Pittsburgh, Pennsylvania (HS). Prepared for AHCPR Panel on Guidelines for Depression. Address reprint requests to: Wayne Katon, M.D., Department of Psychiatry and Behavioral Sciences, RF10, University of Washington, Seattle, WA 98195. GeneralHospital Psychiatry14, 237-247,

1992 0 1992 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010

Ph.D.

care clinic, whereas only 20% are seen by mental health practitioners [6]. Given that the primary care sector is so extensively utilized by depressed persons, three distinctive methodologies have been utilized to investigate the epidemiology of affective disorders in such settings. The first analyzes the prevalence of “conspicuous psychiatric illness,” which is the psychiatric illness recognized by the primary care physician and recorded in the medica charts [7]. The second type of methodology screens primary care patients with depression rating scales which generally are sensitive (few false-negatives) but not specific (many false-positives). The lack of specificity results from the fact that primary care patients with organic illnesses (i.e., hypothyroidism, cancer, or diabetes) and psychiatric illnesses (i.e., alcoholism, schizophrenia, adjustment reactions, and bereavement) may be affectively distressed, but not severely enough to suffer from major depression. The third and most recently developed method for studying the prevalence of depression is through structured psychiatric interviews that generate diagnoses within the framework of DSMIII or ICD-9. As there are no laboratory tests that can define psychiatric illness, the methodology based on structured interviews and operational criteria is considered the “gold standard” in measuring prevalence of psychiatric illness. Of the several possible epidemiologic indices to be calculated for mood disorders, point prevalence rates are the most commonly reported in both the medical and psychiatric literatures. Period prevalence rates and incidence rates have been less frequently reported for depressive illness; indeed, very few such studies have been conducted in the primary care sector. In the following analysis of the available research literature, we review epidemiologic findings and then suggest studies needed 237 ISSN 0163-8343/92/$5.00

W. Katon and H. Schulberg

to better understand the distribution of affective morbidity experienced patients.

and course by medical

Methodology The National Library of Medicine performed a Medline literature search for journals published between 1975 and 1990. This particular time period begins with the formulation of standarized Research Diagnostic Criteria [8] and coincides with their subsequent availability to epidemiologic investigators. Studies published prior to 1975 necessarily utilized the more imprecise diagnostic criteria of DSM-II. Rates generated by this earlier nomenclature are deemed too unreliable for purposes of this epidemiologic analysis. Key words guiding the Medline search included depression’s epidemiology, prevalence, incidence, course of illness, as well as primary care. A total of 983 abstracts were thus identified. In addition to reviewing this body of material, the authors also scanned the bibliographies of depression’s epidemiology in medical settings which they and others cited in earlier reviews. A total of almost 1,000 journal articles were thus assembled. The following criteria were then applied to derive the approximately 83 studies referenced in this report: the papers were published in the English language; the studies were conducted in medical settings located in the United States or Western Europe; and original data were presented quantitatively. This winnowed body of epidemiologic research may be classified as pertaining to either ambulatory medical practices or general hospital inpatient settings. Where possible, findings are subclassified according to whether the studied population was primarily adult or geriatric. The preponderance of available epidemiologic research was found to deal with the former group in ambulatory medical practices. Therefore, we can estimate point prevalence rates for depression among adults when screening instruments as well as structured interview schedules administered to medical outpatients.

Results “Conspicuous” psychiatric morbidity refers to the patients recognized by physicians as having psychiatric illness [7]. Multiple studies have determined that physicians do not accurately diagnose

238

a large percentage of patients with depression. These undiagnosed patients with depression are thus false-negatives when only conspicuous psychiatric morbidity rates are described. Also, a smaller percentage of patients who are diagnosed as depressed by physicians do not meet criteria for depression “caseness” on structured psychiatric interview (these are false-positives). Several large studies have determined that physicians’ prevalence of diagnoses of depression varies between 1.5% and 4.5% [9-111. In an innovative recent study, Casey et al. [12] interviewed 171 consecutive patients, diagnosed by a primary care physician as having a primary psychiatric disturbance, [12] using the Present State Examination (PSE) and Catego program [13]. Seven percent of primary care patients over a one-year period were diagnosed by the PSE as meeting psychiatric caseness criteria and nearly half (3.4%) were depressed. Table 1 outlines the numerous studies of ambulatory patients in which investigators administered depression self-rating scales [14-451. The finding of a wide range in the prevalence of persons reporting extensive affective symptoms (approximately 9-30% likely results from critical methodologic differences among the studies. These include the following: 1. The different scales used (e.g., Beck Depressive Inventory [46], Zung Self-Rating Depression Scale [47], Center for Epidemiologic StudiesDepression Scale [48] 2. The different cutting scores applied with the same screening scale 3. The different populations surveyed, e.g., university clinics which often comprise an overrepresentation of lower socioeconomic status patients; health maintenance organizations with predominantly middle class populations; American, British, or Canadian general practices, and so forth 4. Selection factors in the population studied, such as random versus consecutive sampling, high patient refusal rates producing biased respondent groups, procedural variations, and so forth 5. Inadequate sample sizes affecting the reliability of reported rates. Table 2 presents the 11 studies employing structured psychiatric interviews and specific diagnostic criteria to determine the prevalence of major depression in primary care [43,49-571. Although

Epidemiology

Table 1. Self-rating

scale-Depression

in primary

of Depression

in Primary Care

care

No. subjects

Cutting score and prevalence

Author

Setting

1141

HMO outpts middle class Wisconsin

526

Beck Depression Index; Cutting score 13

12.2% mild, 5.5% moderate, 0.6% psychotic depression

1151

University primary care med; almost half minority, 65% medicaid/ medicine

375

Beck short form

18% mildly depressed, 24% moderately depressed; 8% severely depressed

[I61

Australian primary care, clinic

564

Beck Depression Index

25.1% of women & 16.6% of men scored >lO

1171

Fam pract, university

147

Beck short form: cs=13 Zung SDS: CS=60

16% moderate to severe depression

WI

Fam pract clinic, university practice

222

Beck Depression Index; Cutting score = 21

14% 221 on BDI

[I91

OB clinic, OB private practice

295

Beck Depression Index

% scoring >lO Prepartum 22%, 26%; Postpartum 25%

WI

Duke primary care med clinic: 81% female, 72% white

1086

Zung SDS

13.2% scored 255

PII

Duke primary care med; excluded pregnant & nursing women

499

Zung SDS

12% scored 255

1221

Duke primary care

1537

Zung SDS

Zung 50 or more: blacks 23%, whites 21%; 60 or more: 6% for both groups

~231

VA general med clinic

202

Zung SDS

21% 260

95

Zung SDS

19% minimal depression 50-59 25% moderate 60-69 7% severe 70+

199

Zung SDS

41% had SDS of 50 or more 17% had SDS of 60 or more 7% > 69

404 Age 60 +

Zung SDS

24% score 260

practice

Scale

(x age 69.4) v41

Primary care clinic at UCLA

v51

Fam pract clinic univ practice

WI

VA primary care clinic, Seattle

v71

General pract Sidney

251

Zung SDS

21% score 240

P31

Family pract clinic

298

Zung SDS, cutting score 250

94.% 250 F: 14% M: 2.5%

239

W. Katon and H. Schulberg

Table 1. Continued No. subjects

Setting

Author

Cutting score and prevalence

Scale

1291

VAMC general med clinic

880 X age 59.1

Zung SDS

16.6% 250

j301

Family pract office

166 age 60-86

Zung SDS

25% 260

(311

Univ. family practice

123

Zung SDS

24% 2 55 28% 2 13 33% on medical chart audit

[321

VA gen med clinic

111

Zung SDS, Popoff

24% 260 27% more than cut-off score

1331

Fam pract residency

383

Popoff 15question depression inventory

27% overall Men 15% Women 32%

[341

Canadian family physicians

1250 pts

CES-D

33.2% scored 16 or more

1351

Primary care & ob-gyn pts.

1937

CES-D cutting score of 16

21% scored 16 or greater

j361

Community

fam. pract.

262

CES-D; cutting score >16

27% scored 216 on CESC

1371

U. Alabama GIM clinic

150

CES-D

48% scored 216

1381

Family MD waiting room

809

CES-D

64% scored 210

1391

HMO, Columbia,

1921

CES-D

21% 216

1401

University

618

CES-D

19% 216-26,

1411

Community

105

IDD & DSM-III criteria

6.7%

1421

Fam pract clinic

104

Health Report Checklist

17%-4 or more psychological & vegetative symptoms depression

clinic

Maryland

GIM clinic univ. clinic

[431

RAND MOS Boston,

LA, Chicago

[441

Family pract office

j451

Rural primary care med, largely white middle class

20,128 538 67% Age O50; 33% 50-75 1010

the investigators administered three different structured psychiatric interviews (Diagnostic Interview Schedule, or DIS [58], PSE [13], and Schedule for Affective Disorders and Schizophrenia, or

240

Rand screener

17.3%-19.8%

Physician chart

23.5%

SCL-90 depression items

28.3% 29, 18.3% 212, 8.8% 219

SADS

[59]) in three

States,

Great

16% 227

of

different countries (United and The Netherlands), the studies generated remarkably similar findings. The point prevalence of major depression was found to Britain,

Epidemiology

Table 2. Structured

Author

interview

No. subjects

studies-Major

depression

in Primary Care

in primary care

Prevalence of major depression

Interview

of Depression

Prevalence of other affective disorders

[491

1242 screened with GHQ; 730 patients interviewed

DIS & DSM-III

5% major depression

3.7% dysthymic

disorder

1501

1554 screened with CFS-D; 294 completed DIS

DIS & DSM-III

6.2% major depression

3.0% dysthymic disorder

and adjustment

(511

ECA users of health care

DIS & DSM-III

M: 3.3%-6.5% F: 6.9%-9.3%

Not reported

[431

RAND Medical Outcome Study, LA, Chicago

DIS & DSM-III

4.1%-5.4%

Not reported

t521

165 family health center, San Antonio

DIS & DSM-III

F = 9.8 MDD or dysthymia; M = 11.1 MDD or dysthymia

Not reported

[401

Univ. gen intern med clinic 618 patients

DIS & DSM-III

6.6% prevalence depression

Not reported

[531

Univ. gen intern med: 65 patients

DIS & DSM-III

7.7% prevlence depression

1541

1072 screened with GHQ; 247 completed SADS-L

SADS-L and RDC

5.6% major depression

5.0% intermittent depression; 3.4% minor depression

[551

1055 screened with SCL depression subscale; interviewed 260

SADS-RDC

2.2% with major depression; 6.4% masked major depression

3.6% episodic minor depression; 2.1% chronic depression

[561

2308 screened with GHQ; 1019 interviewed

SADS & PSE RDC

4.8% major depression

5.0% intermittent depression; 3.4% minor depression

[571

2237 screened GHQ

PSE & PSE-10 Bedford College criteria

5.6% cases of depression

4.7% borderline depression (similar to minor depression)

with

range from 4.8% to 8.6% across instruments and countries. Thus, structured instruments of the diagnostic type produce relatively uniform prevalence rates, whereas self-rating scales measuring affective distress generate more variable findings. Less severe forms of depression are even more prevalent in primary care. Of the 11 ambulatory studies with structured interviews, prevalence rates of other affective disorders reported include 1) dysthymic disorder (2.1%-3.7%), 2) minor depression (3.4%-4.7%), and 3) intermittent depression (5.0%).

of major of major

separately

Not reported

Epidemiology of Depression in Medical Inpatients Most studies have investigated the epidemiology of depression in ambulatory medical practice, but a smaller number have focused on the prevalence of this disorder among patients hospitalized on the medical wards of general hospitals. Reports of the frequency of diagnoses assigned by consultationliaison psychiatrists are not germane to this analysis as these clinicians diagnose only patients referred for assessment and not the total hospital 241

W. Katon and H. Schulberg

Table 3. Prevalence

rates of depression

Author

Setting

in general hospitals Assessment

N

Cutting score and prevalence

1611

Medical wards, Italy

325

x

age 41.4

CES-D

58% 216

[Ql

Medical wards, Netherlands

220

x

age 56.5

BDI

32% 213

1631

Medical wards, USA

71

x

age 36.7

BDI

38% 213

1641

Medical wards, Chicago teaching hospital

335 X age 57.1

BDI

22% 13-20; 8% 21-30; 5% 230

1651

Medical services, Yale Med Center

150 ages 18-75

BDI

24% 214

tQ31

General hospital, Italy

201 x age 43.9

Zung

20% 250

(671

Medical wards, England

170 X age F 59.3 M 55.6

GHQ, SPI, depressive illness

45% >12 11%

[681

Medical services MCV, Richmond

455

x

age 49.2

Medical inpt screening test

27.9% “very depressed“

1691

Med-Psych

212

x

age 46.5

M.D. dx.

47.4% any Depressive Disorder 32.8% MDD

1701

General hospital, England

PSE

14.6% 25

unit, Duke UBC

453 age 17-70

population; thus, a denominator is lacking for the purpose of calculating epidemiologic rates. A recent large community study determined that people with one or more medical illnesses had a 41% increased risk of having any recent psychiatric disorder [60]. Affective, anxiety, and substance use disorders were each more prevalent in persons with medical conditions. Table 3 indicates that 10 of the inpatient studies published since the mid1970s are specific to adults [61-701; Table 4 indicates that another five studies are specific to geriatric medical inpatients [66,71-741. Most of these hospital-based research findings emerge from assessments performed with self-rating scales; only one research team administered a structured interview schedule to hospitalized adults [70] and three groups did so with elderly inpatients [71-731. As was noted with regard to ambulatory studies, prevalence rates of “possible” or “probable” depression among general medical inpatients differ markedly when the investigator administers selfrating scales. Among adult inpatients, such instruments generate point prevalence rates of depression ranging from 20% to 58% [60-691. By contrast, the study by Feldman et al. [70], which utilized the structured Present State Exam [13], found only 14.6% of inpatients surpassing ICD-9 criteria for 242

affective caseness. When elderly inpatients were assessed for depressive morbidity, rather wideranging prevalence patterns were found even when structured interviews were administered (Table 4) [66,71-741. Kitchell et al.‘s finding [71] that 45% of the tested inpatients met criteria for a major depression on the modified SADS [59] is extremely high for this population and possibly resulted from the small sample studied (N = 42) and/or the inclusion of neurology patients. The more representative, and likely valid, estimate of the prevalence of depression in elderly hospitalized patients is seen in the fairly uniform findings by Magni et al. [66], Rapp et al. [73], and Koenig et al. [71] that 6%-11.5% of this population experience major depression. In the geriatric studies that reported rates of other affective disorders, prevalence rates of dysthymic disorder ranged from 2.3% to 22.3%, adjustment disorder 3.1 to 8.6%, minor depression 3.3%, and intermittent depression 8.6%.

Course of Major Depression In the Epidemiologic Catchment Area Study (ECA), subjects with a diagnosis of major depressive disorder (N = 423) at first interview were re-

Epidemiology

Setting

[ 661

Geriatric hospital,

[71]

Medical and neurologic Seattle VAMC

[72]

Medical and neurologic Durham VAMC

[ 731

[74]

N

Italy

Assessment

Cutting score and prevalence

178 x age 75.6 Zung

42% 250; 24% 255; 12% 260

services,

42 x age 67.6

33% 260; 68% 210; 45% MDD

services,

130 X age 73.6 DIS, SADS

MDD: 11.5%; dysthymic disorder 2.3%; simple dysphoria” 15.3%; adjustment disorder 3.1%

Medical and surgical services, Jackson, MI VAMC

154 x age 69.3 SADS

6% MDD; 3.3% minor depression; 8.6% intermittent depression

Medical ward

220 x age 75.9

mood was present but not of sufficient or any other specific affective disorder.

“Simple dysphoria-depressed depression

in Primary Care

rates of depression in general hospitals among geriatric patients

Table 4. Prevalence

Author

of Depression

interviewed one year later (18.7% of patients could not be re-interviewed a second time) [75]. Of those diagnosed as depressed at the initial interview, 20% were still depressed one year later. Women aged 30 and older showed significantly increased rates of persistent depression. For women having less than a high school education or an unstable marital history, poor outcome was also more common. Conversely, age, education, or marital history were not associated with outcome among of depressed males. The clinical characteristics depression, such as more than 10 prior episodes, increased episode severity, and a higher comorbidity index (e.g., dysthymic disorder or panic disorder), were significantly related to depression’s persistence in the ECA study. In addition to this community study, one-year follow-up studies with psychiatric patients have found that chronicity ranges from 20% to 35% and that relapse accounts for another 20% to 30% of subjects [76-781. Turning to primary care populations, Table 5 describes the eight studies that assessed course of major depression in medical patients [16,35,23,79831. The first seven studies pertain to outpatients and the eighth to inpatients. The ambulatory care and inpatient studies demonstrated that one-fifth

Zung, Popoff, ID, modified SADS

Depression scale of SCL-90 8.2% major depression; & Geriatric Depression 22.3% dysthymic Scale followed by disorder; 6.4% atypical interview based on depression; 5.9% DSM-III adjustment disorder with depressed mood duration,

specificity,

or severity to warrant a diagnosis of major

to one-half of the patients with major depression are still a “case” at various follow-up times. Mode of assessment (rating scale or structured interview) appears unrelated to these findings. Because the investigators only interviewed patients at two points in time, patients who relapsed between assessments and remitted before the re-interview would not be counted as cases at time two. Thus, cross-sectional follow-up studies likely underestimate intermittent relapse but accurately measure persistent chronicity. Virtually all follow-up studies suggest that severity of initial depressive episode predicts persistence [16,35,79-81,831. Chronic medical illness is also a predictor of persisting depression in the majority of studies investigating course of affective illness [23,35,79,80,83]. Poor social adjustment was a risk factor for poor outcome in two studies but not in the others [79,80].

Conclusion The extensive research data reviewed suggests that the prevalence of major depression increases linearly as studies move from the community (2%4% prevalence) to the primary care clinic (5%-10%) 243

W. Katon and H. Schulberg

Table 5. Course of depression

Author(s)

No. subjects

in medical

patients Six-month to one-year follow-up

Predictive factors of psychiatric illness in second interview

Clinical interview schedule

93 patients successfully followed and 48 (52%) were no longer a “case” at 1 year; 25% chronic, 22% improved; overall 79% showed some improvement

Severity of initial illness, increasing age, physical illness, poor socialadjustment

CES-D

309 of 414 who scored 16 or more reassessed; 155 (50.1%) were still depressed at 1 year

Severity of initial score, chronic medical illness

DIS

17 of 274 had major depression; 12 (71%) were better at 6 months

Prior history of depressive

At 6 mos., 36% of patients had a disorder at both interviews, most of which were anxiety and depression

Less education;

Instruments

Outpatients j791

100

1351

1937

j801

274

[811

247

SADS

episodes; higher number of lifetime DIS symptoms; higher initial scores on CES-D and social maladjustment; higher number of physician medical diagnoses highest initial

GHQ

[I61

N=35 x age 41.4

PSE 25, Zung

At 6 wks, 2% improvement in Zung SDS scores (42.2-41.2); at 20 wks, 6% improvement in Zung SDS scores (42.240.1)

Few predictors significant given small N. Those with episodic depression significantly improved at 20 weeks

[=I

N=207 x age 34.5

Beck Depression Inventory

At 16- to 18-week F/U, 79% of patients with a new episode of depression were fully or much improved

No predictive factors identified in study for those patients with persistent depression

geriatric N=202 x age 69.4

Zung SDS using 260 as cutoff

At 33 mos., 48% of those initially scoring 260 no longer did so; at 33 mos., 14% of those initially scoring 559 now score 260

Alcohol abuse, OPD, greater number of medical diagnoses; number of new medical diagnoses

PSE & index of

One-third of patients with affective disorder at admission were still ill at 4 months

Severity of initial psychiatric disorder as rated by house

Outpatients,

1231

Medical inpatients 54 pts with j831 affective disorder; 54 controls

caseness

to the inpatient medical ward (6%-14%). In all three settings, patients with depressive symptoms that fall short of major depression criteria are at least two to three times as prevalent as patients with major depression. In one-third to one-half of cases, depressive symptoms persist over a 6-month

244

physicians; poor medical outcome as rated by patient

to one-year period. Recent evidence suggests that patients with major depression as well as those with depressive symptoms tend to be high utilizers of medical services and have as significant functional impairments as patients with chronic medical illness [3-51.

Epidemiology

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