This chapter of Clinical Pointers focuses on some critical areas of primary care assessment and intervention in the primary care of depression.

The depressed person usually has a diurnal variation in mood, usually feeling worse in the morning and somewhat better later in the day.

Whereas low energy is often found in the person with depression, irritability and agitation is common, especially in children, teens, and certain adults with normally high levels of activity.

When anxiety occurs along with depression, the anxious mood usually begins after the onset of the depressive symptoms. Also, the person with anxiety may present with certain complaints seldom seen in depression. For example, the person with anxiety often has chronic diarrhea, while constipation is more often found in depression. In anxiety, problems with falling asleep are the rule, while the depressed person complains of persistent early AM awakening.

Primary care providers write 80% of all antidepressant prescriptions and have the tendency to under dose these valuable medications.

With >2 major depressive episodes, there is a 80% risk of relapse in one year without treatment. Treatment of depression includes interpersonal therapy (40-60% efficacy with high relapse rate) and pharmacological intervention (70-80% efficacy, with all agents equally efficacious in therapeutic doses and a high rate of relapse). The primary care provider should consider working with the patient on a long-term plan of care when recurrent depression occurs.

In the pharmacological treatment of depression, SSRIs are significantly less toxic, with about 2 months of a therapeutic dose needed to reach life-threatening toxicity in overdose, where as little as two weeks of a therapeutic TCA dose may be lethal.

The TCAs and atypical antidepressants [nefrazadone (Serzone), venflexor (Effexor), and bupropion (Wellbutrin)], in general have a lower rate of sexual side effects such as anorgasmia, impotency and decreased libido than is found with SSRI use.

Audio tape programs on depression and anxiety are available.