Depression or Exhaustion?

Yesterday I read an article about the need for primary care physicians to be screening all adults, pregnant women and elderly, for depression. It’s an excellent article entitled;

Screening adults for depression in primary care: A position statement of the American College of Preventive Medicine

 (Click here for the position paper) 

Quite frankly I was surprised that in this day and age, screening for depression was not already taking place consistently. What I KNOW is not taking place consistently is primary care screening for sleep disorders. Without this knowledge how can you accurately determine whether a patient has depression or exhaustion? We are left with a chicken-egg scenario.

The paper discusses the economic toll of depression, "Depression is a leading contributor to lost productivity, not only from worker absenteeism, but also from what is known as “presenteeism”—being physically at work but not fully engaged. Thus, depression may be a leading cause of poor organizational performance. Further, employees diagnosed with depression have a higher incidence and longer duration of both work-related and nonwork-related disabilities." I would venture to say that this description adequately applies to all those suffering from sleep disorders as well, does it not?

The paper  also addresses medical costs, "Depression contributes to a higher morbidity and mortality of other medical conditions. For example, people who have a myocardial infarction (MI) with comorbid depression have worse outcomes than those having an MI without depression. However, if the depressive episode is treated successfully, medical and surgical outcomes improve." And it goes on to state, "Furthermore, studies documenting increased cardiovascular morbidity and mortality in patients with depressive symptoms or major depression suggest that depression is an independent risk factor in the pathophysiologic progression of cardiovascular disease, not just a secondary emotional response to the illness".

That last statement concerns me because the article does not indicate that they included sleep testing on all these "depressed" patients, to exclude an underlying sleep disorders prior to gathering their data. One thing we know for sure is that many people have a hard time differentiating between exhaustion and depression. Both zap you of energy and both leave you feeling hopeless that you will ever be able to do and enjoy the things you used to do.

We know that cardiovascular events are intimately associated with sleep disorders and the resulting hypoxia and adrenergic surges. Sleep deprivation and fragmented sleep patterns are associated with postpartum depression. Insomnia is linked to anxiety and psychosis...it goes on and on. We KNOW that Sleep is directly related to Mental Health. 

So, if they sorted through all these patients by means of accurate sleep testing, not just by anecdotal means or questionnaires...and all these patients and were truly left with diagnosable cases of depression then fine. If not...

Then we have a lot of work to do. 

Let's teach primary care physicians to also screen ALL patients for Sleep Disorders!

Julia Worrall