Recognizing MDD in Practice: Presentation, Risk Factors, and Delayed Diagnosis

Welcome back to another Psychiatric Times Peer Exchange series. In "Recognizing MDD in Practice: Presentation, Risk Factors, and Delayed Diagnosis," moderator Gus Alva, MD is joined by Anita Clayton, MD, Charles DeBattista, MD, Lara Shirikjian, MD, and Hara E. Oyedeji, DNP, PMHNP-BC to open the series on major depressive disorder.

Dr. Alva frames the discussion by noting that depression rarely announces itself by name. It arrives dressed as insomnia, fatigue, or unexplained aches, and surfaces only when clinicians go looking for it. He asks Dr. Oyedeji what the typical path to diagnosis looks like, and why the stretch between first symptoms and adequate treatment runs so long.

Dr. Oyedeji explains that she treats across the lifespan, so presentations differ sharply by age and by setting. Children and adolescents often arrive as referrals from a pediatrician or a primary care clinician rather than as depression. Those presentations are frequently entangled with medical comorbidities, which delays recognition. She watches for sleep disturbance, insomnia, and trouble at home or at school as early flags. Some patients arrive by a different route entirely, referred after a hospital discharge and already further along in their depression journey. The better question, she argues, is what actually brought this patient in, and then asking enough to find what sits underneath.

Dr. Alva asks her to make this actionable for primary care, noting that a prior episode remains the single strongest predictor of the next. Dr. Oyedeji separates modifiable factors, such as home environment and relationship stress, from non-modifiable ones that demand an accurate history. She points to medical predisposition and family history of depression as the findings that should raise a flag. She credits primary care for using the PHQ-9 as a first-line assessment that clues the team in on severity. She then urges colleagues to match their response to the level of urgency in front of them. A chronic, severe patient with a stable support system differs from someone presenting for the first time with suicidality. She closes by positioning psychiatry as the ally primary care can turn to.

Our next episode, "Screening for MDD: Distinguishing Depression From Grief and Medical Mimics," features Dr. Clayton on the physical complaints, sex differences, and screening instruments that separate depression from its mimics.