_______________________________________________________________________ Depression and Suicide
Women As noted, women have a higher lifetime prevalence of depres- sion and are particularly vulnerable during their childbear- ing years [11]. In one study, depressed women were found to mention mental symptoms when visiting a primary care provider for medical concerns (e.g., respiratory infection), giving practitioners clues as to their mental state that were not often explored [96]. Primary care providers should be alert to these clues, and screen and follow up with these women, as appropriate. When depression develops during pregnancy, the course and presentation of the disease is often unique [19]. It is important that perinatal depression be identified and treated as early as possible to minimize the risks to the mother and fetus. Screen- ing during the antepartum and postpartum periods should focus on signs and symptoms experienced in the previous week, utilizing a tool designed specifically for this population (e.g., the Edinburgh Postnatal Depression Scale) [97]. Children Depression does develop in children, in some cases at a young age, and the long-term effects can be significant even after resolution of depressive symptoms [97]. There are several inher- ent barriers in the accurate assessment of younger children, including limited cognitive, language, and reading abilities [98]. For this reason, multiple “informants” are used to gain a clear clinical picture; however, it is important to remember that the child has the greatest knowledge regarding his or her own internal state. Several screening tools have been developed specifically for children and adolescents, but these are generally recommended for those 7 years of age and older [99; 100]. Lesbian, Gay, Bisexual, and Transgender Individuals Some depression risk factors occur with greater frequency in gay, lesbian, bisexual, transgender, and other gender and sexual minority (LGBT+) communities, including family rejection, ostracism, bullying and peer victimization, and negative self- image, and depression is more common in this group than in the general population [101; 102]. However, there is some evidence that available screening tools may overestimate the incidence of mental disorders among LGBT+ patients [103]. Because the risk of suicide is high in this population, any pos- sible depressive signs or symptoms should be fully explored. DIFFERENTIAL DIAGNOSIS Because depression can be a manifestation of other psychiatric conditions, substance use disorders, CNS disorders, general medical conditions, or medication side effects, a differential diagnosis should be performed to rule out other conditions that may account for the depression. MDD can co-occur with any medical condition, but depression can also be a biologic manifestation of certain neurologic and medical conditions. In these cases, primary depression is ruled out. Considerations for the conditions discussed in the following section should be made in the differential diagnosis [10; 22; 104].
Similar to other subgroups, older adults with depression often present with nonspecific somatic complaints such as insomnia, appetite disturbances, lack of energy, fatigue, chronic pain, constipation, and musculoskeletal disorders [21]. Stigma also contributes to the denial among elderly patients of the psychologic symptoms of depression and refusal to accept the diagnosis. This appears to be particularly the case with older men, who also have the highest rates of suicide in later life [86; 88]. Provider-Related Factors Provider-specific factors contributing to under-detection and under-treatment of depression include reluctance to inform older patients of a depression diagnosis due to uncertainty over the diagnosis and proper treatment, reluctance to stigmatize, concern regarding medication interactions, lack of access to psychiatric care, and doubts regarding treatment effectiveness and cost-effectiveness [89]. Additional factors are physician overconfidence in their ability to diagnose, treat, and manage depression in the absence of sufficient training and educa- tion and a presumption (based on their familiarity with the patient) that they have nothing new to learn about the patient
[89; 90; 91]. Stereotyping
Healthcare professionals are not immune from harboring the stereotypes of the elderly often found among society in general. These can include attitudes that a depressive response to inter- personal loss, physical limitation, or changing societal role is an inevitable and even normal aspect of aging [89; 92; 93; 94]. The elderly may view their suicidal thoughts as age-appropriate [91]. When held by patients and family members, these erroneous beliefs can lead to under-reporting of symptoms and lack of effort on the part of family members to seek care for patients [93; 94]. When held by clinicians, these beliefs can result in delayed or missed diagnoses, less effective treatment, or suicide in the elderly patient. Studies have shown that a great majority of geriatric suicide cases have visited a physician within one month of their suicide [89; 91]. Systemic Barriers The healthcare system itself has increasingly restricted the time allocated for patient care, forcing mental health concerns to compete with general medical conditions for provider attention. Primary care providers often report feeling too time-pressured to investigate depression in older patients [95]. Polypharmacy First-episode depression in elderly patients may have an undiagnosed neurologic or other medical disorder etiology. Because some medications, such as beta-blockers, can precipi- tate depression in the elderly, consideration should be given to the potential role of medication side effects, particularly because this population is likely to be taking many different medications [22].
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