Background. Since depressive disorders are now eminently treatable and early detection and treatment could bring substantial benefits, it is critical to address alternative presentations of depression in the general medical setting. Concern regarding under-diagnosis of depression in general medical settings has given rise to the question of whether the clinical disorder of depression differs qualitatively or only quantitatively across care settings.

Methods. Symptom profiles of depression were compared across care sectors to investigate how the presentation of depression among general medical service users might differ qualitatively from speciality mental health service users. Data on depression symptoms within 6 months of interview gathered in three community surveys that were part of the NIMH Epidemiologic Catchment Area Program were analysed using methods developed to assess item bias. The subjects were 4931 and 363 persons who reported a visit to the general medical sector or to speciality mental health respectively, within 6 months of interview.

Results. Compared with speciality mental health service users, general medical service users were less likely to present dysphoria (adjusted Odds Ratio, aOR=0·57; 95% Confidence Interval, CI=0·38–0·84) and feeling worthless, sinful, or guilty (aOR=0·63; 95% CI=0·40–0·98), but were more likely to present fatigue (aOR=1·71; 95% CI=1·09–2·69), even after holding constant other characteristics that might influence reporting of symptoms as well as level of depression.

Conclusions. These results suggest that there are qualitative differences in depression presenting in general medical care compared with speciality mental health care and call for a reconceptualization of depression in the general medical setting.