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Approach to Depressive Disorders
I commend Dr Williams et al1 for their recent article in the ARCHIVES. From my view as a working psychiatrist, there is always a need to increase awareness about mood disorders to improve their recognition, proper diagnosis, and treatment. In my opinion, this research enhances that effort (as I say this, I ask myself why clinical and academic psychiatrists do not do more on behalf of this important task of "recognizability").
At the same time that I applaud their effort, I also want to express a concern. When the authors categorized the diagnosis of depression, they did so by describing 3 subgroups: major depression, minor depression, and dysthymia. The criteria for each of these depressive types were apparently defined so that each physician's response would target one patient with one symptom cluster fitting one of these diagnoses. As I understand the description of the methodology, I believe there is a problem with it. Specifically, while the authors cite the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV),2 allegedly to reference depressive symptoms, they also choose to use a diagnostic term, minor depression, that is not based on the DSM-IV. Potentially, this diminishes the effect of one of their expressed desires—to increase quality of care—because the diagnostic problem of depressive disorders is confused by the addition of a novel subtype.
I suggest that problems related to quality of care for treatment of depression are caused by many reasons, one of which is diagnostic uncertainty. Diagnostic clarity, on the other hand, can only improve treatment objectives. To do this, we as health professionals must use the same names to describe the same symptoms. As such, we must be consistent with our depressive diagnostic subgroups to enhance our effective recognition and appropriate treatment of any mood disorder.
Stefan P. Kruszewski, MD
Pottsville, Pa
1. Williams JW Jr, Rost K, Dietrich AJ, et al. Primary care physicians' approach to depressive disorders: effects of physician specialty and practice structure. Arch Fam Med. 1999;8:58-67.
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2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association; 1994.
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In reply
I thank Dr Kruszewski for his interest in our study. He is correct that an important aspect of the study was to understand primary care physicians' approach to different types of depression. In particular, we were interested in depressive disorders that are common in primary care but for which there are varying levels of evidence regarding treatment. "Minor" depression is a less symptomatic and less disabling illness than major depression, but has been associated with higher health care use, functional disability, and an increased risk for progression to major depression. Some primary care based studies have found the prevalence of minor depression to exceed that for major depression. In our study, we defined minor depressive disorder based on the description that is found in appendix B of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. It is defined as an episode of depressed mood or loss of interest of pleasure in nearly all activities for at least 2 weeks. In total, at least 2 but fewer than 5 of the symptoms used to diagnose major depression must be present. In addition, these symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
John W. Williams, Jr, MD, MHS
San Antonio, Tex
Arch Fam Med. 2000;9:19.
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