[Depression as a general medical problem].

M odern psychiatry in the NIS is currently undergoing reforms aimed at democratizing psychiatric care and making it more affordable and accessible to the public. Yet at the same time, such reforms are impossible within the narrow framework of the available mental health services. There is an obvious need for interaction between the mental health and general healthcare systems, specifically in terms of integrating the diagnosis and treatment of certain types of psychiatric care into primary healthcare settings—first of all, into territorial outpatient clinics (polyclinics). One promising area for such an integration is depression. Depression can well be considered a general medical, rather than purely psychiatric, problem. This is due to the specific nature of the clinical manifestations of depression, which heavily affect various somatic functions—sleep, general activity, and physical fitness—while mental activities themselves may remain relatively intact for a long time. It is therefore reasonable for various specialists to participate in the diagnosis and treatment of depression, as well as in the prevention of its severe, chronic, and disabling forms. Depression in its various clinical versions is now considered a key cause of decreased working ability. In terms of years lost from a full-fledged life, depressive disorders outstrip all other mental diseases—including Alzheimer’s, alcoholism, and schizophrenia.1 Depression currently ranks fourth among all diseases, and is expected to rank second after ischemic heart disease by 2020.2 Rates of depression vary widely depending on the criteria used. For the population of the former Soviet Union, the rate of 0.5 percent3 was found for severe depression, although it reflects a rather narrow diagnostic range. And while our understanding of depression has begun to change and its diagnostic range has been expanded, the disease is still on the rise worldwide. Research carried out in the United States with the use of the Diagnostic and Statistical Manual of Mental Disorders— known as DSM-IIIR—criteria4, 5 has revealed a very high percentage (9.5-11.3 percent) of people suffering from various affective disorders—including depression—with a frequency of at least one depressive episode during a given year. That rate may be much higher with the addition of the so-called disorders of the depressive spectrum, namely some forms of pathologic compulsion, some cases of alcohol/psychoactive substance abuse, some somatoform or initial phases of psychosomatic disorders, and numerous conditions generally classified as neuroses. The rate of depression is especially high among patients of primary care facilities. According to a multi-center study conducted in 12 countries, about 10 percent of patient visits to general practitioners are associated with depression.6 However, general practitioners (internists) recognize depressive disorders only in 10-30 percent of these cases. In turn, untimely and inadequate therapy exaggerates the relevant somatic disease (where it accompanies the depression) and renders the depressive state chronic. The key diagnostic category for depressive disorders is termed a “depressive episode” (F 32 according to ICD-10 or 296.2, “major depressive disorder, single episode,” according to DSM-IV). Diagnosis of a depressive episode is based on a low mood and decreased interests and energy, in combination with a number of cognitive and vegetative symptoms that persist for at least two weeks (see Table 1). Similar signs are identified with “recurrent” depression and with depressive episodes related to bipolar affective disorder. The latter shows itself as alternating