Most of us have experienced a day when we didn't want to get out of bed, felt sad and temporarily lost interest in activities that we typically enjoy. We may have struggled with bouts of insomnia or sleeping too much. This is normal, but if one experiences other symptoms such as feelings of worthlessness, lack of concentration, and suicidal thoughts, and these feelings last for two weeks or more, you may have depression.
Recognizing that many service members receive their initial care for symptoms of depression from their primary care provider, the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury offers guidance in the assessment, diagnosis and treatment of depression. Since 70 percent of primary care visits in the United States are related to behavioral health (Robinson and Reiter, 2007), quick and accurate screening and intervention is critical in mitigating symptoms of depression. The following example shows how important it is for primary care clinicians to be aware of the symptoms of mental health conditions such as depression.
Following a lengthy deployment, a service member, with four months of reintegrating into home and the community, visits a primary care physician and reports feeling flu-like symptoms. He describes being lethargic and sleeping most of the day, and further reports having lost a significant amount of weight.
When questioned further about his activities, he discloses not having any interest in continuing his involvement as captain/player of the basketball league that he started. His medical history, physical evaluation, and lab tests are normal and do not indicate any physical cause of these symptoms, yet on the follow-up visit, the service member's symptoms have not changed.
The primary care clinician has just completed reading the provider's guide and decides she should screen for depression by asking two standard screening questions about feelings of depression and thoughts of suicide. The service member reluctantly discloses that he sometimes cries but turns the shower on in the bathroom so that no one can hear him. He doesn't have a plan or intent to commit suicide but often thinks that life isn't worth living. He feels lonely and isolated despite having the loving support of his girlfriend and extended family.
As noted in the VA/DoD clinical guidelines, depression impacts active-duty service members returning from combat in Iraq and Afghanistan at a high rate. For example:
- 7-14 percent of combat soldiers returning from Operation Enduring Freedom (OEF) and 8-15 percent returning from Operation Iraqi Freedom (OIF) met the screening criteria for major depressive disorder (MDD).
- Diagnostic prevalence rates likely underestimate the true occurrence of MDD because many individuals with the disorder never seek treatment. Additionally, primary care providers may not recognize or diagnose it.
- 42 percent of patients diagnosed with clinical depression were first diagnosed by a primary care physician.
- Most depressed patients will receive most or all of their care through primary care physicians.
- Primary care providers often lack the time and/or training to help patients manage these problems in evidence-based ways beyond medication prescriptions.
- Patients with mental disorders have higher usage rates for general medical services and higher related medical costs compared to patients without mental health conditions.
The MDD clinical training manual helps providers review a patient's history related to depression. Providers can identify depression signs and symptoms, ask about risks of self-harm, describe self-management techniques and provide educational resources on depression. When providers learn and use reflective listening skills and demonstrate empathy, it helps service members open up and share honest feelings. Encouraging service members to participate in treatment options empowers them and usually leads to successful recovery.
If you are experiencing other-than-normal symptoms and want to learn if they are consistent with depression symptoms, consider taking a free, confidential online mental health self-assessment. If you are concerned about the results, print out your assessment and share it with your health care provider. Whatever challenges you may be struggling with, it is important you know that you are not alone and help is available.
Darlene Powell Garlington, Ph.D., is a licensed clinical psychologist, certified school psychologist and media psychologist and specializes in providing services to military members. She is a senior policy analyst at Altarum Institute, consulting with DCoE. She is the author of several books on a range of topics that include parenting, psychology and spirituality.