Depression

History

 

Screening questions

Screening should only be carried out only if there is sufficent resources to provide follow-up (USPSTF, 2009)

 

Screening qustions can include:

• Are you depressed?
• Have you lost interest or pleasure in things you normally like to do?
• Do you have troubles sleeping?

 

Diagnosis of Major Depressive Disorder

DSM-IV criteria for MDD include:

At least one of the following: depressed mood anhedonia

At least four of the following minor symptoms (SIG-E-CAPS): Sleep disturbance (insomnia or hypersomnia) loss of Interests Guilt decreased Energy trouble Concentrating or impaired memory change in Appetite Psychomotor agitation or retardation Suicidal ideation

• these criteria must occur within the same 2-week period and reflect a change from previous functioning
• cannot meet criteria for mixed episode 
• must cause impairment or distress in areas of functioning (social, occupational, family, etc.)
• cannot be due to the effects of a substance or general medical condition
• cannot be better accounted for by bereavement or other psychiatric disorders

Major depressive disorder is based on the criteria of MDE but must ensure the following additional criteria are met:

• not better accounted for by schizoaffective disorder and not superimposed on other psychotic disorders
• absence of manic, mixed or hypomanic episode

As above, ensure you ask about a previous hypomanic episode.

 

In the elderly, depressed mood may be less prominent, they are more likely to express somatic compaints (over half with hypochondriacal symptoms), less likely to feel gulity, cognitive imparment or psychosis (somatic, nihilism, persecution) are more common.

 

Late-onset depression is more likely to be associated with cognitive impairment or white matter changes.

Physical Exam

As with most patients, a general screening physical exam should be performed.  This should be focused at ruling out other illnesses or diseases (based on the differential diagnoses) that may contribute to the symptoms of depression (e.g. endocrine disorders, neurological disorders, etc.).  However, the "physical exam" as it pertains to a pyschiatric assessment should really be thought of as the mental status examination (MSE).  Therefore, in assessing a patient with depressive symptoms, one should assees the following:

 

appearance

appropriate dress?

well kept appearance?

nutritional status?

depression: often normal; in severe cases, evidence of  inappropriate self-care becomes apparent 

 

 

attitude

towards the examiner

really an assessment of the quality of the rapport between the patient and clinician during an assessment

depression: patient often distant from the examiner and not particularly cooperative; may at times be hostile

 

 

behaviour

any unusual behaviours or mannerisms?  

any obvious outward signs suggesting emotional state of the patient?

depression: evidence of psychomotor agitation or retardation may be observed

 

mood and affect

mood refers to the patients description of how they feel

affect refers to the visible body language, voice intonation, etc. that are indicative of the patient's emotional state

depression: mood is often reported as poor and patient usually has a flat affect

 

speech

one should observe how the patient is speaking - rate of speech, intonation, difficulties with words/sentences, etc.

depression: speech is often slow, intermittent and quiet

 

thought process 

focuses on the rate and flow of thoughts and is usually ascertained/inferred from the speech

depression: often slowed and not particularly active; loss of interest in usual activities is common 

 

thought content

assessment of delusions, phobias, etc.

depression:usually over-emphasis on negative thoughts and feelings of hopelessness, worthlessness, etc. 

 

perceptions

usually focused on assessment of hallucinations, delusions, etc.

depression: usually not abnormal in patients with depression

 

 

cognition

assessment of mental functioning - i.e. memory, concentration, etc.

depression: patients usually report, and demonstrate, poor memory (short and long term) as well as decreased concentration

 

judgment

assess the patients ability to take appropriate actions when necessary 

i.e. does patient seek medical attention when necessary?  does patient demonstrate sound decision making despite pyschiatric illness?

 

 

insight

assessment of the patients understanding of his or her illness and how it impacts their thoughts/functions

 

suicide risk assessment

critical in every patient with depressive symptoms

ask directly but politely

Ratings Scales

Ratings scales are validated and reliable tools used to objectively assess a patient's symptoms. They have an important role in making a diagnosis, setting the baseline function, and monitoring improvement.

They have been shown to improve patient adherence (ref).

 

Features of effective rating scales include:

• valid and reliable
• sensitive and specific
• easy and quick to use
• validated cut off points
• in the public domain
• incorporated into the electronic medical record
• available in different languages

There are two main types of scales - self-administered, or observer-administered. These can be used in tandem for cross-validation.

 

Self-rating scales:

Beck's widely used copyrighted	Burn's freely available
MDQ	GDS

 

 

Observer rating scales:

PHQ	HAM-D
CGI

 

Lab Workup

Each patient should undergo a complete history and physical examination.  Furthermore, any suspicions of medical disease at play should be considered and investigated.  Common blood work that may be considered include:

• CBC
• electrolytes
• BUN
• creatinine
• serum blood glucose
• liver profile
• TSH
• toxicology screen
• urinalysis

 

Ultimately, major depressive episode/disorder is a clinical diagnosis and investigations should only be ordered where deemed appropriate by the clinician.  However, in many centers, any psychiatric patient will have to be "medically cleared" before being assessed by psychiatry.  This usually involves some basic blood work (some of which is listed above) in order to rule out organic causes to the patient presentation. 

Seasonal

Seasonal depression, or seasonal affective disorder (SAD), has a pattern of onset the same each year. This is most often in the fall or winter.

Melancholic

either a loss of

• loss of pleasure in all, or almost all, activities
• lack of reactivity to usually pleasurable stimuli

and three or more of the following

• distinct anhedonia
• early morning waking
• anorexia
• excessive guilt

Atypical

mood reactivity, and two or more of the following:

• significant weight gain or increase in appetite
• hypersomnia
• leaden paralysis
• long-standing of interpersonal rejection sensitivity
• MAOIs

Postpartum

• Discriminate from 'baby blues'.
• Severe persitent, progressive. Interferes with function.
• Peaks at 4-6 weeks and 4-6 months.
• High levels of co-morbid anxiety and irritability, with excessive worry.
• Prominent cognitive dysfunction.
• New obsessive thoughts and images can arise.
• Suicide is not as common as escape fantasies
• Increased risk of prior depression or premenstrual dysphoria, family history, and lack of social supports

Psychotic

• more commonly delusions than hallucinations
• often mood congruent

Catatonic

at least two of the following:

• motoric immobility, with catalepsy or stupor
• excessive motoric activity, apparently purposeless and not influenced by external stimuli
• extreme negativism or mutism
• peculiarities of voluntary movement as evidenced by posturing, stereotyped movements, or prominent mannerisms or grimacing
• echopraxia or echolalia

Antidepressants are important drugs for treating depression (Gill and Hatcher, 2004).  After initiating treatment, sleep and appetite come back first, concentration next, and mood last.  Consider affordability, history of prior response, side effect profile, depression subtype, drug interactions, medical comorbidity, clinician and patient preference, patient age, and fertility status.

 

Cipriani et al, 2009: Sertraline.

 

Treatment Goals

short-term (8-12 weeks)

• reduction of symptoms - remission, not just response
• improvement in quality of life
• return to normal level of functioning (not the same as symptom reduction; often life is never the same again afterwards)

long term (>3 months)

• prevention of a return to depressive or anxious symptoms (no relapse)
• maintenance of a stable mood/ability to manage stress

end of treatment

• reduce or eliminate risk for discontinuation reaction - switch to a longer half life, etc
• venlafaxine and paroxetine can have a terrible withdrawal

As the biology is thought to be altered for 6-12 months, following symptom resolution, continuation therapy should be continued to prevent relapse.

 

Patients with the following risk factors should be maintained for at least two years: older age; frequent, recurrent, or chronic episodes; difficult-to-treat or severe episodes; psychotic features.

 

Assess patient status, therapeutic response, and adverse effects of antidepressant therapy on a regular basis beginning within 1 to 2 weeks of initiation of therapy.

 

 

Refractory Depression

When treating refractory depression (6-8 weeks of treatment), attempt to:

• optimize: ensure adequate dose
• augment: add a non-antidepressant (thyroid hormone, lithium, atypical antipsychotic)
• combine: add another antidepressant
• substitute: change the primary antidepressant, within or outside a class

 

If using fluoxetine or paroxetine,

TCAs and

Coumadin and fluvoxamine

MAOI and RIMA with reuptake inhibitors

Counselling and Psychotherapy

 

Mental Hygiene basics

proper exercise, diet, sleep, and education (ie "the Feeling Good Handbook")

 

Psychotherapy

Cognitive behavioural therapy (CBT), interpersonal therapy, or psychodynamic therapy can be helpful for treating depression.

Regarding CBT, behavioural activation is a key first step. Mastery, enjoyment and attention to avoidance.

 

Brief interventions

Brief interventions have been shown to improve depression in situations where adequate CBT services are not available. These include:

• bibliotherapy (providing readings)
• CBT-based websites
• CBT-based computer programs

These interventions appear more successful if they have greater structure, have a shorter intervention period, and have frequent contact or reminders with health care providers or staff (McNaughton, 2009).

 

Other Techniques

• ECT: gold standard for depression with psychosis
• light therapy
• transcranial magnetic stimulation (whoa!)

If depression is treatment-resistant, always review the diagnosis. Optimize the antidepressant by increasing the dose as tolerated before switching to an alternate agent. Consider augmenting with lithium or T3, and as a last resort, consider adding an antidepressant.