Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Depression
Depression - Key Features
1. In a patient with a diagnosis of depression:
a) Assess the patient for the risk of suicide.
b) Decide on appropriate management (i.e., hospitalization or close follow-up, which will depend, for example, on severity of symptoms, psychotic features, and suicide risk).
2. Screen for depression and diagnose it in high-risk groups (e.g., certain socio-economic groups, those who suffer from substance abuse, postpartum women, people with chronic pain).
3. In a patient presenting with multiple somatic complaints for which no organic cause is found after appropriate investigations, consider the diagnosis of depression and explore this possibility with the patient.
4. After a diagnosis of depression is made, look for and diagnose other co-morbid psychiatric conditions (e.g., anxiety, bipolar disorder, personality disorder).
5. In a patient diagnosed with depression, treat appropriately:
- drugs, psychotherapy.
- monitor response to therapy.
- active modification (e.g., augmentation, dose changes, drug changes).
- referral as necessary.
6. In a patient presenting with symptoms consistent with depression, consider and rule out serious organic pathology, using a targeted history, physical examination, and investigations (especially in elderly or difficult patients).
7. In patients presenting with depression, inquire about abuse: - sexual, physical, and emotional abuse (past and current, witnessed or inflicted). - substance abuse.
8. In a patient with depression, differentiate major depression from adjustment disorder, dysthymia, and a grief reaction.
9. Following failure of an appropriate treatment in a patient with depression, consider other diagnoses (e.g., bipolar disorder, schizoaffective disorder, organic disease).
10. In the very young and elderly presenting with changes in behaviour, consider the diagnosis of depression (as they may not present with classic features).
Background:
1. A type of mood disorder (includes: depressive, bipolar, and secondary to general medical condition (GMC))
2. Must distinguish between normal sadness i.e. bereavement
3. Prevalence rate of 3 to 5% in general population in Canada
4. Runs a chronic or recurrent course with high risk of mortality and morbidity
5. Neurotransmitter dysfunction at level of synapse (decreased activity of serotonin, norepinepherine, dopamine)
6. Mean onset ~30 year, M:F 1:2
History:
Depression: MSIGECAPS
- M: Depressed Mood
- S: Increase/decreased Sleep
- I: Decreased Interest
- G: Guilt
- E: Decreased Energy
- C: decreased Concentration
- A: Increased/decreased Appetite
- P: Psychomotor retardation
- S: Suicidal ideation
Mania: GST PAID
- G: Grandiosity
- S: Sleep, decrease need
- T: Talkative
- P: Pleasure and pain
- A: Activity
- I: Inattention
- D: Distractibility
Psychotic features: up to 20% of MDD patients can exhibit psychotic features of hallucination or delusions
Medical Workup for Mood Disorder:
Routine screening
- • Physical examination (to rule out general medical condition)
- • CBC-d, electrolytes, liver panel, glucose, urea, creatinine, folate (metabolic disturbance), Vit B12
- • Thyroid function test
- • Electrolytes
- • Urinalysis, urine drug screen
- • ECG
- • Ethanol level (intoxication or withdrawal)
Major Depressive D/O
1. 5 (or more) symptoms that affect function for >2 weeks and represent a change in function. (See DSM IV)
2. Not due to physiological effects of a general medical condition or substance abuse
Differential:
Dysthymia, Bipolar Disorder, Substance Induced Mood Disorder
Treatment:
1. Emergent: admit to hospital for high suicide risk or danger to self or others. May require certification.
2. Treatment Options:
- a) Medication (SSRI, SNRI, Bupropion, Mirtazipine, TCA, and MAOI) If patient is started on medication they must be monitored weekly for suicidal ideation for 4 to 6 weeks. Note: anxiety and depression often co-exist so treatment of depression can unmask anxiety disorder and unresponsive anxious patients should be screened for bi-polar
- b) Psychotherapy (interpersonal, cognitive, behavioural, supportive, psychodynamic)
- c) Social: Education, regular exercise program, establish therapeutic alliance
3. Follow up: close follow up for response and safety assessment
4. Referral: refer to psychiatry if treatment resistant, psychotic features, thought disorder or unsure of diagnosis.