Depression
Depression: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Jeffrey M. Lyness
Depression is a major public health problem because of its high prevalence and attendant morbidity and mortality. Although commonly seen in primary care settings, too often it goes unrecognized or untreated or undertreated.
Approach.
Major (unipolar) depression has a point prevalence of 5% to 10% in adults seen in primary care settings, and a lifetime prevalence of at least twice that figure. The female to male ratio is approximately 2:1, although this ratio lessens with older age. Although major depression has received the most empirical study, so-called “lesser” depressions, including dysthymic disorder, minor depression, and “subsyndromal” depression have even greater combined prevalences and cumulative morbidity. Depressive conditions are a leading cause of functional impairment, including lost time from work, days spent in bed, and greater overall healthcare utilization. They also are risk factors for mortality, including but not limited to death by suicide.
Primary care physicians should evaluate for depression in all patients with any of the following presentations or risk factors (1): chronic medical illness; other psychiatric condition such as an anxiety or substance use disorder; recent psychosocial stressors, especially losses; multiple medical visits or unexplained symptoms; dysfunction at work or in social relationships; complaints of fatigue, sleep disturbance, and sexual dysfunction; or multiple worries. Begin the evaluation by asking the patient, “During the past month, have you been bothered by (a) feeling down, depressed, or hopeless or (b) little interest or pleasure in doing things?” (2) A positive response to either of these queries should lead to a more detailed history and examination.
History and mental status examination (MSE)
A. Symptoms and signs. The diagnosis of major depression depends on a systematic assessment of psychiatric symptoms and signs (i.e., the history and MSE). At least five symptoms from the following list must be present most of the day, nearly every day, for 2 consecutive weeks or more: depressed mood; decreased interests or pleasure; weight or appetite change; sleep disturbance; psychomotor agitation or retardation; anergia; worthlessness or guilt; trouble thinking, concentrating, or making decisions; or recurrent thoughts of death or suicidal ideation, plan, or attempt. One of the symptoms must be depressed mood or decreased interests. Although somewhat arbitrary, the following grouping of symptoms may facilitate their recall.
1. Mood—depressed mood: “How is your mood, your spirits?” “Sad,” “blue,” “down,” crying spells; the patient also may have irritability, anxiety, decreased mood reactivity, and decreased hedonic capacity.
2. Ideational or psychological—decreased interests: thoughts of worthlessness, helplessness, hopelessness, suicide; decreased ability to concentrate; and ruminative thinking (thoughts dwelling on depressive themes). Given the risk of suicide, all patients with clinically significant depressive symptoms should be asked about their suicidal thoughts (“Many people who are depressed have thoughts about dying, wanting to be dead, or wanting to kill themselves. What thoughts like this have you had?”) (Chapter 3.4).
3. Neurovegetative or somatic—change in appetite and weight: anorexia and weight loss are most common but hyperphagia and weight gain are possible; change in sleep (insomnia, especially early morning awakening is most common but hypersomnia is possible); decreased energy, decreased libido, psychomotor slowing or agitation; diurnal variation (in more severe cases, mornings are worse is the most common pattern).
B. Other factors. In addition to the symptoms that define the condition, other factors should be assessed:
1. Function. How is the depression affecting performance at work? Interpersonal relations? Attention to grooming and other activities of daily living?
2. Psychosocial stressors. Both acute life events and ongoing stressors may be relevant.
3. Prior depressive episode. Detailed information about previous episodes and their treatments will guide both prognosis and current treatment.
4. Family history may reflect genetic vulnerability toward the condition, and also can shape the patient’s perceptions about the illness and recommended treatments.
5. General medical history. Careful review of past and current illnesses and drugs (including alcohol and other recreational drugs) is needed to identify potential physiologic causes or contributors.
6. Other pertinent negatives. A past history of mania or psychosis suggests bipolar or schizoaffective disorder rather than major depression. Objective cognitive deficits (as opposed to merely subjective cognitive complaints) require further evaluation to determine the presence and cause of delirium or dementia, in which depressive symptoms are frequent.
Physical examination.
Any patient with severe depression sufficient to warrant treatment should have both a general screening physical examination, paying particular attention to signs of anemia and endocrinopathies (e.g., hypothyroidism) and a careful screening neurologic examination.
Testing.
For typical mild major depressions, no tests are routinely indicated except as guided by the general medical history and physical examination. However, the following circumstances do warrant a laboratory workup: first onset of depression in later life; severely debilitating or treatment-refractory depression; or the presence of atypical features (e.g., onset despite the absence of past or family history or psychosocial stressors; severe cognitive complaints). Few empirical data guide the cost-effective use of screening laboratory tests in these cases, but most experienced clinicians would agree with performing most of the following: complete blood count; erythrocyte sedimentation rate; serum electrolytes, glucose, blood urea nitrogen, creatinine, hepatic transaminases, and serologic test for syphilis; and urinalysis. Older patients should also have an electrocardiogram and a chest x-ray study.
Diagnostic assessment
If the history and mental status examination reveal five depressive symptoms (including either depressed mood or decreased interests) present most of the day, nearly every day for a minimum of 2 consecutive weeks, then the patient has a major depressive syndrome. Such a syndrome can occur in the context of many conditions and not merely idiopathic major depression, so definitive diagnosis depends on the larger clinical picture. Depressive symptoms can occur in the context of delirium or dementia, either of which are evidenced by the presence of cognitive deficits (Chapters 4.3 and 4.4). Prior episodes of mania are indicative of bipolar disorder, whereas prior episodes of psychosis in the absence of mood syndrome indicate schizoaffective disorder. If the depression is caused by an identifiable physiologic factor (e.g., drugs or a general medical or neurologic disorder), it is a secondary depression (formerly known as “organic mood disorder”).
Clinically meaningful depressive symptoms that do not meet full criteria for a major depressive syndrome are even more common than full-fledged major depression in the primary care settings. Whereas some such patients are captured by diagnostic concepts such as dysthymic disorder or minor depression, many elude diagnostic categorization. Making the diagnostic distinction between major depression and other forms is important, because a large body of empirical evidence supports the efficacy of specific treatments for major depression and dysthymic disorder; however, the efficacy of treatments for other depressive conditions is largely unknown.
The following should lead to psychiatric referral sooner rather than later: prominent or imminent suicidality; psychotic symptoms; history of mania; psychiatric comorbidity such as alcohol dependence or a personality, anxiety, or eating disorder; and treatment intolerance or failure to respond to therapy.
References
1. Depression Guideline Panel. Depression in Primary Care: Volume 1. Detection and diagnosis. Clinical Practice Guideline, Number 5. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; April 1993. AHCPR publication 93-0550.
2. Spitzer RL, Williams JBW, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA 1994;
272:1749–1756.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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