Depression

Mood Disorders present with any symptom in the book.  We suspect them when there’s a give-away affect, or if chronology & descriptors of symptoms such as “fatigue,” “headache,” “back pain,” etc. aren’t consistent with organic etiology.  But whenever we think we’ve identified Depression, it’s important to approach it directly.

This can be very difficult in a busy practice.  But the worst case scenario is to miss suicidality.  And we can’t ask about this too easily without establishing that depression does in fact exist.  Imagine going right from, “So your chronic headache is feeling worse now; have you thought of killing yourself?”

I tend to segue from physical complaints into psych by asking about “stress.”  It’s often an easier word for people to relate to.  If they endorse “stress,” I might get into the specific causes (if time permits), but especially need to define whether they’re talking about anxiety, depression, both, or even thought disorders [see below].

The DSM-4 diagnoses “Major Depressive Disorder” (MDD) if 5 of the following nine criteria are present most of the day, nearly every day, for 2 weeks (at least one of the ** symptoms must be included).

  • Depressed mood **
  • Loss of interest or pleasure in most or all activities **
  • Insomnia or hypersomnia
  • Change in appetite or weight
  • Psychomotor retardation or agitation
  • Low energy
  • Poor concentration
  • Thoughts of worthlessness or guilt
  • Recurrent thoughts of death or suicide

There are all sorts of other categorizations besides MDD, including:

  • Minor Depression (2 of above Sx for 2 weeks)
  • Dysthymic Disorder (2 of above Sx for 2 years)
  • Adjustment Disorder (depression for specific reason)

The subtleties in distinguishing are mostly for purposes of treatment.  I confess, I’m lazy in this sense.  If a patient is depressed most of the day, I treat.  If symptoms were of long duration, I treat for a while.  If they were profound, I treat until they’re lots better, & am then cautious about tapering.

The following are questions that I use to elicit the 9 criteria (some are pretty obvious).

Depressed mood
  • “Do you feel sad or depressed?”
  • “Do you feel like crying often?”
Loss of interest or pleasure in most or all activities
  • “What do you do to have fun?”
  • “Is there anything you do that’s fun?”
  • “Do you like to have sex?”
  • “Are you interested in sex?”
Insomnia or hypersomnia
  • “Do you have trouble sleeping?” [if pt responds, “Oh, No!”], then:
  • “Do you feel like sleeping all day?”
Change in appetite or weight
  • “How’s your appetite?”
Psychomotor retardation or agitation
  • No questions; it’s an objective observation
Low energy
  • “When you wake up in the morning, do you just want to stay in bed all day, or do you get up energetic & looking forward to the day?”
  • “Do you often ‘just not feel like doing anything’?”
Poor concentration
  • “Is it hard to stay focused?
Thoughts of worthlessness or guilt
  • “Are you happy with yourself as a person?”
  • “Do you put yourself down a lot?”
  • “Do you feel guilty for things, in general?”
Recurrent thoughts about death or suicide
  • “Do you think about death a lot?”
  • “Do you think about dying?”

I ask specifically about death, not suicide, because I want an idea how morbid a person’s thoughts are, even if they don’t consider suicide.  If I lump the 2 queries together, the latter overshadows the former, & I may get a false-negative.

But if I think someone has any degree of depression, then I always ask, “Have you ever felt so depressed (or “sad”) that you’ve thought of hurting or killing yourself?”  I’m surprised how often I get affirmatives.  If so, assess lethality to see if you need to call the police for transport to an involuntary hold.

Also ask if they ever feel in danger at home.  Unfortunately, Domestic Violence is common, resources are scarce, & solutions not easy.  But you’ll never help anybody with their depression if DV is in play & you don’t realize it.

I don’t use diagnostic questionnaires or scoring tools, because I personally feel more comfortable developing rapport face-to-face.  But I’m sure to document all positive responses, primarily as parameters to monitor treatment.  For hypertension, we follow blood-pressures.  For Depression, we have to ask, “You said a month ago that you had trouble concentrating [etc.]; is that still the same?”

If you diagnose any type of depression, never treat without ruling-out Bipolar Disorder.  Antidepressant therapy can precipitate frank mania, which is much more dangerous.  So it’s critical to inquire about past episodes compatible with Mania or Hypomania, especially if there’s a family history of mental illness.  Click for DSM-4 criteria; the questions I ask are:

1.  “Have you ever in the past gone through a 4-5 day period where you felt the exact opposite of depressed, like you were so high, or so full of energy, or irritable, that you couldn’t function normally?”

2.  If they reply affirmatively, I continue: “During that time, did you also…

  • …feel really, really good about yourself?”
  • …sleep less than 3 hours a night, & not feel tired?”
  • …talk non-stop, or feel like you had to keep talking?”
  • …think about one thing, then another, & another, like the thoughts couldn’t stop racing?”
  • …get distracted by tiny little things, over & over?”
  • …start to do something, go on to something else, & something else, without ever finishing what you were doing?”
  • …have sex over & over, or go out buying all sorts of things you didn’t need, or lose lots of money on gambling or silly investments?

For a depressed person with a history compatible with Bipolar Disorder, it’s essential to combine the antidepressant with a mood stabilizer.  They’re best managed by psychiatry, but in many settings where it’s not immediately available, primary care may need to get treatment going.

Also rule out Psychotic Depression before treating with a simple antidepressant.  Sometimes it’s obvious; the patient’s thought or affect is actively disordered or bizarre right then and there.  But if not, it’s essential to inquire about:

  • Hallucinations (“Do you ever hear voices talking when nobody’s around?”)
  • Paranoias (“Do you ever feel that strangers are watching you, or following you?”)
  • Delusions

I’ve never had problems asking about hallucinations & paranoias, but have always been puzzled how to inquire about delusions, because 1) they may be so varied; and 2) the patient considers them real, not delusions.  Then a very bright psychiatrist suggested I ask, “Do you ever have any thoughts that other people consider really strange or unusual?”

If a depressed patient manifests thought disorder, combine the antidepressant with an antipsychotic if psychiatric referral will be delayed.  And as always, assess suicidality.

Never settle for a diagnosis of any psychiatric disorder without:

  • Inquiring about substance use; and
  • Ordering basic labs like CBC, Chemistries, TSH, maybe a Vitamin B12 level, maybe syphilis serology.

Depressed patients often have Anxiety; medications for the former may also work for the latter (if any are going to work at all).  Still, if your depressed patient manifests significant worry, certain types of anxiety are worth exploring at some point, because cognitive behavioral therapy might help.  These include:

  • Post-Traumatic Stress Disorder (PTSD)
  • OCD
  • Social / other Phobias
  • Panic disorder

It’s especially important to inquire about trauma.  Whether or not you want to call it PTSD, if trauma has a significant connection to a person’s mood disorder, you’ll get nowhere & lose credibility if you never find out.

SUMMARY

For whatever reason, you suspect a patient may have a mood disorder:

1.  Ask if they’re depressed?  If not, ask if they wake up each day with a bright outlook, & have fun in life.

2.  If #1 sounds like Depression, or if their affect looks like it, go through a bunch of the other queries.

3.  If you lean toward the diagnosis:
  • Evaluate for suicidality (1 question for rule-out)
  • Inquire about Mania (a few questions)
  • Rule out Psychosis (a few questions)
  • Ask about Substance Use
  • Order basic screening lab tests

This minimum allows you to begin anti-depressants if you’d like, or refer to psychiatry or behavioral health as available.  Elicit other pieces during follow-up.  It may sound like a lot but doesn’t take that long.  Of course, treatment isn’t easy, but DiagnosisDude has the luxury of stopping here.

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