Depression

A collection of educational materials in the Online Learning Center.

Mental Health and Burnout, Part 1

While there has been increased awareness of the concept of burnout in general, many Internal Medicine physicians may have gaps in their knowledge as to what burnout is and how they may be affected by it. Given that over 50% of physicians have experienced symptoms of burnout at some point during their careers (with rates significantly increasing during the COVID-19 pandemic), it is imperative that they understand the signs and the physical and mental consequences burnout can have. This includes increased rates of medical errors, depression, suicide, and leaving the medical field.

How Would You Manage This Patient With Iron Deficiency Anemia? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Iron deficiency anemia (IDA) is the most common cause of anemia worldwide and a major cause of disability, manifesting with symptoms including fatigue, weakness, exercise intolerance, worsening heart failure, impaired concentration, irritability, and depression. Women of reproductive age are disproportionately affected due to menstrual blood loss and gynecologic disorders. Iron deficiency anemia is diagnosed in patients who have both iron deficiency (ID), noted by low ferritin level and/or transferrin saturation, and anemia.

Geriatrics and Palliative Medicine for Internal Medicine Physicians: 2025 Video Recordings Package

Highly knowledgeable clinician educators will focus on practical, evidence-based strategies that the internal medicine physician can use across care settings to better identify and treat serious and chronic conditions common to older populations, such as cognitive impairment; function assessment, frailty, and falls; depression and anxiety; and hazards of hospitalization.

Geriatrics and Palliative Medicine for Internal Medicine Physicians: 2024 Video Recordings Package

Expert clinician-educations will focus on practical, evidence-based strategies that the internal medicine physician can use across care settings to better identify and treat serious and chronic conditions common to older populations, such as cognitive impairment; function assessment, frailty, and falls; depression and anxiety; and hazards of hospitalization.

Primary Care Psychiatry: Practical Skills for Internal Medicine Physicians: 2025 Video Recordings Package

Expert clinician educators will provide an evidence-informed update for internal medicine physicians on practical approaches to interviewing patients to recognize, diagnose, treat, and/or refer patients with commonly encountered mental health disorders. Faculty with training in both internal medicine and psychiatry will emphasize the importance of a patient-centered approach, motivational interviewing, and simple cognitive behavioral techniques that can be quickly used in medical settings.

Primary Care Psychiatry: Practical Skills for Internal Medicine Physicians: 2024 Video Recordings Package

Expert clinician-educators will provide a practical, evidence-based update for internal medicine physicians on approaches to interviewing patients with the goal of recognizing, diagnosing, treating, and/or referring patients with commonly encountered mental health disorders. Faculty with training in both internal medicine and psychiatry will emphasize the importance of a patient-centered approach, motivational interviewing, and quick cognitive behavioral techniques that can be quickly used in medical settings.

Primary Care Psychiatry: Everything Practicing Internal Medicine Physicians Need to Know: 2026 Focused Topic Recordings

This Online Learning Center activity features expert clinician-educators providing an evidence-informed update designed to teach internal medicine physicians practical approaches to recognizing, diagnosing, treating, and triaging patients with commonly encountered psychiatric disorders.

Geriatrics and Palliative Medicine for Internal Medicine Physicians: 2026 Focused Topic Recordings

This Online Learning Center activity focuses on practical, evidence-based strategies that the internal medicine physician can use across care settings to better identify and treat serious and chronic conditions common to older populations.

Digital Health Equity: Bridging the Divide

The digital divide is the gap between those who have access to technology or the Internet and those who do not, typically on the basis of higher versus lower socioeconomic status. Thirteen percent of U.S. adults do not use the Internet; of these, 19% do not use it because of cost barriers related to Internet service or computer ownership. In addition, demographic variables, such as age, education, community (rural, urban, or suburban), or income, may contribute to non-adoption of technology.

Quality Indicators for Major Depressive Disorder in Adults: A Review of Performance Measures by the American College of Physicians

Physician Suicide Prevention and the Ethics and Role of a Healing Community: An American College of Physicians Policy Paper

Identifying Core Clinical Topics and Recommending Core Performance Measures for Internal Medicine Physicians

ACP Response to Senate Finance Committee Inquiry Concerning Policies to Improve Behavioral Health Care

ACP Letter to the Senate Supporting Passage of Lorna Breen Healthcare Provider Protection Act of 2021

ACP Letter to the House Supporting Passage of Lorna Breen Healthcare Provider Protection Act of 2021

ACP Support Letter to the Senate HELP Committee for S. 3679, the Dr. Lorna Breen Health Care Provider Protection Reauthorization Act

ACP Letter for the Record on the Dr. Lorna Breen Health Care Provider Protection Act

Testosterone Treatment in Adult Men with Age-Related Low Testosterone: A Clinical Guideline from the American College of Physicians (2020)

Evidence-Based Interventions to Improve the Palliative Care of Pain, Dyspnea, and Depression at the End of Life

Performance Measures Depression

Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the eligible encounter.

Depression Utilization of the PHQ-9 Tool

The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with a diagnosis of major depression or dysthymia who have a completed PHQ-9 tool during a four month measurement period.

Depression Response at Twelve Months, Progress Towards Remission

The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia who are progressing towards remission by achieving a response (PHQ-9 or PHQ-9M score reduced by 50% or greater) twelve months (+/- 60 days) after an index visit.

Depression Response at Six Months- Progress Towards Remission

The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia who are progressing towards remission by achieving a response (PHQ-9 or PHQ-9M score reduced by 50% or greater) six months (+/- 60 days) after an index visit.

Depression Remission at Twelve Months

The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date.

Depression Remission at Six Months

The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission six months (+/- 60 days) after an index event date.

Bipolar Disorder and Major Depression: Appraisal for Alcohol or Chemical Substance Use

INACTIVE REVIEW: This measure review is older than five years. Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use.

Adult Major Depressive Disorder (MDD): Comprehensive Depression Evaluation: Diagnosis and Severity

INACTIVE REVIEW: This measure review is older than five years. Percentage of patients aged 18 years and older with a diagnosis or recurrent episode of major depressive disorder (MDD) with evidence that they met the DSM-IV criteria for MDD AND for whom there is an assessment of depression severity during the visit in which a new diagnosis or recurrent episode was identified.

Anti-Depressant Medication Management

"Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported. a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).

Depression

This issue provides a clinical overview of depression, focusing on screening, diagnosis, treatment, and practice improvement. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.

Comparing the Effectiveness of Depression Treatments for Patients Undergoing Maintenance Hemodialysis

Medicine and Nonmedicine Options for the Treatment of Adults With Major Depressive Disorder

Screening for Depression in Children and Adolescents: U.S. Preventive Services Task Force Recommendation Statement

Quality Indicators for Major Depressive Disorder in Adults: A Review of Performance Measures by the American College of Physicians

Major depressive disorder (MDD) is a severe mood disorder that affects at least 8.4% of the adult population in the United States. Characteristics of MDD include persistent sadness, diminished interest in daily activities, and a state of hopelessness. The illness may progress quickly and have devastating consequences if left untreated. Eight performance measures are available to evaluate screening, diagnosis, and successful management of MDD. However, many performance measures do not meet the criteria for validity, reliability, evidence, and meaningfulness. The American College of Physicians (ACP) embraces performance measurement as a means to externally validate the quality of care of practices, medical groups, and health plans and to drive reimbursement processes. However, a plethora of performance measures that provide low or no value to patient care have inundated physicians, practices, and systems and burdened them with collecting and reporting of data. The ACP’s Performance Measurement Committee (PMC) reviews performance measures using a validated process to inform regulatory and accreditation bodies in an effort to recognize high-quality performance measures, address gaps and areas for improvement in performance measures, and help reduce reporting burden. Out of 8 performance measures, the PMC found only 1 measure (suicide risk assessment) that was valid at all levels of attribution. This paper presents a review of MDD performance measures and highlights opportunities to improve performance measures addressing MDD management.

The American College of Physicians Living Guideline on Depression: A Step Forward, but Gaps Remain

The Management of Major Depressive Disorder: Synopsis of the 2022 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline

Description: In February 2022, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline (CPG) for the management of major depressive disorder (MDD). This synopsis summarizes key recommendations. Methods: Senior leaders within the VA and the DoD assembled a team to update the 2016 CPG for the management of MDD that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy CPGs. The guideline panel developed key questions, systematically searched and evaluated the literature, created two 1-page algorithms, and distilled 36 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Select recommendations that were identified by the authors to represent key changes from the prior CPG are presented in this synopsis. Recommendations: The scope of the CPG is diverse; however, this synopsis focuses on key recommendations that the authors identified as important new evidence and changes to prior recommendations on pharmacologic management, pharmacogenomics, psychotherapy, complementary and alternative therapies, and the use of telemedicine.

Trends in Depressive Symptoms and Associated Factors During Residency, 2007 to 2019: A Repeated Annual Cohort Study: Annals of Internal Medicine: Vol 175, No 1

Background: Efforts to address the high depression rates among training physicians have been implemented at various levels of the U.S. medical education system. The cumulative effect of these efforts is unknown. Objective: To assess how the increase in depressive symptoms with residency has shifted over time and to identify parallel trends in factors that have previously been associated with resident physician depression. Design: Repeated annual cohort study. Setting: U.S. health care organizations. Participants: First-year resident physicians (interns) who started training between 2007 and 2019. Measurements: Depressive symptoms (9-item Patient Health Questionnaire [PHQ-9]) assessed at baseline and quarterly throughout internship. Results: Among 16 965 interns, baseline depressive symptoms increased from 2007 to 2019 (PHQ-9 score, 2.3 to 2.9; difference, 0.6 [95% CI, 0.3 to 0.8]). The prevalence of baseline predictors of greater increase in depressive symptoms with internship also increased across cohorts. Despite the higher prevalence of baseline risk factors, the average change in depressive symptoms with internship decreased 24.4% from 2007 to 2019 (change in PHQ-9 score, 4.1 to 3.0; difference, −1.0 [CI, −1.5 to −0.6]). This change across cohorts was greater among women (4.7 to 3.3; difference, −1.4 [CI, −1.9 to −0.9]) than men (3.5 to 2.9; difference, −0.6 [CI, −1.2 to −0.05]) and greater among nonsurgical interns (4.1 to 3.0; difference, −1.1 [CI, −1.6 to −0.6]) than surgical interns (4.0 to 3.2; difference, −0.8 [CI, −1.2 to −0.4]). In parallel to the decrease in depressive symptom change, there were increases in sleep hours, quality of faculty feedback, and use of mental health services and a decrease in work hours across cohorts. The decrease in work hours was greater for nonsurgical than surgical interns. Further, the increase in mental health treatment across cohorts was greater for women than men. Limitation: Data are observational and subject to biases due to nonrandom sampling, missing data, and unmeasured confounders, limiting causal conclusions. Conclusion: Although depression during physician training remains high, the average increase in depressive symptoms associated with internship decreased between 2007 and 2019. Primary Funding Source: National Institute of Mental Health.

Improving Depression Care

Harmonized Outcome Measures for Use in Depression Patient Registries and Clinical Practice

Major depressive disorder is a common mental health condition that affects an estimated 16.2 million adults and 3.1 million adolescents in the United States. Yet, a lack of uniformity remains in measurements and monitoring for depression both in clinical practice and in research settings. This project aimed to develop a minimum set of standardized outcome measures relevant to both patients and clinicians that can be collected in depression registries and clinical practice. Twenty-nine depression registries and related data collection efforts were identified and invited to submit outcome measures. Additional measures were identified through literature searches and reviews of quality measures. A multistakeholder panel representing clinicians; payers; government agencies; industry; and medical specialty, health care quality, and patient advocacy organizations categorized the 27 identified measures using the Agency for Healthcare Research and Quality's supported Outcome Measures Framework. The panel identified 10 broadly relevant measures and harmonized definitions for these measures through in-person and virtual meetings. The harmonized measures represent a minimum set of outcomes that are relevant to clinicians and patients and appropriate for use in depression research and clinical practice. Routine and consistent collection of these measures in registries and other systems would support creation of a national research infrastructure to efficiently address new questions, improve patient management and outcomes, and facilitate care coordination.

Opioid-Induced Adrenal Insufficiency With Concurrent Opioid-Induced Esophageal Dysfunction Presenting With Achalasia-Like Features | Annals of Internal Medicine: Clinical Cases

Long-term opioid therapy has been increasingly recognized to cause multisystem complications beyond dependence and respiratory depression. Among these, opioid-induced adrenal insufficiency and opioid-induced esophageal dysfunction remain underdiagnosed and poorly understood in routine clinical practice. We report the case of a 64-year-old woman with chronic high-dose methadone use who developed secondary adrenal insufficiency with refractory hypotension and subsequently manifested with progressive esophageal dysfunction with imaging findings suggestive of achalasia. This case highlights the need for increased clinical suspicion of endocrine and gastrointestinal complications in patients undergoing prolonged opioid therapy.

Chronic Eosinophilic Pneumonia With Multiple Drug-Related Risk Factors: Diagnosis and Management | Annals of Internal Medicine: Clinical Cases

Chronic eosinophilic pneumonia is a rare illness characterized by pneumonic infiltrates with peripheral eosinophilia. The underlying cause is unknown, but it is associated with multiple medications. The present article reports a woman in her 60s with a history of chronic sinusitis and asthma who presented with subacute cough and hemoptysis and significant peripheral and bronchioalveolar eosinophilia. This patient also had anxiety and depression treated chronically with trazodone and venlafaxine, which are associated with eosinophilic pneumonia. Symptoms promptly resolved within 24 hours following steroid treatment. This article highlights the diagnostic challenge eosinophilic pneumonia presents.

Apathetic Thyrotoxicosis Presenting With New-Onset Pulmonary Hypertension | Annals of Internal Medicine: Clinical Cases

Apathetic thyrotoxicosis is a distinct clinical entity of hyperthyroidism that occurs in elderly patients. Manifestations include depression, weight loss, mild tachycardia, and symptoms of heart failure. Noteworthy is the absence of typical hyperkinetic motor symptoms. Pulmonary hypertension is an often-overlooked manifestation of thyrotoxicosis. Here, we present a case of a 67-year-old woman who presented to the clinic with complaints of dyspnea on exertion, orthopnea, leg edema, and 20-lb weight loss. Further work-up revealed pulmonary hypertension with thyrotoxicosis, without the typical sympathetic symptoms. After achieving a euthyroid state with methimazole therapy, she experienced resolution of her symptoms, and her pulmonary artery pressures normalized.

Successful Cryoablation of a Sacral Phosphaturic Mesenchymal Tumor Causing Tumor-Induced Osteomalacia | Annals of Internal Medicine: Clinical Cases

Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome caused by fibroblast growth factor 23 (FGF23)–secreting phosphaturic mesenchymal tumors. We report a 63-year-old man with TIO whose sacral tumor was identified after 2 years of nonlocalizing functional imaging. Owing to the surgically challenging location, computed tomography (CT)-guided cryoablation was performed. The patient's FGF23 level normalized 1 month postprocedure, and biochemical remission has been sustained for over 4 years. This case demonstrates that CT-guided cryoablation provides durable remission for sacral phosphaturic mesenchymal tumors not amenable to surgical resection, representing one of the longest reported follow-ups for cryoablation of sacral TIO.

Recurrent Pulseless Electrical Activity Arrests Due to Coronary Vasospasm Without Obstructive Coronary Artery Disease | Annals of Internal Medicine: Clinical Cases

This case describes recurrent pulseless electrical activity arrests in a postoperative patient caused by coronary vasospasm, an underrecognized but reversible trigger of cardiac arrest. Transient ischemic electrocardiogram changes, nonobstructive coronary angiography, rapid improvement with vasodilator therapy, and recovery of left ventricular function supported the diagnosis. The case emphasizes that vasospasm can mimic acute coronary syndromes and precipitate life-threatening instability, particularly in critically ill patients. It adds to current knowledge by highlighting the need for early suspicion, careful vasopressor selection, and prompt initiation of vasodilators to prevent irreversible myocardial injury and improve outcomes.

Acute Thigh Pain in a Patient With Diabetes Mellitus: A Rare Case of Diabetic Myonecrosis | Annals of Internal Medicine: Clinical Cases

Diabetic myonecrosis (also known as diabetic muscle infarction, or DMI) is a rare complication of poorly controlled diabetes, with fewer than 200 discrete cases reported in the English language medical literature over the past 60 years. In most published cases, diabetic myonecrosis occurs concurrently with other micro/macrovascular diabetic sequelae (e.g., nephropathy). Here, we describe a case of a patient with DMI without nephropathy, whose presentation was otherwise pathognomonic for DMI. We share this case to increase clinician awareness of this uncommon condition and to highlight the diagnostic and treatment considerations to keep in mind when managing suspected DMI, as choice of treatment can dramatically affect clinical course.

Dermatitis Neglecta: A Case Report of Hyperpigmentation Resulting From Impaired Mechanical Cleansing | Annals of Internal Medicine: Clinical Cases

Dermatitis neglecta (DN) results from inadequate frictional cleansing and is often associated with psychiatric or neurologic impairments. It is frequently misdiagnosed owing to its rarity and variable presentation. We report a 71-year-old woman with extensive hyperpigmented plaques from the mid-back to posterior thighs. Initially suspected to be tinea corporis, the primary lesion did not fluoresce on Wood's lamp examination. Mechanical cleansing with soap, water, and alcohol swabbing removed the pigmentation, confirming DN. This case emphasizes the importance of recognizing DN, particularly in patients with functional limitations, to avoid unnecessary testing and ensure effective management.

Symptomatic Methemoglobinemia at Low Levels in a Patient With Obstructive Sleep Apnea | Annals of Internal Medicine: Clinical Cases

Previously reported cases of hypoxemia secondary to methemoglobinemia usually had measured methemoglobin percentages of around 20% or greater. We report an unusual case of methemoglobinemia secondary to dapsone use in a 66-year-old man with obstructive sleep apnea who presented with dyspnea and hypoxia with a methemoglobin percentage of less than 10%.

Nocturnal Enuresis in an Adult With Obesity | Annals of Internal Medicine: Clinical Cases

We present a case of nocturnal enuresis (NE) in an adult with obesity that resolved with treatment of obstructive sleep apnea (OSA). The patient reported daytime somnolence and enuresis with no daytime urinary incontinence. A home sleep study diagnosed OSA. The patient received continuous positive airway pressure (CPAP) treatment with immediate resolution of enuresis. This case highlights the importance of recognizing enuresis as a potential symptom of sleep apnea.

Isolated Subcutaneous Sarcoidosis (Darier–Roussy Disease) Without Systemic Involvement: Diagnostic Challenge and Remission Following Intralesional Therapy | Annals of Internal Medicine: Clinical Cases

Subcutaneous sarcoidosis (Darier–Roussy disease) is a rare variant of cutaneous sarcoidosis characterized by painless subcutaneous nodules. We present the case of a 55-year-old woman with a firm, nontender mass overlying her right triceps region, initially misdiagnosed as cellulitis. Biopsy revealed a noncaseating granuloma consistent with subcutaneous sarcoidosis. Extensive systemic work-up was unremarkable, confirming isolated disease. The lesion resolved within 6 months following 2 intralesional corticosteroid injections administered 2 months apart, with no recurrence over 4 years. This case highlights the diagnostic challenges of subcutaneous sarcoidosis and the importance of histopathologic confirmation and multidisciplinary evaluation, even in the absence of systemic symptoms.

Community health worker intervention improved anxiety, depression in minority patients

Diets may slightly reduce depressive symptoms in people with elevated cardiometabolic risk

Digital intervention helped improve depression outcomes in primary care

Depression risk lower with GLP-1 receptor agonists than DPP-4 inhibitors, target trial finds

Anxiety, depression treatment linked with improved outcomes in cardiovascular disease

Walking, jogging, yoga, and strength training help treat depression, analysis finds

Mobile apps can help treat moderate to severe depression

ACP's updated depression guideline recommends CBT, second-generation antidepressants

Portal-based population health screening appears effective for depression

U.S. veterans may not always receive preferred treatment for depression

Caregiver burden high during HaH admissions | ACP Hospitalist

Going, going, gone | ACP Hospitalist

Weekly insulin, medication for agitation in Alzheimer's approved | ACP Hospitalist

New focus on frailty | ACP Hospitalist

The healing power of music | ACP Hospitalist

Ageism, an often invisible bias | ACP Hospitalist

ACS in premenopausal women addressed by scientific statement | ACP Hospitalist

Expectations of recovery | ACP Hospitalist

Patients perceived as difficult across settings | ACP Hospitalist

Potassium chloride injections recalled | ACP Hospitalist

Depression risk lower with GLP-1 receptor agonists than DPP-4 inhibitors, target trial finds

Depression associated with death in older patients with type 2 diabetes

Exercise and CBT are cost-effective for diabetes patients with depression

Antidepressants associated with decreased mortality rates in patients with diabetes and depression

Spotlight on depression in diabetes

Spotlight on diabetes and sleep

GLP-1 receptor agonists show effects on substance disorders, infections

ADA releases updated Standards of Care for 2025

MKSAP quiz: Elevated HbA1c level, loss of energy in older patient

Spotlight on GLP-1 receptor agonists and suicidality

Antidepressants may mitigate link between inflammatory bowel disease and depression

Depression may be associated with higher risk for aggressive IBD

Spotlight on avoidant/restrictive eating

Spotlight on IBS interventions

Clinical practice update advises on management of cyclic vomiting syndrome

In primary care, second-line IBS therapy with amitriptyline vs. placebo reduced symptoms at 6 mo

Cyclic vomiting syndrome affects 42 per 100,000 Medicaid beneficiaries, study finds

Low-dose amitriptyline appears effective as second-line treatment for IBS

Spotlight on psychological factors and GERD

PPIs, H2 blockers not linked to cognitive problems in older patients, study finds