Depression

By Paula Domenici, PhD
     Head, Division of Training Programs

Depression is one of the world’s top public health problems, and it affects approximately 7% to 12% of men and 20% to 25% of women across their lifetime (Kessler, 2003). While depression may not be commonly associated with traumatic experiences such as combat, rates of depression in our servicemen and women are not insignificant. Hoge et al., (2004) found rates between 14% and 15% in soldiers and Marines 3 to 4 months after deployment to Iraq or Afghanistan. These findings are consistent with the rate of 14% identified in individuals after they had served in Iraq or Afghanistan (RAND Report, 2008). Some military personnel struggle with depression irrespective of a deployment. In veterans seeking care at VA hospitals, depression presents at an even higher rate -- about 25% -- either alone or along with conditions like PTSD and substance use (OIF & OEF Deployment Roster, VA Healthcare, 2008).

In the wake of these findings, identification of depressive disorders in the military is crucial. Following the guide, SIGECAPS (VHA/DOD Clinical Practice Guideline for the Management of MDD, 2000), is a simple yet effective strategy to begin assessing for depression. Check if an individual has 5 or more of the following symptoms for at least 2 weeks (one must be depressed mood or decreased interest):

  • Sleep (increased or decreased)
  • Interests (decreased) and /or Depressed mood
  • Guilt
  • Energy (decreased)
  • Concentration (decreased)
  • Appetite (increased or decreased)
  • Psychomotor changes (increased or decreased)
  • Suicidal thoughts

Consider red flags, such as chronic illness, decreased function, history of abuse or neglect, family history of depression, significant losses and other psychiatric problems (VHA/DOD Clinical Practice Guideline for MDD, 2000). Also, examine military risk factors for depression identified by the RAND Report (2008): no longer active duty (e.g., Reserve Component); older age; enlisted personnel; female; Hispanic; more lengthy deployments and greater exposure to combat to trauma. Recent studies by the Mental Health Advisory Team (MHAT) show a linear relationship between combat exposure and mental health complaints, including depressive symptoms, in persons deployed to Iraq and Afghanistan.

The 2-item Primary Care Evaluation (PRIME MD) is a basic screen for depression whose items are part of the military’s longer Post-Deployment Health Assessment (PDHA) and Post-Deployment Health Reassessment (PDHA). These two items are also asked as part of initial screenings at VA hospitals. Endorsement of one of the two items denotes “positive”, warranting referral for further evaluation. Following a “positive” PRIME MD finding, the PHQ-9 Symptom Checklist (9 items) is commonly used. This easy-to-score test is available in the public domain. The Center for Epidemiological Studies (20 items), Beck Depression Inventory (21 items), Zung Depression Scale (20 items) and Hamilton Depression Rating Scale (17 to 31 items) are other depression instruments with good psychometric properties. While somatic complaints are not traditionally assessed by such measures, regard them as possible indicators of depression, especially with military personnel.

A thorough suicide risk assessment should be conducted carefully if an individual endorses suicidal ideation. Take into account these military suicide risks based on the acronym, SADPERSONS (www.PDHealth.mil):

 

  • Sex: Males more likely to kill themselves than females by more than 3 to 1
  • Age: 20-24 years old highest risk
  • Depression: Precedes suicide 70% of the time
  • Previous Attempts: Most completed on 1st or 2nd attempt
  • Ethanol Use: Substance abuse increases risk of suicide completion
  • Rational Thinking Loss: Profound cognitive slowing, distorted perceptions, psychotic depression
  • Social Support: Relationship or job loss, legal difficulties or illness that cause social withdrawal
  • Organized Plan: A specific plan and means
  • No Spouse: May be cause or result of depression, especially within one year of divorce
  • Sickness: Comorbid medical illnesses

An evaluation incorporating self-report instruments as described above and a thorough clinical interview will help determine if a depressive disorder is present and, if so, which one: major depressive disorder; adjustment disorder with depressed mood; depression not otherwise specified; dysthmia or bipolar disorder. Traditionally, a diagnosis of bipolar disorder will prevent an individual from being deployed and, in most cases, from ever entering the military.

It also is important to flesh out overlap between PTSD and depression since they share many symptoms in common, such as sleep disturbance, anhedonia and irritability. Reexperiencing symptoms like flashbacks and physiological reactions to triggers can distinguish PTSD from depression. At the same time, comorbidity rates of PTSD and depression are high, so both conditions may be present.

Efforts are underway in the Army to screen more rigorously for depression and PTSD in Primary Care clinics through a program called, Re-Engineering Systems-Based Intervention for Primary Care and Treatment of Depression in US Army Personnel (RESPECT-Mil). This initiative emerged from the recognition that soldiers are more likely to go to their PC doctor than a mental health provider. Approximately 90% of service members typically have one or more visits in PC clinics per year, which provides the opportunity for medical staff to identify depression and intervene early and for the service member to face reduced stigma. Collaborative efforts between PC and mental health clinics in both military and veteran hospitals are on the rise to combat depression.

Fortunately, depression is a treatable disorder. Empirically-validated treatments recognized by the VHA/DOD Clinical Practice Guideline for the Management of MDD (2000) comprise of cognitive therapy, behavioral therapy, interpersonal therapy, marital therapy, and medication. Cognitive-behavioral therapies and interpersonal therapy have received the strongest research support in terms of effectiveness. The combination of psychotherapy and medication, when needed, has been shown to be effective for treating depression. No anti-depressant medication has been shown to better than another in efficacy or time to respond, however, and service members may be hesitant to take it. The benefits of problem-solving therapy and exercise in reducing depressive symptoms have been demonstrated. The brief, directive nature of these strategies and cognitive-behavioral approaches, in general, are especially helpful for treating depression in the military culture.
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