Major depressive disorder is common. Estimates suggest about 18 million adults, aged 18 or older, experienced a major depressive episode in 2018.¹ While depression is associated with increased morbidity and mortality, as well as diminished quality of life, it is estimated that only 65 percent of adults with depression receive treatment.^1,2 Depression is also a risk factor for suicide, the tenth leading cause of death in the United States, and it is estimated that almost half of adults who committed suicide had contact with a primary care provider in the month before their death.^2,3

Regular patient screening supports the identification and diagnosis of depression, ensuring appropriate treatment and follow-up care. However, some patients may not admit to or mention concerns about depressed mood, cognition changes, or physical symptoms. As a result, it is important to consistently assess patient risk factors and presenting symptoms.

Depression risk factors and symptoms

Multiple risk factors could contribute to a diagnosis of depression. The following are risk factors to consider:

• presence of a serious chronic illness;
• biochemical changes;
• genetic factors;
• hormonal changes due to a recent pregnancy;
• social factors.

Depression can follow a recently diagnosed condition, may be triggered by certain medications, or can be related to substance abuse. People with co-occurring serious chronic medical illnesses and depression tend to have more severe symptoms of both illnesses, requiring additional treatment and care, and incurring added medical costs.⁴ Depression may follow child birth and is associated with adverse maternal and infant outcomes. It is estimated that 12 percent of women in the U.S. will experience postpartum depression; some states report this rate may be as high as 20 percent.⁵

Patients experiencing depression may have chief complaints of non-specific symptoms such as:

• changes in appetite;
• lack of energy;
• sleep disturbances;
• general aches and pains;
• headaches;
• menstrual symptoms;
• digestive problems or abdominal pain;
• sexual dysfunction.²

When patients present with non-specific symptoms, it is common to consider medical conditions (e.g., fatigue and weight changes can be associated symptoms of thyroid disease or anemia).² It may be important to consider depression as a differential diagnosis and to further discuss the presence of other symptoms, including:

• depressed mood, sadness, or excessive crying;
• loss of interest or pleasure in hobbies or activities;
• impairments in functioning at home, work, or socially;
• changes to weight or appetite;
• insomnia or hypersomnia;
• restlessness or slowed body movements;
• fatigue;
• feelings of worthlessness or guilt;
• slowed thinking, diminished concentration, or indecisiveness;
• thoughts of death;
• acute suicidality or psychotic symptoms.

Screening tools and other resources

Risk reduction strategies include regular use of a depression screening tool for your general adult population, including pregnant and postpartum patients. Magellan Healthcare, Inc. (Magellan) provides a Behavioral Health Toolkit for Medical Providers for more information about identifying and treating depression, including access to screening tools, clinical guidelines, and patient resources.

Referral to a behavioral health provider is recommended for complex cases, including patients with bipolar depression, acute suicidality, psychosis, or pregnancy. If you refer your patient to a behavioral health provider, regular communication and coordination will help ensure an accurate diagnosis, effective treatment, and appropriate follow-up care. For most of your Independence patients, Magellan administers behavioral health benefits. Call the number on the back of the member’s benefits card to arrange a referral.

Other useful resources include:

• Suicide Prevention Resource Center: This service provides information on state prevention plans, resources, and programs as well as trainings and materials for professionals.
• Zero Suicide: This framework provides functional tools and resources for system-wide transformation toward safer suicide care in health and behavioral healthcare.
• National Alliance on Mental Illness Philadelphia: This service provides information and support to people with mental illness as well as their families, caregivers, and friends.
• SAMHSA’s National Helpline: The Substance Abuse and Mental Health Services Administration (SAMHSA) helpline provides 24-hour, confidential treatment referral and information about mental and/or substance use disorders, prevention, and recovery.
  • 1-800-662-HELP (1-800-662-4357) (TTY: 1-800-487-4889)
• Suicide Prevention Lifeline: This is a 24-hour, confidential, suicide prevention hotline available to anyone in suicidal crisis or emotional distress.
  • 1-800-273-TALK (1-800-273-8255) (TTY: 1-800-799-4889)

Be sure to discuss appropriate resources with your patients. Please encourage the member to call the number on the back of their ID card if they need mental health services.

¹SAMHSA. “Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health.” HHS Publication No. PEP19?5068, NSDUH Series H?54. 2019. Available from: https://www.samhsa.gov/data/report/2018-nsduh-annual-national-report

²Ferenchick, E. K., Ramanuj, P., & Pincus, H. A. “Depression in primary care: part 1–screening and diagnosis." British Medical Journal; 365, l794. 2019. Available from: https://www.bmj.com/content/bmj/365/bmj.l794.full.pdf

³Centers for Disease Control and Prevention, National Center for Health Statistics. “Health, United States, 2017: With special feature on mortality.” Hyattsville, MD. 2018. Available from: https://www.cdc.gov/nchs/data/hus/hus17.pdf

⁴National Institute of Mental Health. "Chronic Illness & Mental Health." NIH Publication No. 15-MH-8015. Available from: https://www.nimh.nih.gov/health/publications/chronic-illness-mental-health/index .shtml

⁵Ko, J. Y., Rockhill, K. M., Tong, V. T., Morrow, B., & Farr, S. L. “Trends in Postpartum Depressive Symptoms – 27 States, 2004, 2008, and 2012." Morbidity and Mortality Weekly Report; 66, 6. 2017. Available from: https://www.cdc.gov/mmwr/volumes/66/wr/pdfs/mm6606a1.pdf

Magellan Healthcare, Inc., an independent company, manages mental health and substance abuse benefits for most Independence members.