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Depression

Definition

(Show Disclaimer)
Note: I copy the "definition" of something straight from the book. I find it's best to have an all-encompassing definition in order to better orient myself when I am studying.

(Show DSM-V Diagnosis Criteria for Depression)
DSM-IV Criteria for Major Depressive Disorder (MDD):
  1. Depressed mood or a loss of interest or pleasure in daily activities for more than two weeks.
  2. Mood represents a change from the person's baseline.
  3. Impaired function: social, occupational, educational.
  4. Specific symptoms, at least 5 of these 9, present nearly every day:
    1. Depressed mood or irritable most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
    2. Decreased interest or pleasure in most activities, most of each day
    3. Significant weight change (5%) or change in appetite
    4. Change in sleep: Insomnia or hypersomnia
    5. Change in activity: Psychomotor agitation or retardation
    6. Fatigue or loss of energy
    7. Guilt/worthlessness: Feelings of worthlessness or excessive or inappropriate guilt
    8. Concentration: diminished ability to think or concentrate, or more indecisiveness
    9. Suicidality: Thoughts of death or suicide, or has suicide plan
  5. DSM – V proposed (not yet adopted) anxiety symptoms that may indicate depression: irrational worry, preoccupation with unpleasant worries, trouble relaxing, feeling tense, fear that something awful might happen.

Depression is a mental health disorder that interferes with a person’s daily life. 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, and physically, as well as one’s behaviour. 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 (a) major depression, single episode or recurrent (mild, moderate, or severe with or without psychotic features); (b) persistent depressive disorder (dysthymia); (c) premenstrual dysphoric disorder; (d) postpartum depression; (e) seasonal affective disorder (SAD); and (f) bipolar disorder. Depression is frequently a concomitant diagnosis with other physical or mental disorders.

Incidence/Prevalance

  1. 1 in 8 Canadians experience it in their lifetimes.
  2. Women affected more than men by a factor of 2.
  3. Majority of ppl with depressive disorders do not seek treatment.

Predisposing factors

There is a very long list of predisposing factors, they are listed directly from the book (below), but these are few I want to remember for the test:

  1. Female.
  2. Stressors: Loss of loved one, lack of social support, early parental loss.
  3. Family history
  4. Maladaptive personality characteristics: absence of resilience, flexibility, and optimism in response to stress.
(Full list - click to expand)
  1. Age (between 25 and 32 years and the elderly).
  2. Lack of social support/living alone.
  3. A history of early parental loss.
  4. Female gender:
    1. Most common in childbearing years, from ages 25 to 45.
    2. Premenstrual.
    3. Perimenopausal.
    4. Postpartum.
  5. Family history of depression.
  6. Frequent exposure to stressful events.
  7. Nutritional disorders:
    1. Vitamin B12 deficiency.
    2. Pellagra (niacin deficiency).
  8. Personality characteristics that include absence of resilience, flexibility, and optimism in response to stress.
  9. Anger not dealt with and turned in on the self.
  10. Negative interpretation of one’s life experiences.
  11. Poor physical health.
  12. Postsurgical diagnosis of cancer.
  13. Chronic pain.
  14. Chronic medical problems, such as hypothyroidism and hyperthyroidism, Cushing’s syndrome, hypercalcaemia, hyponatraemia, diabetes mellitus, lupus erythematosus, fibromyalgia, rheumatoid disease, and chronic fatigue syndrome.
  15. Neurologic disorders, such as stroke, subdural haematoma, multiple sclerosis, brain tumour, Parkinson’s disease, epilepsy, dementias, and Huntington’s disease.
  16. Alcoholism/drug misuse or dependence/withdrawal.
  17. Infectious aetiology, such as mononucleosis and other viral infections, syphilis, HIV, and Lyme disease.
  18. Side effect of prescription drugs, such as methyldopa, antiarrhythmic, benzodiazepines, barbiturates/central nervous system (CNS) depressants, beta-blockers, cholinergic drugs, corticosteroids, digoxin, H2-blockers, and reserpine.

Common Findings

Anhedonia along with somatic sx such as digestive problems, chronic pains.

Other Signs and Symptoms

  1. Vegetative: (Click to expand)
    1. Δ in sleep (↑ or ↓), weight, appetite.
    2. Poor grooming/hygiene.
    3. Poor eye contact, flat affect.
    4. Loss of energy.
    5. Lacks sexual interest.
    6. Psychomotor retardation/agitation.
  2. Cognitive: (Click to expand)
    1. Guilt/Low self-esteem/worthlessness.
    2. Problems w/ attention span, concentration, memory, frustration tolerance, distorted negative perceptions, mild paranoia, psychosis.
  3. Impulse control: Suicidal/Homicidal thoughts.
  4. Behavioural: (Click to expand)
    1. Depressed mood, anxiety, irritability.
    2. Isolation, decreased motivation, fatigability, anhedonia.
  5. Physical sx: (Click to expand)
    1. Digestion/Nausea/Constipation/Diarrhea/Dry Mouth.
    2. Fatigue/Difficulty sleeping.
    3. Chronic aches/pains/recurrent headaches/backaches/stomach aches (without apparent cause).
    4. Increased muscle tension.

Note:(Vegetative Symptoms Definition - Click to Expand)

History

Consider family/friends collateral information if possible.

  1. HPI:
  2. ROS:
  3. ALL/MEDS/HIITS: (What are HIITS? - Click to expand)
    1. Review any exposure to infectious disease.
  4. PMH/FAMHx/OBGYN:
    1. Previous hx of depression, including postpartum depression.
    2. Include previous depression treatments.
    3. If female, are sx of menopause (sleep Δ, irregular menses/amenorrhea, hot flash, veginal dryness, dyspareunia present? Consider mnemonic HAVOC (Click to expand) (Hot Flashes, Amenorrhea/Atrophy of vagina, Vaginal dryness, Osteoporosis, Coronary artery disease)
  5. SOCHx:
    1. Must evaluate suicide/homicide potential.
    2. Assess for stressors/losses in life. The client’s perception of the loss/stressor is what is important.
    3. Diet, weight Δ, inquire about ADLs, sleep, home exposure to lead.

Physical Exam

Coming soon.

Diagnostic Tests

Tests necessary to r/o non-organic causes of depression. They should not delay treament initiation, however.

  1. Perform mental status examination with appropriate Depression inventory.
    (Click to expand)
    1. Beck Depression Scale/Geriatric Depression Scale/SIGECAPS tool/PHQ-9.
  2. Bloodwork: CBC with diff./Electrolytes (including Ca²⁺, PO₄³⁻), TSH, LFTs, Vit. D/B12/Folate levels, FSH/LH, Serum EtOH, serum lead levels.
  3. Viral cultures/Monospot
  4. Urine drug screen
  5. CT/MRI scan.

DDx

  1. Mood disorders due to: (Click to expand)
    1. Adjustment disorder
    2. Anxiety disorders such as GAD, PTSD, OCD.
    3. Seasonal affective disorder
    4. Schizoaffective disorder
  2. Substances: (Click to expand)
    1. Substance Abuse
    2. Medication side fx
    3. Lead/Heavy metal
  3. Medical causes: (Click to expand)
    1. Infectious
    2. Endocrine
    3. Cancer: 50% of ppl with cancer develop depression before tumor is found
    4. Early dementia
    5. (Physiological) Menopause
  4. Misc: Nutritional deficits

Plan

In addition to general teaching, describe to client that medications will take time to have effect.

Consider also non-pharmacological approaches to treatment: CBT, exercise, proper diet, support system, restorative sleep.

Rx therapy: SSRI, SNRI. Medication must be tapered if it is to be stopped.

Follow-up

1 - 2 wks. Assess suicidality at every office visit.

Consultation/Referral

Failure to respond to treatment. Suicide attempt.

Individual Considerations

Woman with history of depression have increased risk of postpartum depression.

A teen at risk for depression (sudden loss of loved one/friend) who "suddenly" feels better is at high risk for suicide, due to the suicide plan bringing temporary relief.

A teen who takes SSRI initially will feel rush of energy < 4 weeks after starting SSRI. They may be at risk for suicide during this time. Follow closely.

Elderly have atypical symptoms, depression may be mistaken for delirium, exhibit psychomotor retardation rather than retardation.


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