REVIEW ARTICLE
DEPRESSION IN PRIMARY CARE
PART 1: SCREENING AND DIAGNOSIS
Grief reaction
Another condition which shares some of the major depressive disorders features is grief reaction. Grief can be due to the death of loved ones or reaction towards terminal illness.15 Grief reaction in the terminally ill patient where the patient is preparing himself for his final separation from this world is known as preparatory grief or anticipatory grief reaction.15 Grief and depression can be differentiated clinically although some symptoms overlap.16 There will be a temporal variation of mood in grief, i.e. a mixture of ‘good and bad’ days, in contrast to persistent dysphoria in depression. Guilt feelings in grief will be focused on certain issues and not generalised as in depression. A disturbed self esteem or sense of hopelessness is not typically seen in grief and hope in a grieving patient may shift but not be lost. Therefore, the desire for an early death or suicidal ideation is highly suggestive of depression. In a grieving person, social support helps in providing acceptance and assistance. In depression, social support is helpful in some depressed patients but it will not resolve depression. The inability to feel pleasure (anhedonia) is characteristic of depression and it is absent in grief reaction.
Case vignettes
The following case vignettes illustrate the different presentation of depression.
Case 1
Ms A, a 26-year-old ex-clerk, was admitted to hospital with a four-month history of feeling low after she broke up with her boyfriend. She became increasingly sad and unable to concentrate on her work. She felt tired easily and was unable to get up in the morning. She finally quit her job two months ago. She lost about eight kg within four months. She had lost interest in most things. Her mother noticed that whenever she was alone, she would just stare and appeared blank. She had been quieter and lately she refused to come out from her room. She needed supervision for her personal hygiene and her mother had to coax her to eat. For the past two weeks, she repeatedly told her mother that “I am going to die. My body has no blood and the heart is getting weaker”.
Case 2
Ms B, a 30-year-old hairdresser had been referred to the clinic after she had broken down in tears in front of her clients for the third time in a week. Three weeks ago, her boyfriend of four years decided to break off their relationship. She said that she was in a state of shock for three days and gradually managed to pull herself together. She still thinks about her boyfriend and finds it difficult to focus on her work. She felt constantly on the verge of crying. She had some difficulty falling asleep but her appetite remained the same. Her main fear was the prospect of being alone.
Case 3
Mrs C, a 35-year-old lady complained of frequent episodes of headache and back pain for the past four years. It started after her husband left her. The pain became worse last year after her eldest son left the house. She experienced the pain almost everyday and she was not able to work. She also had poor sleep due to pain. She could not carry out household chores as she felt tired easily. She spent most of her time lying on the bed. She was seen by a number of doctors of different specialty and thorough investigations were made. There was no organic cause for the headache and back pain. Her pain was not relieved by analgesics. On further questioning, she fulfilled the criteria of major depression.
Case discussion
Although all patients develop depression following a break off in their relationships, the presenting features are not the same. Ms A fulfils the criteria for severe major depression with psychotic features as she presented with nihilistic delusion. She could not function socially as well as occupationally. On the other hand, Ms B presents with depressive features which are not severe enough to qualify the diagnosis of major depression and since her functioning is affected, a diagnosis of adjustment disorder with depressed mood is warranted. Ms B can progress to major depression if she continues having a maladaptive reaction to the situation. Mrs C presented with somatic complaints which had no organic cause. Mrs C is more likely to be suffering from major depression and the diagnosis was missed when she first presented to the clinic. In a primary care setting, presenting complaints of depression are more likely to be somatic such as back pain, chest pain, shortness of breath, heart palpitations, problems with sleep or appetite and fatigue.17
