When Depression Isn’ t Just Depression: A Structured Approach for Primary Care
The Diagnostic Challenge in Primary Care
Primary care physicians are often the first point of contact for patients with mental health symptoms, yet these presentations rarely arrive with a clear diagnostic label. Instead, clinicians hear about fatigue, sleep disturbance, anxiety, vague bodily complaints or difficulty functioning at work or home. Within a brief visit, it can be difficult to sort out whether these symptoms reflect depression, bipolar spectrum illness, anxiety disorders, early psychosis, substance use or medical causes of psychiatric symptoms.
Most commonly used screening tools focus on a single condition, such as depression or anxiety. While helpful, these instruments can unintentionally fragment mental health assessment. A depression questionnaire may accurately detect low mood but fail to identify bipolar activation or subtle psychotic features. Early psychotic symptoms may be missed entirely if the evaluation is limited to mood-based scales. This diagnostic fragmentation can delay recognition of serious mental illness and contribute to partial or inappropriate treatment strategies in primary care.
A Structured Way to Think Through Psychiatric Symptoms
To address this challenge, the MERON Diagnostic Framework was developed as a simple clinical heuristic to organize psychiatric evaluation in primary care. Rather than starting from a single suspected diagnosis, MERON encourages clinicians to move systematically through five major diagnostic domains:
» M – Mood: Assessment of depressive and elevated mood states, including anhedonia, hopelessness, irritability or periods of conspicuously elevated or expansive mood.
20 LOUISVILLE MEDICINE
by Bhupendra Kishore Gupta, MD, DPM
» E – Energy: Evaluation of activation patterns such as agitation, reduced need for sleep, psychomotor slowing or episodes of unusually high energy and goal-directed activity.
» R – Reality Testing: Identification of hallucinations, delusions, disorganized thinking or marked suspiciousness.
» O – Organic Causes: Consideration of medical contributors such as endocrine disorders, neurologic illness, systemic infections, medication side effects and substance use.
» N – Neurodevelopmental Factors: Assessment of intellectual disability, autism spectrum traits, long-standing cognitive limitations and developmental history that may shape symptom expression and functioning.
This structured approach functions as a cognitive map. It is intended to be flexible, usable within a few minutes and compatible with the realities of busy primary care settings.
Prioritizing What Matters Most
A key feature of the MERON framework is its hierarchical structure. The model begins with an assessment of reality testing, asking first whether psychotic symptoms may be present. Early identification of hallucinations, fixed delusional beliefs or grossly disorganized thinking is critical because psychotic disorders typically require urgent psychiatric evaluation, early intervention and close follow-up. If psychosis is present or strongly suspected, rapid referral or co-management with psychiatry becomes a high priority.
If reality testing appears intact, the clinician then focuses on mood orientation and energy level. This step helps distinguish unipolar depressive disorders from bipolar spectrum conditions. For example, a