Articles  |   August 2003
Editor's Message
Author Notes
  • Dr Osborn is a professor of neurobehavioral sciences and the vice president for medical affairs and dean at Kirksville College of Osteopathic Medicine of A.T. Still University of Health Sciences in Kirksville, Mo. 
Article Information
Articles   |   August 2003
Editor's Message
The Journal of the American Osteopathic Association, August 2003, Vol. 103, S1-S2. doi:
The Journal of the American Osteopathic Association, August 2003, Vol. 103, S1-S2. doi:
Depressive disorders are the most common clinical problems seen in primary care medicine. It is therefore ironic that early recognition, differential diagnosis, and management of depressive disorders are so under-represented in medical student education and primary care residency programs. 
Although many research articles verify the ubiquity of depression, the most profound and compelling is The Global Burden of Disease (GBD),1 a cooperative long-range research project by the Harvard School of Public Health, the World Bank, and the World Health Organization. The GBD's findings emphasize the critical importance of disability as well as mortality. The sweeping effects of disability prior to this sophisticated study have been almost invisible to clinical medicine. The section titled “The Unseen Burden of Psychiatric Disease” notes that of the top ten causes of disability worldwide, five are psychiatric disorders, and unipolar major depression is at the top of that list.1 The authors make it a point to emphasize the burden is greatest in developed countries—and the problem is becoming worse! In disability-adjusted life years (DALYs), depression is increasing significantly in the order of disease burden worldwide, from fourth ranked in 1990 to a predicted second ranked in 2020.1 
It is against this backdrop that the JAOA supplement on depression is so important and timely. In the first article, Murray H. Rosenthal, DO, addresses the various factors that account for the difficulties in making the early and accurate diagnosis of a depressive disorder. These difficulties include the highly variable presentation of signs and symptoms, stigma, and a health care delivery system that imposes severe time constraints on clinicians. Dr Rosenthal's article offers realistic solutions, including the clinician's high index of suspicion, effective use of screening instruments, and a well-trained multidisciplinary staff with the physician as team leader. He presents a relatively new antidepressant (escitalopram oxalate) and an anticipated one (duloxetine hydrochloride), both showing significant promise. He continues with a discussion of the physiologic mechanisms of stress, the role of neurokinins, and comprehensive multimodal treatment strategies that include promising noninvasive techniques in the treatment of depression. 
Dr Rosenthal's second article is one of the clearest explanations I have seen in the general review literature of the interaction of depressive disorder and comorbid medical illness. Especially significant is the presence of depressive disorder as an independent risk factor for myocardial infarction. Dr Rosenthal emphasizes also how depression compromises patients' ability to cooperate with their care and adhere to treatment plans. He argues persuasively that comorbid depression complicates all medical problems and their effective treatment. 
The final article, by David A. Baron, DO, MSEd, describes two clinical cases that exemplify of the issues covered by Dr Rosenthal. Dr Baron emphasizes the importance of information from collateral sources, especially family members. He discusses the importance of screening for concomitant substance abuse, commonly a phenomenon of self-medication. Finally, he describes how an appearance and experience of sadness may be the exception rather than the rule in depressive disorders and how commonly the presenting mood and patient experience are anxiety or irritability or both. 
Both authors agree strongly about the utility of rating instruments for screening and monitoring treatment progress. Drs Rosenthal and Baron also agree that physicians should not settle for mere response to treatment but have as the treatment goal the remission of the disorder. By diagnosing and treating depressive disorders, primary care physicians will be greatly improving the overall health and well-being of their patients. 
 The contents of this JAOA Supplement were developed in part from lectures and discussion at a symposium planned and implemented in accordance with the American College of Osteopathic Neurologists and Psychiatrists and the American Osteopathic Association. The program was presented at the AOA's 107th Annual Convention and Scientific Seminar in Las Vegas on October 10, 2002.
Murray CJL, Lopez AD. The Global Burden of Disease (Summary). . Boston, Mass: Harvard University Press;1996 .