Depression

Differential Overview

❑ Dysthymia

❑ Major depression

❑ Adjustment disorder with depressed mood

❑ Seasonal affective disorder

❑ Bipolar disorder

❑ Drug-induced

❑ Grief

❑ Thyroid disease

❑ Dementia

❑ Stroke

❑ Paraneoplastic

Diagnostic Approach

Depression often presents in primary care settings masked in the form of somatic symptoms, such as anorexia, weight loss, fatigue, insomnia (especially early morning awakening), or difficulty concentrating. It is also common for the perception of symptoms produced by another organic cause to be heightened by depression. Depression becomes pathologic when it interferes with normal function.

Once depression is identified, it is critical to assess suicide risk. The best way to do this is to straightforwardly ask patient, if they have thought of harming themselves and if so, do they have a plan. Risk factors for suicide include living alone, prior suicide attempt, family history of suicide attempt or substance abuse, general medical illness, extreme hopelessness, psychosis, and substance abuse.

The SQ is a one-question screen: “Have you felt depressed or sad much of the time in the past year?”. The CAGE questionnaire is designed to identify drinkers who are alcohol-dependent or heavy drinkers (>8 drinks/day):
1) “Have you ever felt you should Cut down your drinking?” 2) “Have people Annoyed you by criticizing your drinking?” 3) “Have you ever felt bad or Guilty about your drinking?” 4) “Have you ever taken a drink first thing in the morning (Eye-opener)?”.

Clinical Findings

Dysthymia  Characterized by lifelong low-grade feelings of depression, negative thinking, and anhedonia with minor or no neurovegetative symptoms.

Major depression  The DSM-IV criteria for diagnosing major depression include at least 5 of 9 of the following: depressed mood most of the day; anhedonia (loss of interest in activities); significant weight loss or gain; insomnia or hypersomnia; psychomotor agitation or retardation; fatigue or loss of energy; feelings of worthlessness or guilt; impaired concentration or indecisiveness; or recurring thoughts of death or suicide. There is often a family history of depression or alcoholism.

Adjustment disorder with depressed mood  This depression is triggered by a significant life stress. Thoughts are preoccupied with the precipitating event. Depressed mood is associated with anxiety, hopelessness, helplessness, and worthlessness.

Seasonal affective disorder  Recurrent winter depression appears with atypical neurovegetative signs such as hypersomnia, overeating, and carbohydrate craving. This syndrome occurs more commonly in women than men.

Bipolar disorder  It usually presents as a major depression but with a history of transitory manic symptoms such as elation or expansive mood, increased energy, decreased need for sleep, inflated self-esteem, and inappropriately low concern for the consequences of actions.

Drug-induced  Alcohol, sedative, or cocaine abuse and withdrawal are commonly associated with depression. Reserpine, beta-blockers, methyldopa, estrogens, levodopa, and corticosteroids can also produce depression.

Grief  Depressive symptoms frequently follow loss of a close relationship. Display of full major depression symptoms early in the course of grief predicts a prolonged recovery with substantial morbidity.

Thyroid disease  Apathetic hyperthyroidism in the elderly or hypothyroidism at any age can produce depression. Other findings such as lethargy, cold intolerance, edema, and delayed reflex relaxation phase must be sought.

Dementia  Subcortical dementias are often heralded by depression.

Stroke  Depression commonly accompanies limbic or frontal strokes, usually manifest as inappropriate crying.

Paraneoplastic  Depression is especially prominent in the presentation of pancreatic cancer, accompanied by unexplained weight loss and chronic vague abdominal/back pain.

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Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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