Depression. Even the word sounds despairing and urgent. Yet if we work in primary care medicine, let alone pain-related specialties such as rheumatology, depression is often a comorbidity of conditions we see every day. It is thought that one in every six patients we see in clinical practice is depressed. Unfortunately, depression is only identified in half of these cases let alone treated appropriately. 1-3

If a patient is depressed, we may discover he or she is less likely to participate in the given treatment regimen.



At the onset of adolescence, the incidence of depression has a 1:1 male to female ratio. After puberty, that male to female ratio doubles to 1:2.1 Many have cited theories for why this dramatic change occurs. Researchers have extensively studied the female brain and hormonal influences have been postulated and proven as a probable, if not strongly, contributing cause.4 Although it would stand to reason that postmenopausal women might experience less depression, the previous brain changes coupled with hormonal deterioration can actually make it more likely for a depression to recur or become worse.4

Comorbidities, such as the onset of a new disease, may precipitate a depressive episode even if the patient has not had such an episode in the past. Even without the more severe symptoms that may occur with end-stage disease, a newly diagnosed patient may present with tearfulness, lack of energy and decreased sleep. All of these are hallmarks of depressive illness.

A Guide To
The SIGECAPS Symptoms
In my clinical experience, once one has identified a patient’s depression, a major mistake is telling the patient that he or she will “get over it.” I encourage all clinicians to inquire about any potential suicidal thoughts and plans. If the depression has progressed to that level of severity, you will have identified the need for aggressive treatment.

The definition of depression is when the patient has more than five of the following symptoms for at least the same two week period. SIGECAPS is the mnemonic for sleep, interest, guilt, energy, concentration, appetite, psychomotor and suicide.5

• Sleep. The patient may be sleeping too little or too much. Either is an indicator of depression.
• Interest. The patient may find no pleasure in usual activities or shut oneself off from what was previously enjoyable.
• Guilt. He or she may have a feeling of culpability for what has occurred, whether it is real or imagined.
• Energy. The patient may have decreased abilities to do what must be completed. There may be much energy with a “crash” that may indicate bipolar-depressive disorder (BPD).
• Concentration. Reduced concentration is common with a depressed patient.
• Appetite. A depressed patient may have either too much or too little appetite. Either is important for the diagnosis of depression.
• Psychomotor. There is usually a slowing of physical functions. A clinician may notice he or she is actually fatigued after interacting with this patient. Alternatively, a patient may present with agitation — an observed anxiety and constant motion in his or her physical actions.
• Suicide. This is a poor prognosticator of the depressed patient. We must ask these patients as they may not tell us.

Unfortunately, one may confuse these symptoms with those of the diseases we are treating. These symptoms may also be indicative of the progression of illnesses or possible side effects of medications we use to combat these illnesses. So what is a clinician to do?

Underscoring The Need For
A Multidisciplinary Approach
In my experience, facilitating a multidisciplinary approach can be an adventure in terms of orchestrating an appropriate therapy regiment for patients with depression but it is absolutely necessary.

First and foremost, one should keep the primary care provider involved. Maladies as common as a sore throat to the more complicated coronary artery disease or diabetes need episodic and often intensive interventions. The use of disease-modifying antirheumatic drugs in rheumatology settings and the use of prednisone and nonsteroidal antiinflammatory drugs (NSAIDs) in various practices can sometimes compound iatrogenic complications.

Perhaps there is indeed a “mismatch” in therapeutic plans with primary care and clinicians. Keeping everyone on the team allows the patient to get the most comprehensive and safe treatment. It is easier to identify depression with vigilant, experienced practitioners as advocates.6

Emphasizing Exercise
And Physical Therapy
One way to help these patients is to encourage them to utilize the local YMCA or other exercise facility. Most of these facilities have gentle exercise programs designed for the aging body. If there is no facility like this nearby, consider requesting the community center to start a yoga or T’ai Chi activity class.

However, keep in mind that when we mention exercise, there may be a tendency for the eyes of our patient to glaze over and then he or she does not hear anything else we say. Use the word “activity” and the patient’s ears perk up. Episodic activity is a known deterrent of depression and a definite adjunct modality for arthritis-related pain.7

While physical therapy is often disregarded when it comes to chronic pain and depression, a therapist who is trained to address balance, strength and flexibility can make a difference in the functionality or usefulness of a given treatment regimen. Indeed, clinicians should encourage and facilitate independence as long as possible. Chiropractors and acupuncturists may not be viewed as fitting within the traditional model of physical therapists but many can help when allopathic medicine has not.

Other Considerations
With Referrals
Further, if a patient asks for a referral to one of the alternative practitioners, it is advantageous to listen and guide the person to what is safe and away from known quackery. Such benign therapies such as bee pollen may be acceptable but unknown herbs and roots compounded by naturopathic practitioners may not be safe.
Utilized in the course of medical therapy, psychology is not only helpful for depression but may also be beneficial for managing pain and minimizing barriers that prevent patients from participating in the management of their condition.8 Consider referring the patient to a professional specifically trained in pain management if one is present in your community.

Be especially aware of a depressed patient who presents to your practice with no hope of recovery or a disease with known precipitous deterioration. Chronic pain is one of the risk factors for suicide.9 Asking a question such as “Have you thought of hurting yourself or others?” may be enough to save a life. If a person states yes to this question, refer him or her to a trained professional for assistance. I often add that I will work very hard to support the patient. Just knowing someone cares can make a difference.

Although treatment of major depressive disorder (MDD) is beyond the scope of this column, we in clinical medicine have anecdotally noticed relapses despite effective treatment and achieving remission in patients with depression.

A recent study verified that the phenomenon of recurrence is more difficult to treat with each subsequent episode.10 Although this may mean continuing effective antidepressant modalities, whether they are medications, lifestyle modifications, counseling or any combination thereof, one must make the decision with the patient’s input and understanding of the depressive disease process.

In Conclusion
Patients with depression present a growing concern in the primary care practice as well as specialty arenas. Since we see most of these patients first, the responsibility is upon us to not only identify but effectively and aggressively treat the depressed patient.

Physician assistants and nurse practitioners also need to recognize possible comorbidities of depression such as cancer and pain disorders as well as associated presentations and manifestations such as generalized anxiety disorder and bipolar disorder illness. Reviewing and being aware of the current therapies — pharmacological, biomedical and psychotherapeutic modalities — is integral and necessary for the practicing, prescribing clinician.