Depression
Karen M. Kress, Jill C. Cash, Cheryl A. Glass, and Alyson Wolz
Definition
A.Depression is a mental health disorder that interferes with a person’s daily life. Depressive disorders are characterized by sad, empty, or irritable mood lasting at least 2 weeks in duration. Depression may be mild or severe, depending on signs and symptoms expressed, as well as the length of time symptoms are present. Depression affects multiple body systems and may impact one emotionally, cognitively, or physically, as well as behaviorally. Symptoms of depression may include difficulty sleeping, depressed mood, inability to function at work, change in appetite, and inability to enjoy activities that bring one pleasure. There are many forms of depression, and treatment varies depending on the specific diagnosis. Types of depression include major depressive disorder, persistent depressive disorder (dysthymia), premenstrual dysphoric disorder, disruptive mood dysregulation disorder, depressive disorder due to another medical condition, and other specified depressive disorders.
B.Diagnostic criteria include depressed mood most of the day, decreased pleasure in activities, weight loss or weight gain, insomnia or hypersomnolence, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or guilt, decreased concentration, thoughts of death, suicidal ideation, and suicide attempt or plan for self-harm.
Incidence
A.One in 10 adults experiences one or more episodes of depression during his or her lifetime. Depression can occur at any age. In the United States, incidence of depression peaks in the 20s, but first onset in late life can occur. The lifetime risk is estimated to be as high as 30%. Women have a two-fold to three-fold higher rate of reported depression than men. Estimated rates of major depression in the elderly are 3% to 5% for those living in a community dwelling, 15% to 30% for those living in an institutional setting, and 13% for those living in nursing homes.
B.Only 10% to 25% of people with depressive disorders seek treatment. There is a high mortality from suicide if untreated (see Suicide
section of this chapter).
C.No single causal factor has been identified. Depressive syndromes are so varied in course and symptomatology that a single cause is unlikely. Several factors appear to contribute, including genetics, neurochemical abnormalities (reductions in adrenergic or serotonergic neurotransmission), electrolyte disturbances, and neuroendocrine abnormalities such as hypothalamic, pituitary, adrenal cortical, thyroid, and gonadal functions. Higher concentrations of proinflammatory cytokines, tumor necrosis factor (TNF)-alpha, and interleukin (IL)-6 have been found in depressed subjects, compared with control subjects.
D.Depression is frequently a concomitant diagnosis with other physical or mental disorders. Personality and psychodynamic factors of depression include low self-esteem, self-criticism, and interpersonal loss. A childhood history of emotional, physical, and/or sexual abuse can also contribute to adult-onset depression.
Predisposing Factors
A.Age (peak onset in 20s and the elderly).
B.Lack of social support/living alone.
C.A history of early parental loss.
D.Female gender:
1.Most common in childbearing years from ages 25 to 45 years.
2.Premenstrual.
3.Perimenopausal.
4.Postpartum.
E.Family history of depression.
F.Frequent exposure to stressful events.
G.Nutritional disorders:
1.Vitamin B12 deficiency.
2.Vitamin D deficiency.
3.Magnesium deficiency.
4.Folate deficiency (may result in poor response to antidepressants).
5.Iron deficiency.
H.Personality characteristics that include absence of hardiness factors in response to stress (lack of resilience, flexibility, and optimism).
I.Anger not dealt with and turned in on the self.
J.Negative interpretation of one’s life experiences.
K.Poor physical health.
L.Postsurgical diagnosis of cancer.
M.Chronic pain.
N.Chronic medical problems such as hypothyroidism and hyperthyroidism, Cushing’s syndrome, hypercalcemia, hyponatremia, diabetes mellitus, lupus erythematosus, fibromyalgia, rheumatoid disease, and chronic fatigue syndrome.
O.Neurologic disorders such as stroke, subdural hematoma, multiple sclerosis, brain tumor, Parkinson’s disease, epilepsy, dementias, and Huntington’s disease.
P.Alcoholism/drug abuse or dependence/withdrawal.
Q.Infectious etiology such as mononucleosis and other viral infections, syphilis, HIV, and Lyme disease.
R.Side effect of prescription drugs, such as alphamethyldopa, antiarrhythmics, benzodiazepines, barbiturates/central nervous system (CNS) depressants, beta-blockers, cholinergic drugs, corticosteroids, digoxin, H2-blockers, and reserpine.
Common Complaints
A.Lack of interest in pleasurable activities.
B.Digestive problems.
C.Chronic aches and pains that are not otherwise explained.
Other Signs and Symptoms
A.Vegetative:
1.Changes (increased or decreased) in sleep, appetite, and weight.
2.Changes in appearance: Poor grooming and hygiene.
3.Poor eye contact, staring downward, flat affect.
4.Loss of energy.
5.Decreased interest in sex.
6.Psychomotor retardation or agitation.
B.Cognitive:
1.Sense of guilt, worthlessness, low self-esteem.
2.Problems with attention span, concentration or memory, frustration tolerance, negative distortions, mild paranoia, and psychosis.
C.Impulse control:
1.Suicidal or homicidal thoughts or acts. Any statements made by the patient, such as Life isn’t worth living, I wish I were dead, I don’t deserve to be alive, I can’t deal with this,
should be taken seriously. Refer the patient for emergency mental health assessment and treatment.
D.Behavioral:
1.Depressed mood, anxiety, and irritability.
2.Isolation, decreased motivation, fatigability, and anhedonia (inability to derive gratification from pleasurable activities).
E.Physical symptoms:
1.Digestion problems, nausea, constipation, diarrhea (less common), and dry mouth.
2.Fatigue, but difficulty sleeping.
3.Physical pain, chronic aches, and pains that cannot be explained.
4.Recurrent headaches, backaches, or stomachaches that have no cause.
5.Migrating pain that disappears when depression lifts.
6.Increased muscle tension.
Subjective Data
A.Review the onset, duration, and course of presenting symptoms.
B.Review any previous history of depression (such as postpartum depression).
C.Determine how the previous depression was treated.
D.Evaluate the patient’s suicide potential. Ask: Have you ever thought of hurting yourself or others?
Does the patient have a current suicide plan or vague ideas of suicide? Has the patient had any previous history of suicide attempts? If so, evaluate how life threatening they were.
E.Review the patient’s medical history (see Predisposing Factors
).
F.Review the patient’s drug history for prescription, overthe-counter (OTC), and recreational/illicit drug use (how much, how long, how often), and review his or her history of alcohol consumption (how much, how long, how often).
G.Review the patient’s history for recent major life changes such as pregnancy, death, divorce, or any loss that may be normal throughout the stages of life. The patient’s perception of the loss is what is important.
H.Review dietary intake since the symptoms have begun.
I.Establish usual weight, review weight gain/loss, and in what time span.
J.Review the patient’s activities of daily living (ADLs). Does the patient get up and dress daily, perform daily hygiene, put on makeup?
K.Review how many hours of sleep and quality of sleep per day.
L.Review the disruption of usual activities: Return to work, return to school, exercise.
M.Review the amount of crying per day, and for what length of time (days, weeks).
N.Assess whether the depression is cyclic/seasonal (starts in the fall, ends in the spring).
O.Review occupational/home exposure to lead and lead-based products.
P.Review any exposures to infectious diseases, including Lyme disease (refer to Chapter 19 for specific questions). Does anyone else such as family, friends, or coworkers have similar symptoms?
Q.If female, review for symptoms of menopause (sleep disturbances, irregular menses/amenorrhea, hot flashes, vaginal dryness, dyspareunia).
Physical Examination
A.Check pulse, respirations, blood pressure, and weight.
B.Inspect:
1.Observe overall appearance; note grooming, tone of voice, conduct of patient during communication, and breath (smell of alcohol).
2.Complete neurologic examination with screening tool of choice.
3.Complete dermal examination for signs of substance use (refer to Substance Use Disorders
section of this chapter).
C.Palpate:
1.Palpate the neck and thyroid; evaluate for presence of goiter.
2.Palpate the axilla and groin for lymphadenopathy (infectious etiology).
3.Check the joints for swelling, arthritis, and range of motion (ROM;rule out musculoskeletal cause).
D.Auscultate:
1.Auscultate the heart, lungs, and abdomen (as applies to physical complaints).
Diagnostic Tests
A.Complete blood count (CBC) with differential.
B.Electrolytes, serum calcium, and phosphorus.
C.Thyroid profile.
D.Liver profile.
E.Lead level.
F.Follicle-stimulating hormone (FSH)/luteinizing hormone (LH).
G.Viral cultures.
H.Blood alcohol.
I.Urine drug screen.
J.Monospot.
K.CT and MRI scans.
L.Dexamethasone suppression test.
M.Screening for vitamin/nutritional deficiencies.
N.Perform mental state examination with depression rating scale of choice:
1.Beck Depression Inventory Scale, available at beckinstitute.org/get-informed/tools-and-resources/professionals/patient-assessment-tools
2.Geriatric Depression Scale (GDS), available at www.healthcare.uiowa.edu/familymedicine/fpinfo//geridepr.htm
3.Patient Health Questionnaire (PHQ-9), available online at www.phqscreeners.com
Differential Diagnoses
A.Bipolar disorder.
B.Chronic untreated anxiety disorders such as generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), or obsessive-compulsive disorder (OCD).
C.Personality disorders.
D.Schizoaffective disorder.
E.Seasonal affective disorder (SAD):
1.Seasonal pattern: Starts in the fall, linked to lack of light exposure.
2.Women more than men.
3.Age typically in the 20s.
F.Alcoholism and drug abuse/dependence.
G.Early dementia.
H.Endocrine etiologies (see section Predisposing Factors
).
I.Infectious etiologies (see section Predisposing Factors
).
J.Menopause.
K.Side effect of medication (see section Predisposing Factors
).
L.Cancer: 50% of patients with tumors, particularly of the brain and lung, and carcinoma of the pancreas develop symptoms of depression before the diagnosis of tumor is made.
M.Heavy metal poisoning.
N.Nutritional deficit (see section Predisposing Factors
).
Plan
A.General interventions:
1.Keep the patient safe from self-harm.
2.Treat physical/laboratory findings. Recommend dietary change, iron supplements, or hormone replacement therapy per findings (see related chapters).
B.Patient teaching:
1.Encourage the patient to take medications as prescribed. Educate the patient that some medications may take time to get into the system to work and time should be allowed to see the effects of the medication. Review side effects.
2.Encourage the patient to express feelings or worsening of symptoms if this occurs prior to the next appointment. Have the patient make a client contract with you that he or she will not hurt himself or others; if he or she begins having these thoughts, the patient agrees to contact you or go to the nearest emergency room.