Sándor Kalmár M.D. Ph.D.

There are several possible reasons for the lack of proper recognition of depression in Primary Care Practice in Hungary:

1. General practitioners, who have graduated several years ago, only formally participate in CME courses, lack a holistic approach and do not possess sufficient knowledge, do not think of depression and do not recognise it.

2. The majority of Hungarian GPs has a predominantly somatic approach, and is little concerned about the mental wellbeing of their patients.

3. There is no effective supervision to guide the work of GPs.

4. A part of Hungarian physicians is supposedly affected by some type of affective and/or anxiety disorders or alcohol problems. It is a proven fact that the prevalence of suicide ideation is significantly higher in physicians and especially female physicians compared to other university graduates. Female suicide rate in Hungary: 11.4; suicide rate of female physicians: 40.5 It was reported that 3% of medical students use psychoactive drugs, 25% of medical students is likely to suffer from affective disorder, and this per cent significantly rises as the beginning of their career draws closer (Gönczi A, Márton H. 2008). If the physican has a susceptibility for depression this will prevent him from noticing the patient’s verbal and subtle nonverbal signs, gestures which reflect an interest in seeking help, affection and understanding problems including suicide intent which demands emergency intervention. In these cases, besides the lack of proper knowledge and preparedness, the inadequate approach of the physician can also be the source of iatrogeny, known as “malignant psychotherapy” (Pethő B, 1989)

5. In case of depressed patients, hypochondriac symptoms are the most common beyond anxiety symptoms, irritability and suicidal intent. This is generally disregarded by the predominantly somatically-oriented physician. Ferenc Pápai Páriz writes about melancholia hypochondriaca in his 1697 book “Pax Corporis. Hypochondriac symptoms have been observed in 12.97% of patients in involutional depression (86 patients of 663) and 4.98% of patients in psychogenic depression (33 patients from the 663). Anguish underlying hypochondriac fears concerns not only the patient’s own health, but also existential problems, his/her and his/her family’s future and their productivity as a prerequisite for their social security. Ensuring existential safety is the most important aspiration of personality and, along with the pursuit for security (which, according to Sullivan, is the opposite of anxiety) and Eriksonian basic trust creates the possibility of social coexistence. (Koronkai B, 1995)

6. Patients know neither ICD-10, nor DSM-IV criteria for depression, therefore they do not attempt to structure their complaints accordingly when reporting them. Of course, these two consensus-based nosological systems are not perfect, but they are the most prevalent and maybe also the best, in spite of the fact that their advantage (consensus) may also be at the same time their disadvantage as well. Polydiagnostic systems are certainly better, however, their prevalence is limited by their complexity (Ban TA, 1989). Those inexplainable pains and diffuse, dubious symptoms which have a serious negative impact on wellbeing and are thus important for the patient as well as existing somatic diseases often mislead physicians. The short time available for GP visits does not allow the patient to report all his complaints in details, therefore the majority are locked inside the patient. Self-report scales and complaint-based semi-structured interviews which would help diagnosis are not used, often leading to false diagnoses.

7. Family medicine departments at universities do not pay sufficient attention to the prevalence and significance of mental disorders in general practices.

References

Ban TA (1989) Composite Diagnostic Evaluation of Depressive Disorders. IUNCP Company, USA.

Gönczi A, Márton H. (2008) Depresszióra gyanús hangulatzavar előfordulása orvostanhallgatók körében a pályára való felkészülés különböző időszakaiban. CSAKOSZ VII.Kongresszus. 2008.02.29-03.01.

Koronkai B. (1995) Tanítások tanítója. A hipochondriás tünet a különböző depressziókban. (pp. 83-85) Animula Kiadó, Budapest.

Pethő B. Részletes Pszichiátria. Funkcionális betegségek és zavarok. Magyar Pszichiátriai Társaság, Budapest, 1989. (pp. 1178-1198)