Depression in the Primary Care Setting

Abstract

A 45-year-old woman with hypothyroidism that has been treated with a stable dose of levothyroxine presents to her primary care provider with depressed mood, negative feelings about herself, poor sleep, low appetite, poor concentration, and lack of energy. These symptoms began several months ago during a conflict with her partner. Although she has been able to continue with work and life responsibilities, she feels sadness most days and occasionally thinks that she would be better off dead. How would you evaluate and treat this patient?

Figure 1.. Depression and Suicide Screening Tools.

On the Patient Health Questionnaire 2 (Panel A), a score of 3 or higher is 83% sensitive and 90% specific for a diagnosis of major depression. On the Ask Suicide-Screening Questions (Panel B), if the patient answers “no” to all four questions 1 through 4, the screening is complete and it is not necessary to ask question 5. No intervention is necessary (clinical judgment can always override a negative screening test). If the patient answers “yes” to any of questions 1 through 4 or declines to answer, the screening test is considered to be positive, and question 5 should be asked to assess severity. If the patient answers “yes” to question 5, the test is considered to be positive with an imminent risk identified. The patient requires immediate safety and a full mental health evaluation and cannot leave until he or she is evaluated for safety. Keep the patient in sight, remove all dangerous objects from the room, and alert the physician or clinician who is responsible for the patient’s care. If the patient answers “no,” the screening test is considered to be a positive test with a potential risk identified. He or she requires a brief suicide safety assessment to determine whether a full mental health evaluation is needed and cannot leave until he or she is evaluated for safety. Alert the physician or clinician who is responsible for the patient’s care. Data are adapted from www.nimh.nih.gov/labs-at-nimh/asq-toolkit-materials/index.shtml#outpatient.