​Major depressive disorder is common. Estimates suggest about 19 million adults, aged 18 or older, experienced a major depressive episode in 2019.¹ While depression is associated with increased morbidity and mortality, as well as diminished quality of life, it is estimated that only 66 percent of adults with depression receive treatment.^1,2 Depression is also a risk factor for suicide, the tenth leading cause of death in the United States, and it is estimated that almost half of adults who committed suicide had contact with a primary care provider in the month before their death.^2,3

Everyone reacts differently to stress and the coronavirus disease pandemic (COVID-19) may be especially stressful. Fear and anxiety about one's health, the health of loved ones, uncertain financial situations, or the loss of support services can be overwhelming. While necessary, social distancing may make people feel isolated and lonely, increasing stress and anxiety.

Regular patient screening supports the identification and diagnosis of depression, ensuring appropriate treatment and follow-up care. However, some patients may not admit to or mention concerns about depressed mood, cognition changes, or physical symptoms. As a result, it is important to consistently assess patient risk factors and presenting symptoms.

Depression risk factors and symptoms

Multiple risk factors could contribute to a diagnosis of depression. The following are risk factors to consider:

• presence of a serious chronic illness
• biochemical changes
• genetic factors
• hormonal changes due to a recent pregnancy
• social factors

Depression can follow a recently diagnosed condition, may be triggered by certain medications, or can be related to substance abuse. People with co-occurring serious chronic medical illnesses and depression tend to have more severe symptoms of both illnesses, requiring additional treatment and care, and incurring added medical costs.⁴ Depression may follow childbirth and is associated with adverse maternal and infant outcomes. It is estimated that 12 percent of women in the U.S. will experience postpartum depression; some states report this rate may be as high as 20 percent.⁵

Patients experiencing depression may have chief complaints of non-specific symptoms such as:

• changes in appetite
• lack of energy
• sleep disturbances
• general aches and pains
• headaches
• menstrual symptoms
• digestive problems or abdominal pain
• sexual dysfunction²

When patients present with non-specific symptoms, it is common to consider medical conditions (e.g., fatigue and weight changes can be associated symptoms of thyroid disease or anemia).² It may be important to consider depression as a differential diagnosis and to further discuss the presence of other symptoms, including:

• depressed mood, sadness, or excessive crying
• loss of interest or pleasure in hobbies or activities
• impairments in functioning at home, work, or socially
• changes to weight or appetite
• insomnia or hypersomnia
• restlessness or slowed body movements
• fatigue
• feelings of worthlessness or guilt
• slowed thinking, diminished concentration, or indecisiveness
• thoughts of death
• acute suicidality or psychotic symptoms

Screening tools and other resources

Risk reduction strategies include regular use of a depression screening tool for your general adult population, including pregnant and postpartum patients. Magellan Healthcare, Inc. (Magellan) provides a Behavioral Health Toolkit for Medical Providers for more information about identifying and treating depression, including access to screening tools, clinical guidelines, and patient resources.

Referral to a behavioral health provider is recommended for complex cases, including patients with bipolar depression, acute suicidality, psychosis, or pregnancy. If you refer your patient to a behavioral health provider, regular communication and coordination will help ensure an accurate diagnosis, effective treatment, and appropriate follow-up care. For most of your Independence patients, Magellan administers behavioral health benefits. Call the number on the back of the member's benefits card to arrange a referral.

Other useful resources include:

• Suicide Prevention Resource Center: This service provides information on strategic suicide prevention planning, resources and programs, and trainings for professionals.
• Zero Suicide: This framework provides functional tools and resources for system-wide transformation toward safer suicide care in health and behavioral health systems.
• Independence COVID-19 Emotional Health Resources: This webpage provides information about the behavioral and mental health benefits, support, and resources available to our members dealing with the stress and anxiety of COVID-19.
• National Alliance on Mental Illness: This service provides information and support to people with mental illness as well as their families, caregivers, and friends.
• SAMHSA's National Helpline: The Substance Abuse and Mental Health Services Administration (SAMHSA) helpline provides 24-hour, confidential treatment referral and information about mental and/or substance use disorders, prevention, and recovery.
• 1-800-662-HELP (1-800-662-4357) (TTY: 1-800-487-4889)
• Suicide Prevention Lifeline: This is a 24-hour, confidential, suicide prevention hotline available to anyone in suicidal crisis or emotional distress.
• 1-800-273-TALK (1-800-273-8255) (TTY: 1-800-799-4889)
• Patient Health Questionnaire (PHQ-9 & PHQ-2): These are reliable and cost-effective psychological screening instruments for depression intended for use by clinicians or researchers in primary care settings.

Be sure to discuss appropriate resources with your patients. Please encourage the member to call the number on the back of their ID card if they need mental health services.

¹SAMHSA. “Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health." HHS Publication No. PEP20-07-01-001, NSDUH Series H-55. 2020. Available from: https://www.samhsa.gov/data/report/2019-nsduh-annual-national-report

²Ferenchick, E. K., Ramanuj, P., & Pincus, H. A. “Depression in primary care: part 1–screening and diagnosis." British Medical Journal; 365, l794. 2019. Available from: https://www.bmj.com/content/bmj/365/bmj.l794.full.pdf

³Centers for Disease Control and Prevention, National Center for Health Statistics. “Health, United States, 2018." Hyattsville, MD. 2019. Available from: https://www.cdc.gov/nchs/data/hus/hus18.pdf

⁴National Institute of Mental Health. "Chronic Illness & Mental Health." NIH Publication No. 15-MH-8015. Available from: https://www.nimh.nih.gov/health/publications/chronic-illness-mental-health/index.shtml

⁵Ko, J. Y., Rockhill, K. M., Tong, V. T., Morrow, B., & Farr, S. L. “Trends in Postpartum Depressive Symptoms – 27 States, 2004, 2008, and 2012." Morbidity and Mortality Weekly Report; 66, 6. 2017. Available from: https://www.cdc.gov/mmwr/volumes/66/wr/pdfs/mm6606a1.pdf

Magellan Healthcare, Inc., an independent company, manages mental health and substance abuse benefits for most Independence members.