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This chapter was developed by searching the National Guideline Clearinghouse for all available treatment guidelines for depression. These guidelines were narrowed down to those focused on depression in the primary care setting. Epidemiologic information about depression was obtained from the National Institute of Mental Health and the World Health Organization. Additional evidence-based information from each section was obtained through Medline searches using the words, “depression” or “depressive disorder,” “antidepressants,” and “primary care.”


Depression is a whole body illness that can affect one’s mood, thoughts, and physical well-being. Depressive symptoms may last weeks, months, or even years if left untreated.1 The lifetime prevalence for major depressive disorder (MDD) ranges from 10% to 25% for women and 5% to 12% for men.2 Statistics from the National Institute of Mental Health show that depression is a widespread illness affecting approximately 18.8 million Americans in any given year.3 It is estimated that 32 to 35 million American adults will suffer from MDD in their lifetime.4 Nearly one in six individuals with severe, untreated depression will commit suicide.1


In 2004, the World Health Organization (WHO) reported that 11.9% of disability is caused by unipolar depressive disorders; these disorders are the leading source of years with disability.5 Depression causes more disability than hypertension, diabetes, cardiovascular disease, or low back pain.1 It is estimated that the annual direct cost of depression in the United States is $ 26 million.4 Workers with depression cost employers in excess of $30 billion per year in lost productivity.1 By the year 2020, depression is projected to reach second place on disability adjusted life years calculated for all ages by the WHO.5


Depression is one of the top five conditions seen by primary care physicians. In fact, depressive disorders are one of the most common reasons for primary care visits. Fifty to sixty percent of all antidepressant therapy prescriptions are generated by primary care physicians.6 Despite its recognition as a major health concern, depression is often under-recognized and left untreated. The WHO reported that fewer than 25% of all individuals with depression receive care.5 Many patients are reluctant to seek treatment for fear of the stigma of having a mental disorder or are unaware of the gravity of the illness.


Individuals with a depressive disorder present with varying symptoms, the most evident being depressed mood. Patients may report loss of interest in activities, including sex. Patients may also report sleep disturbances, alterations in appetite, or significant changes in weight. Concentration may be impaired or patients may complain of distractibility. Hopelessness, helplessness, or feelings of excessive guilt may be present. Patients can feel fatigued, worn down, or exhausted even with little to no exertion. Movements may be either visibly slowed or increased. In addition, rate of speech may be decreased, as well as volume.


Healthcare providers must also be cognizant of non-specific signs ...

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