A.Five (or more) of the following symptoms present during the same 2-week period and represent a change from previous functioning. At least one of the symptoms must be either (a) depressed mood or (b) loss of interest or pleasure.
1.Depressed mood most of the day, nearly every day, by subjective report (sad, empty, hopeless) or observed by others (appears tearful).
2.Markedly diminished pleasure in all or most activities.
3.Significant weight loss (more than 5% in a month) or decrease or increase in appetite nearly every day.
4.Insomnia or hypersomnia nearly every day.
5.Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
6.Fatigue or loss of energy nearly every day.
7.Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day.
8.Diminished ability to think or concentrate, indecisiveness, nearly every day (subjective or observed).
9.Recurrent thoughts of death (not just dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan.
B.Symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning.
C.The episode is not attributable to the physiological effects of a substance or to another medical condition.
D.With postpartum onset: If symptoms are within 4 weeks postpartum. Commonly includes psychosis.
E.Mnemonic: SIGE CAPS.
1.Sleep disturbance.
2.Interest and pleasure decrease.
3.Guilt.
4.Energy lower.
5.Concentration decrease.
6.Appetite increase or decrease.
7.Psychomotor agitation or retardation.
8.Suicidal/hopeless.
Incidence
A.12-month prevalence is approximately 7% with increase in 18- to 29-year-olds.
B.Females have 1.5- to 3-fold higher rates than males beginning in early adolescence.
C.Mean age of onset is 40 years of age with 50% of persons having an onset between the ages of 20 and 50 years.
Pathogenesis
A.Heritability: 50%.
B.8% to 17% risk if first degree relative has diagnosis.
1.Neurochemical imbalance: Most basic level is the monoamine hypothesis, an imbalance in the following neurotransmitters.
a.Norepinephrine.
b.Dopamine.
c.Serotonin.
Predisposing Factors
A.No close interpersonal relationships.
B.Divorced or separated.
C.More common in rural than urban areas.
D.Stressful life events precede first episode.
E.Depression in older persons is common. Individuals with the following are at higher risk of developing depression: Lower socioeconomic status, loss of spouse, current physical illness, and social isolation.
Subjective Data
A.Common complaints/symptoms.
1.Agitation or restlessness.
2.Psychomotor retardation.
3.Flat affect.
4.Loss of energy.
5.Feeling of worthlessness.
6.Diminished ability to concentrate.
7.Loss of pleasure in activities.
8.Recurrent thoughts of death.
B.Common/typical scenario.
1.Patients may not seek attention for depression but typically complain of other symptoms, such as insomnia, headaches, abdominal upset, and difficulty concentrating.
C.Family and social history.
1.Depression can be familial.
2.Social history is noncontributory.
D.Review of systems.
1.Noncontributory.
Mental State Examination
A.General description: Psychomotor retardation, hand wringing, stooped posture, downcast gaze.
B.Mood and affect: 50% persons deny depressed feelings/constricted affect.
C.Speech: Decreased rate and volume with limited response to questions.
D.Perceptual disturbances: Assess for hallucinations (auditory are most common), delusions, paranoia.
E.Thought content: Negative worldviews, rumination, and guilt. Assess for suicidal (10%–15% commit suicide) and homicidal ideation.
F.Cognition: Cognitive impairment seen in 50% to 70% of depressed patients.
G.Impulse control: If the patient has psychotic symptoms, may consider harming others. HIGH RISK for self-harm exists when energy is improving; the individual can carry out the plan.
H.Suicide assessment.
1.Ask about ideation: Onset, duration, frequency, active thoughts, lethality, stressors, use of substances.
2.Ask about plan: Wish to die, means, and understands consequences.
3.Ask about means: Access to carry out plan, taken steps to prepare to end life, lethality.
4.Ask about intent: Protective or risk factors.
5.Screening instrument: Columbia Suicide Severity Rating Scale.
I.High risk populations for suicide.
1.Older single white males.
2.Divorced/widowed.
3.Unemployed.
4.Psychosis.
5.Homeless.
6.LGBT.
7.Veterans.
8.Comorbid physical and/or substance use disorder.
9.Previous attempt and/or family history.
10.Access to lethal means.
J.Homicidal assessment.
1.Ideation, means, plan, and intent.
2.Assess for anger, rage, and interpersonal conflict.
3.If actively homicidal: Inpatient psychiatric hospitalization, notify law enforcement and Duty to Warn: Tarasoff v. Regents of the University of California (1976)—must notify victim.
Diagnostic Tests
A.Thyroid profile.
B.Complete blood count.
C.Comprehensive metabolic panel.
D.And based on history: Vitamin D level, folate level, B12, or thiamine level.
E.Medical rule outs.
1.Endocrine disorders: Hypothyroidism, diabetes, adrenal dysfunction.
2.Neurological disorders: Dementia, seizures, tumors, Parkinson’s disease, sleep apnea, cerebrovascular accident (CVA), neoplasms.
3.Cardiac disease: Congestive heart failure, hypertension.
4.Infection: Mononucleosis, HIV/AIDS, pneumonia, TD.
5.Nutrition deficits: Anemia, low vitamin D/folate/B12/thiamine.
6.Other: Side effects of medications such as cardiac medications, hypnotics, antibacterial medications, antineoplastic medications, analgesics, antiepileptics, or antiparkinsonian drugs.
F.Screening instruments (in public domain): Positive screen DOES NOT indicate a disorder; REQUIRES validation with comprehensive interview/assessment.
1.Patient Health Questionnaire (PHQ)—2.
2.Patient Health Questionnaire (PHQ)—9.
3.Mood Disorders Questionnaire (MDQ).
4.Edinburgh Postnatal Depression Scale (EPSD).
5.Geriatric Depression Scale.
Differential Diagnosis
A.Bipolar disorder, depressed phase.
B.Mood disorder due to general medical condition.
C.Eating disorder.
D.Substance-induced mood disorder.
E.Adjustment disorder.
Evaluation and Management Plan
A.General plan.
1.Meets criteria for major depressive disorder, single episode or recurrent, and, if postpartum onset, psychosis or suicide/homicidal ideation.
2.If patient is not actively suicidal, homicidal, or psychotic, discuss treatment options.
3.Psychotherapy for mild symptoms or if patient refuses medication.
4.Prior to starting antidepressant treatment, bipolar disorder has been ruled out.
B.Patient/family teaching points.
1.Teach patients about early signs of relapse and rationale of treatment choices made.
2.Family members need to be taught about depression and how to be supportive.
3.Encourage patient to learn more about biology behind the disease to increase compliance.
4.Provide information on local support groups and other national resources.
C.Pharmacotherapy.
1.Medication treatment options.
a.Selective serotonin reuptake inhibitors.
i.Boxed warning for increase in suicidal thinking up to age 24 (for all antidepressants in all classes).
ii.Risk of serotonin syndrome.
iii.Discontinuation syndrome—abrupt discontinuation of medication that is more common in medications with short half-lives.
1)Mnemonic FINISH.
a)Flu-like symptoms.
b)Insomnia.
c)Nausea.
d)Imbalance.
e)Sensory disturbance.
f)Hyperarousal.
2)Treatment: Place back on medication.
iv.Serotonin syndrome (risk with any medication that increases serotonin levels).
1)Mnemonic HARMED (medical emergency).
a)Hyperthermia.
b)Autonomic instability.