Domino_5-Minute Clinical Consult, 33e

DEPRESSION Afsha Rais Kaisani, MD • Tasaduq Hussain Mir, MD, FAAFP • Michael A. Armstrong, MD

HISTORY • The presence of four “SIGECAPS” symptoms plus depressed mood suggests depression. – Sleep: changes in sleep habits from baseline; excessive sleep, early waking, or inability to fall asleep – Interest: loss of interest in previously enjoyable activities – Guilt: excessive or inappropriate guilt that may or may not be related to a specific problem or circumstance – Energy: perceived lack of energy – Concentration: inability to concentrate on specific tasks – Appetite: an increase or decrease in appetite – Psychomotor: restlessness and agitation or the perception that everyday activities are too strenuous to manage – Suicidality: the desire to end one’s life or hurt oneself, harmful thoughts directed internally, or recurrent thoughts of death or homicide • Depression may present differently between men and women. Women may report physical ailments: headache, myalgias, and/or GI distress; men may report aggression, substance use, and/or risky behavior (2). Pediatric Considerations May present with somatic symptoms (headaches, GI upset), irritability, difficulty with concentration, frequent absences from school, or sudden change in grades Geriatric Considerations Difficult to diagnose due to medical comorbidities; may present as memory difficulties; geriatric Depression Scale (GDS 15) improves the rate of diagnosis. PHYSICAL EXAM Comprehensive physical and mental status examination • Level of consciousness and orientation • Appearance: hygiene, posture, clothing • Attitude: hostility, apathy • Behavior: eye contact, psychomotor agitation • Mood: depressed, anxious, angry, tearful, etc. • Affect: mood-congruent, flat, labile, manic • Memory: immediate, recent, and remote • Speech: fluency, repetition, comprehension • Thought process: delusions, hallucinations, suicidal/ homicidal thoughts, flight of ideas, grandiosity, obsessions/compulsions • Insight: understanding of own illness • Judgment: ability to make rational decisions • Medical comorbidity: adrenal disease, hypothyroid ism, diabetes, liver or renal failure, malignancy, sleep disorders, chronic fatigue syndrome, fibromyalgia, vitamin deficiencies DIAGNOSTIC TESTS & INTERPRETATION • The Patient Health Questionnaire-9 (PHQ-9) if PHQ-2 is positive; other tools: Beck Depression Inventory, Zung Self-Rating Depression Scale, or GDS 15 • Screen postpartum women using Edinburgh Postnatal Depression Scale (EPDS). • Assess for suicidal/homicidal ideation. DIFFERENTIAL DIAGNOSIS • Depressed phase of bipolar disorder • Adjustment disorder with depressed mood

Initial Tests (lab, imaging) Laboratory test to exclude other conditions: compete blood count, electrolytes, kidney and liver function, thyroid-stimulating hormone, rapid plasma reagin test, HIV test, toxicology screen, vitamin levels (D, B 12 , folate); consider pregnancy test in all reproductive-aged women. Diagnostic Procedures/Other CT/MRI of brain should be considered for organic brain syndrome or hypopituitarism. TREATMENT American Psychiatric Association (APA) treatment guidelines recommend the following: • Acute phase (first 3 months of treatment) – Full evaluation, including risk to self and others, with selection of appropriate treatment setting; the goal should be symptom remission and recovery of function. – Offer either psychotherapy or second-generation antidepressant (selective serotonin reuptake inhibitors [SSRIs] or serotonin-norepinephrine reuptake inhibitors [SNRIs]) or combined therapy in severe cases (3). – Follow up 2 to 4 weeks of starting medication, q2wk until improvement, and then monthly. – Continue to increase dosage q3–4wk until remission; the full effect is achieved in 4 to 6 weeks. May need second medication. – $ 6 visits are recommended for monitoring (younger patients, those at high suicide risk, see within 1st week, and follow frequently). • Continuation phase (4 to 9 months of treatment)/ maintenance phase ( . 9 months of treatment) – Monitor for relapse; q3–6mo if stable – Use depression rating scales and patient reports to monitor response. – Add psychotherapy for patients without response to medication alone. – Continue the dosage for at least 6 to 9 months to reduce relapse once the remission is achieved. Cognitive-behavioral therapy (CBT) is effective in reducing relapse (visits are typically q2wk). – Taper medication gradually (weeks to months) to allow the detection of recurring symptoms and minimize discontinuation syndrome. Taper dose by 25% q4wk (3). GENERAL MEASURES Pharmacotherapy and psychotherapy, alone, can relieve depressive symptoms. Combination therapy has high rates of improvement, increased quality of life, and better treatment compliance. Psychotherapy methods include the following: • CBT: combines cognitive psychotherapy with behav ioral therapy; proven effective • Interpersonal psychotherapy (IPT): identifies a trigger of the depressive episode, facilitates mourn ing, promotes recognition of affects, resolves role disputes and role transitions, and builds social skills • Psychodynamic psychotherapy: helps identify uncon scious thoughts leading to behavior • Family and marital therapy: addresses family or relationship-oriented problems • Problem-solving therapy: combines elements of CBT and IPT into a brief treatment lasting 6 to 12 ses sions; may have a role in those with mild symptoms of depression

BASICS

DESCRIPTION Primary mood disorder characterized by a sustained feeling of sadness and/or decreased interest in all or most activities once enjoyed, which represents a change from previous state EPIDEMIOLOGY Prevalence • Lifetime prevalence of major depressive disorder (MDD) is 20.6% (1). • Low risk before early teens; highest prevalence in teens and young adults; average age of onset is 30 years. ETIOLOGY AND PATHOPHYSIOLOGY Pathophysiology is poorly understood. Genetics Twin studies suggest 37% concordance. RISK FACTORS • Female . male (2:1) • Adverse life events (2) • First-degree relative or spouse with depression, bipolar, suicide, substance abuse • Presence of comorbid medical conditions including neurodegenerative diseases GENERAL PREVENTION Physical activity lowers the risk of depression (3). COMMONLY ASSOCIATED CONDITIONS Bipolar disorder, cyclothymic disorder, grief reaction, anxiety disorders, somatoform disorders, schizophrenia/schizoaffective disorders, conduct disorder, substance abuse DIAGNOSIS DSM-5 requires the following criteria for MDD: • Criterion A: $ 5 of the following symptoms present nearly every day during the same 2-week period, with at least 1 being either depressed mood or loss of interest or pleasure: – Dysphoria: subjective or observation by others of depressive mood most of the day – Anhedonia: decreased interest or pleasure in previously enjoyable activities most of the day either by subjective report or observation from other people – Notable change in appetite or unintentional significant weight loss – Insomnia or hypersomnia – Fatigue or energy loss – Agitation, restlessness, or slowed speech or body movements observable by others – Diminished thinking/concentration, poor memory – Worthlessness, inappropriate guilty feelings – Recurrent thoughts of death/harm, suicidal ideations, or suicide attempt or a devised plan for suicide • Criterion B: Symptoms cause social, occupational, or functional distress. • Criterion C: symptoms not attributable to substance effects or other medical conditions. • Minor depression: 2 to 4 of the following symptoms of Criteria A plus B and C as above and: – Persistent depressive disorder (dysthymia) and cyclothymic disorder not present – The mood disturbance does not occur exclusively during a psychotic disorder.

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