Depression

Depression is a mood disturbance characterized by feelings of sadness, despair, and loss of interest or pleasure in activities. These feelings may be accompanied by somatic complaints, such as changes in appetite, sleep disturbances, restlessness or lethargy, and decreased concentration. The patient also may have thoughts of death, suicide, or injuring herself.

Clinical depression must be distinguished from “the blues,” periodic bouts of dysphoria that are less persistent and severe than the clinical disorder. The criterion for major depression is one or more episodes of depressed mood, or decreased interest or ability to take pleasure in all or most activities, lasting at least 2 weeks.

Major depression strikes 10% to 15% of adults, affecting all racial, ethnic, age, and socioeconomic groups. It’s twice as common in women as in men and is especially prevalent among adolescents. Depression has numerous causes, including genetic and family history, medical and psychiatric disorders, and the use of certain drugs. It can also occur in the postpartum period. A complete psychiatric and physical examination should be conducted to exclude possible medical causes.

History and physical examination

During the examination, determine how the patient feels about herself, her family, and her environment. Your goal is to explore the nature of her depression, the extent to which other factors affect it, and her coping mechanisms and their effectiveness. Begin by asking what’s bothering her. How does her current mood differ from her usual mood? Then ask her to describe the way she feels about herself. What are her plans and dreams? How realistic are they? Is she generally satisfied with what she has accomplished in her work, relationships, and other interests? Ask about changes in her social interactions, sleep patterns, appetite, normal activities, or ability to make decisions and concentrate. Determine patterns of drug and alcohol use. Listen for clues that she may be suicidal. (See Suicide: Caring for the high-risk patient, page 234.)

Ask the patient about her family—its patterns of interaction and characteristic responses to success and failure. What part does she feel she plays in her family life? Find out if other family members have been depressed and whether anyone important to her has been sick or has died in the past year. Finally, ask the patient about her environment. Has her lifestyle changed in the past month? Six months? Year? When she’s feeling blue, where does she go and what does she do to feel better? Find out how she feels about her role in the community and the resources that are available to her. Try to determine if she has an adequate support network to help her cope with her depression.

Cultural Cue: Patients who don’t speak English fluently may have difficulty communicating their feelings and thoughts. Consider using someone outside the family as an interpreter to allow the patient to express her feelings more freely.

Medical causes

Organic disorders

Various organic disorders and chronic illnesses produce mild, moderate, or severe depression. Among these are metabolic and endocrine disorders, such as hypothyroidism, hyperthyroidism, and diabetes; infectious diseases, such as influenza, hepatitis, and encephalitis; degenerative diseases, such as Alzheimer’s disease, multiple sclerosis, and multi-infarct dementia; and neoplastic disorders such as cancer.

Psychiatric disorders

Affective disorders are typically characterized by abrupt mood swings from depression to elation (mania) or by prolonged episodes of either mood. In fact, severe depression may last for weeks. More moderate depression occurs in cyclothymic disorders and usually alternates with moderate mania. Moderate depression that’s more or less constant over a 2-year period typically results from dysthymic disorders. Also, chronic anxiety disorders, such as panic and obsessive-compulsive disorder, may be accompanied by depression.

Other causes

Alcohol abuse

Long-term alcohol use, intoxication, or withdrawal commonly produces depression.

Drugs

Various drugs cause depression as an adverse effect. Among the more common are barbiturates, chemotherapeutic drugs such as asparaginase, anticonvulsants such as diazepam, and antiarrhythmics such as disopyramide. Other depression-inducing drugs include centrally acting antihypertensives, such as reserpine (common with high doses), methyldopa, and clonidine; beta-adrenergic blockers such as propranolol; levodopa; indomethacin; cycloserine; corticosteroids; and hormonal contraceptives.

Postpartum period

Although its cause hasn’t been determined, postpartum depression occurs in about 1 in every 2,000 to 3,000 women who have given birth. Symptoms range from mild postpartum blues to an intense, suicidal, depressive psychosis.

Special considerations

Caring for a depressed patient takes time, tact, and energy. It also requires an awareness of your own vulnerability to feelings of despair that can stem from interacting with a depressed patient. Help the patient set realistic goals; encourage her to promote feelings of self-worth by expressing her opinions and making decisions. Try to determine her suicide potential, and take steps to help ensure her safety. The patient may require close surveillance to prevent a suicide attempt.

Make sure the patient receives adequate nourishment and rest, and keep her environment free from stress and excessive stimulation. Arrange for ordered diagnostic tests to determine if her depression has an organic cause, and administer prescribed drugs. Also arrange for follow-up counseling, or contact a mental health professional for a referral.

Pediatric pointers

Because emotional lability is normal in adolescence, depression can be difficult to assess and diagnose in teenagers. Clues to underlying depression may include somatic complaints, sexual promiscuity, poor grades, and abuse of alcohol or drugs.

Use of a family systems model usually helps determine the cause of depression in adolescents. Once family roles are determined, family therapy or group therapy with peers may help the patient overcome her depression. In severe cases, an antidepressant may be required.

Geriatric pointers

Many elderly patients have physical complaints, somatic complaints, agitation, or changes in intellectual functioning (memory impairment), making the diagnosis of depression difficult in these patients. Depressed older adults who are age 85 and older, have low self-esteem, and need to be in control have the highest risk of suicide. Even a frail nursing home resident with these characteristics may have the strength to kill herself.

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Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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