As nurses, sometimes all we can do is wait-for a test result, treatment response, disease recurrence. In slowly progressing conditions or where intervention may do harm, waiting makes sense. But for serious, predictable, treatable conditions-ones driving global disease burden-waiting is irresponsible. We take a proactive clinical approach for many common, costly, and life-limiting conditions like type 2 diabetes and cardiovascular disease (CVD). The American Diabetes Association and American Heart Association have clear recommendations for increasing monitoring and encouraging risk-lowering strategies for patients in suspected prodromal states. However, for depression-a condition that affects one in five people, costs the United States $210 billion per year, and increases morbidity and mortality-clinical recommendations often ignore those at risk for developing the condition as well as its potential gravity and far-ranging consequences. A passive approach reliant on reaction to crisis rather than prevention or mitigation is no longer acceptable.
The relationship between depression and type 2 diabetes or CVD has been characterized as bidirectional. When depression is comorbid with type 2 diabetes and/or CVD, it increases the risk of complications (poor glycemic control, amputation), decreases quality of life, and compounds costs.
Even without comorbidities, depression can diminish social and occupational functioning and life expectancy. However, unlike type 2 diabetes and CVD, depression has no objectively measurable physiological indices that are referential to population-based standards, although major depressive disorder can include somatic symptoms. Combined with the lack of diagnostic biomarkers, clinical heterogeneity can impede detection, as hundreds of symptom combinations exist that meet the criteria for a depressive disorder. The individual depression experience may include specific cardinal symptoms such as depressed mood or anhedonia joined by one or more other symptoms such as changes in sleep, appetite, or concentration, or feelings of worthlessness, hopelessness, or irritability.
Early intervention can prevent crisis while improving cardiometabolic health, as depressive symptoms can interfere with self-monitoring, treatment adherence, and self-care activities. In parallel, the lived experience and treatment burdens of chronic conditions can exacerbate depression. Timely clinical identification is key to interrupting this cycle.
The Patient Health Questionnaire-9 (PHQ-9) is a depression screening tool widely used in primary care for good reason, as it is comparably sensitive and specific for major depressive disorder and other disorders of concern compared to measures that take longer to administer. Scores range from 0 to 27, and scores of 10 or higher indicate possible depressive disorder and correspond to clinical guidance for counseling and pharmacotherapy. However, the PHQ-9 recommendation of "watchful waiting" for patients with subclinical scores that are just below this cutoff is a missed opportunity for critical education and prevention efforts.
More-not less-caution is sometimes warranted for patients with subclinical scores, which may be underestimates of true symptom burden. As with many screening tools, historically minoritized populations were underrepresented in the development of the PHQ-9. Underrepresentation is significant because outward expressions of depression are tied to cultural norms. Moreover, underrepresented racial, ethnic, sexual, and gender identity populations are known to have disproportionate exposure to depression risk factors such as discrimination, violence, and poverty, along with less access to mental health specialists. Even if scores reflect true estimates, subclinical symptoms have known negative effects on morbidity, mortality, and functioning, reinforcing the need for clinical action at this stage.
Clear guidelines reflecting the magnitude of this public health crisis are urgently needed for patients with subclinical depressive symptoms. Nurses across settings, but especially in primary care, can disclose subclinical screening results and provide education about depression's many symptoms, risk factors, and impacts on health, seizing these opportunities to build trust, destigmatize mental illness, and share resources. Helping patients identify accessible health-promoting strategies can preserve cardiometabolic health and have a positive impact on mood.
Depression is not inevitable, and the choice between a passive or proactive clinical approach is obvious. We cannot afford to wait.