Symptoms Of Major Depression

SIG: K(ncrgy) CAPS. Each letter stands for a criterion (except for depressed mood) used in diagnosing a major depressive episode. Five or more of the following criteria are needed for at least 2 weeks: S—sleep changes I—(decreased) interest G—(excessive) guilt E—(decreased) energy C—(decreased) concentration A—appetite changes P—psychomotor agitation or retardation S—suicidal ideation

APPROACH TO DEPRESSIVE DISORDER Definitions

Atypical depression: Depressed mood with increased sleeping, increased eating, weight gain, and increased sensitivity to rejection.

Dysthvniia: Fewer, milder, but persistent depressive symptoms with low mood for more than 2 years.

Major depression: Depressed mood or loss of interest in activities for 2 weeks plus three or four of the other symptoms for a total of five (Table 59-1).

Somatization: Conversion of a mental or psychological disorder into a physical symptom.

Clinical Approach

Depression is highly prevalent in medical outpatients, thought to be second only to hypertension in general practice. It is estimated that 15% of the general population will experience a major depressive episode at some point in their life. Between 6 and 8% of outpatients in a primary care setting are estimated to satisfy diagnostic criteria for depression, although many seek care for other complaints. Consequently, a depressive condition may not be recognized or properly treated. Because of the high frequency of the disorder and the good outcomes with appropriate treatment, the United States Preventive Services Task Force recommends screening for depression, which may be as simple as asking questions about depressed mood or anhedonia.

When a patient presents with features of depression, the clinician must try to distinguish a depressive disorder from a transient situational disturbance or a more chronic personality problem, as well as considering medical illness that may mimic depression. One of the most common situational disturbances a primary care physician must assess and treat is an uncomplicated grief reaction. Patients experiencing uncomplicated bereavement after a significant loss, such as the death of a loved one, may have depressive symptoms for a period of time sufficient to qualify as major depression. However, these symptoms usually are self-limited, resolve spontaneously, and do not respond well to antidepressant medications. Treatment may include supportive counseling and medications to alleviate symptoms, such as sleep aids for insomnia. More extreme symptoms, such as anhedonia, suicidal ideation, or persistent depressive symptoms, may signify a more complicated grief reaction and may require psychiatric evaluation.

Depression shares several symptoms with other common medical disorders. A careful history with a thorough review of systems and physical examination may be all a physician must perform to exclude some diseases, such as some cancers, but others may require laboratory testing. When the suspicion of depression is high, the clinician should explain this to the patient at the beginning of the evaluation. Otherwise, when everything is normal and the patient is told all the symptoms are just a result of depression, sometimes this is interpreted as meaning, "It's all in your head."

Hypothyroidism often causes fatigue and mental slowing. Patients and physicians may interpret this as depression: however, the patient's mood usually is not altered. Nor should patients be experiencing the guilty feelings and poor self-esteem of depression. Anemia, especially the macrocytic anemia of vitamin B|: deficiency, often presents with neuropsychiatric changes early in the course of disease, especially in the elderly. Folate deficiency can produce similar symptoms, although they usually are less profound. Metabolic disorders, such as renal failure, hyperglycemia, hyponatremia, and hypercalcemia. can present with fatigue and mental confusion that may be mistaken for depression or dementia, especially in the elderly. However, these patients often have other symptoms, such as polyuria and polydipsia, or are taking medications that have such side effects. Other conditions that should be considered in evaluating a patient with depressive symptoms is substance abuse, although the two often coexist, organic brains disease in a patient with a history of brain injury, and dementia in elderly patients.

When depressive symptoms are discovered, it is essential to assess the patient's suicide risk. Suicide is the most serious outcome of a depressive episode: approximately 15% of patients requiring hospitalization for depression die by suicide. Asking questions about suicidal or homicidal ideation does not "put the idea into the patient's head"; rather, it lets the patient know that you are willing to help. Patients who are an immediate threat to themselves or others require emergent admission to a psychiatric facility. Risk factors for suicide include male gender, older age. living alone, history of suicide attempt, or current suicidal ideation (especially when a specific plan has been formulated). High-risk patients require immediate psychiatric evaluation and possible inpatient care.

Most patients, however, can be treated on an outpatient basis with medications and perhaps psychotherapy. In general. 60-70% of depressed patients will respond to any antidepressant, regardless of the drug class used. If a patient has taken an antidepressant previously and had a good response, that drug should be the first choice for treatment. Conversely, if a patient has discontinued a medication because of unacceptable side effects, that is important information in choosing an agent or class of drugs. Overall, antidepressants are chosen based on side effect profile, patient preference, and medical considerations such as drug interactions. SSRIs have low side effect profiles, primarily gastrointestinal complaints, which usually are short lived, and sexual dysfunction in approximately 30% of patients. They are considered safer than the older tricyclic antidepressants (TCAs) because of the risk for cardiac arrhythmias caused by TCA overdose, a particular concern in patients with suicidal ideation. Most SSRIs do have a number of drug interactions with medications metabolized through the cytochrome P450 system. Some SSRIs have specific indications for anxiety as well as depression.

Other agents include trazodone, which is highly sedating, and may be a good choice in patients with insomnia, and bupropion, which is nonsedating (in fact, may cause insomnia) and has a low incidence of sexual dysfunction but lowers seizure threshold in patients with epilepsy. TCAs are efficacious and useful in patients without active suicidal ideation, especially if cost is a factor, because TCAs are available in generic form.

Comprehension Questions

[59.11 A 23-year-old woman is brought to the emergency room by ambulance for chest pain. She is frantic, crying, hyperventilating, and holding her chest. She says that she feels like she is about to die and that her heart is pounding out of her chest. Her blood pressure is 120/74 mm Hg. heart rate 118 bpm. respiratory rate 30 breaths per minute, and oxygen saturation 100% on room air. Her ECG, except for a sinus tachycardia, is completely normal. After a few minutes she begins to calm down, and she explains that she has these episodes about once per week. She suddenly feels like she can't breathe, that she's going to die, and that her heart is pounding. She's been to the emergency room four times with similar episodes, and nothing abnormal has been found. Which of the following is the most likely diagnosis?

A. Wolff-Parkinson-White syndrome

B. Myocardial ischemia

C. Panic disorder

D. Depression with anxious mood

E. Pheochromocytoma

[59.2] A 73-year-old woman, whose health has always been perfect, is brought to your office by her family for worsening forgetfulness and personality changes. Until 6 months ago, she was active in her church and with her family. Now the family states that she rarely leaves her bed unless she is coerced, and she is sloppy in her personal appearance and in her housekeeping. The patient denies being sad, but says she doesn't have the energy she used to have. Mental status testing demonstrates poor short-term memory and concentration. Which of the following should be your next step?

A. Prescribe a serotonin selective reuptake inhibitor

B. Prescribe a tricyclic antidepressant

C. Assess thyroid-stimulating hormone (TSH) level

D. Referral to psychiatrist

[59.3] A 35-year-old woman presents to your office for a second opinion. She believes that she has fibromyalgia and has suffered for years with daily generalized muscle pain that worsens with activity and responds only minimally to over-the-counter analgesics. Testing for rheumatologic disorders has been repeatedly negative. Following an exhaustive workup, her last doctor tried to start her on antidepressants. Although she is fatigued, lacks energy, has trouble concentrating, and feels sad, she believes these symptoms are caused by her disease and so she never filled the prescription. What would be your advice?

A. Repeat laboratory testing

B. Continue with over-the-counter analgesics and follow the response

C. Depression often complicates chronic illnesses

D. Recommend a nuclear bone scan

E. She has no symptoms of depression

Answers

[59.1 [ C. This young woman is most likely suffering from panic disorder. The other diagnoses are unlikely given her normal blood pressure, ECG, and age. Panic disorder is the unexplained occurrence of sudden episodes of intense fear, often associated with palpitations, sweating, dizziness, difficulty breathing, and chest pain. These episodes are recurrent and unpredictable. The first episode often occurs outside the home, and the unpredictable nature may lead to fear of leaving the house (agoraphobia). Depression is frequently a concomitant diagnosis. Illicit drug use also must be considered.

159.2J C. In this otherwise healthy, elderly woman, a sudden change in her behavior is concerning for a metabolic problem. Depression is a possibility, even though this patient denies feeling sad, as depression often is "masked" by symptoms of dementia in the elderly. Tests to consider in addition to assessment of TSH level are complete blood count, electrolytes. liver and renal function tests, and calcium level.

(59.3) C. In many disorders, such as fibromyalgia, chronic fatigue syndrome, and chronic pain, which physicians poorly understand and for which we have few therapeutic options, depression may be present. It often is difficult to determine whether the depression preceded the illness or is a result of the illness. However, some patients with fibromyalgia or chronic pain do seem to benefit from the administration of antidepressant medications.

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