Clinical depression resident survival guide

Clinical depression Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S.

Synonyms and keywords: Approach to depression, Approach to suicide, Suicide workup, Depression workup, Depression management

Overview

Depression often leads to poor quality of life and impaired functioning. Clinical depression is defined as loss of interest (anhedonia) and/or depressed mood for two or more weeks with at least 4 of the following features: sleep disturbances, loss of appetite/increased appetite, feeling guilty/worthless, loss of energy, loss of concentration, psychomotor retardation, or suicidal ideation.The pathophysiology of depression is not completely understood, but it is thought that decreased levels of monoaminergic neurotransmitters Dopamine, Serotonin and Nor-epinephrine are responsible for depressed mood. When a patient with depressed mood comes to primary care, a detailed psychiatric interview is important to evaluate the psychiatric symptoms and assess the effect of symptoms on functioning of the patient. A physician is required to foster a positive rapport with the patient and help with sensitive matters. If needed, family and friends of the patient may be involved and cultural, social, and situational factors should be considered to diagnose triggering factors.

Causes

Life Threatening Causes

Life-threatening causes include conditions includes:

• Major depressive disorder with suicidal ideation

Common Causes

• Genetic predisposition
• Life experiences
  • Divorce or the end of a serious relationship
  • Eating disorders
  • Financial difficulties or poverty
  • Gambling addiction
  • Grief over the death of a child, spouse, other family members, or friends.
  • Job loss or unemployment
  • Loss of religious faith
  • Ongoing major health problems
    • Rape
    • Sexual difficulties
    • Trauma
    • Work-related stress
• Medical conditions
  • Cardiovascular disease
  • Hepatitis:
    There is a high prevalence of depression in patients with hepatitis B and hepatitis C infection, especially those who are on Interferon therapy.
  • Mononucleosis
  • Hypothyroidism
  • Sleep apnea
  • Fructose malabsorption
  • Parkinson disease
  • Multiple Sclerosis
  • Hormonal contraception
  • Steroids
  • Addison's disease
  • Syphilis
  • Post- stroke
  • Thyrotoxicosis
  • Diabetes Mellitus
• Attention-Deficit/Hyperactivity Disorder (ADHD)
• Dietary
  • Alcohol
  • Poor diet:
    Deficiency of vitamins, minerals, and omega-3 fatty acids
• Seasonal Affective Disorder:
• Due to production of excessive melatonin
• Postpartum Depression
• Drugs:
  • Cardiovascular drugs:
    ACEI,Calcium Channel blockers,Digitalis,Clonidine, Hydralazine,Methyl-dopa, Procainamide,Propanolol,Thiazide and Zolamide diuretics, Reserpine
  • Anti-parkinsonian drugs:
    Levodopa, Amantadine, Bromocriptine
  • Anti-convulsants:
    Ethosuximide, Phenobarbital, Phenytoin,Vigabatrin,Tiagabine
  • Anti-psychotic:
    Fluphenazine,Haloperidol
  • Chemotherapeutics:
    Azathioprine, Bleomycin, Cisplatin,Cyclophosphamide, Vinblastine, Vincristine
  • Stimulants:
    Amphetamine withdrawal, Cocaine withdrawal
  • Anti-retroviral:
    Atazanavir,Efavirenz, Zidovudine, Saquinavir
  • Sedative and anxiolytics:
    Barbiturates, Ethanol, Benzodiazepines

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Clinical Depression

Patient with clinical depression

Take complete history

Do initial screening

Screening and ask about previous 2 weeks: Over the past 2 weeks how often have you been bothered by any of the following problem? 1.Little interest or pleasure in doing things 2.Feeling down, depressed or hopeless

Yes

No

Repeat screening annually

Ask the following questions about last 2 weeks: ❑ Do you feel low/ hopeless or sad? ❑ Have you lost interest/pleasure in doing things you used to like ❑ Have you noticed any changes in body weight recently( weight gain/ weight loss) ❑ Is there any sleep disturbances? ❑ Is there any trouble falling or staying asleep, or sleeping too much ❑ Do you feel guilty about anything?Do you feel bad about yourself—or that you are a failure or have let yourself or your family down ❑ Do you feel tired/ fatigued most of the time of the day? ❑ Can you concentrate on usual work? Are you having trouble concentrating on things, such as reading the newspaper or watching television ❑ Have you noticed any changes in appetite? ❑ Have you been moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual ❑ Have you had any thoughts of death and/or suicide, suicide planning, or a suicide attempt

General Physical Examination: ❑ Look for thyroid swelling ❑ Look for symptoms of malnutrition and specific nutritional deficiency

Record the vitals: ❑ Blood pressure ❑ Weight ❑ Body Mass Index ❑ Waist circumference

Perform mental status examination: ❑ Level of consciousness: See if patient reacts to stimuli ❑ Appearance and general behavior: Look for patient's physical appearance, grooming (clean/untidy or dishevelled appearance), dress (subdued/riotous), posture (erect/kyphotic) ❑Speech and motor activity: Ask them open-ended questions and check if there is any word-finding difficulties, or the rapid and pressured speech, tics or unusual mannerisms,look for slowness and loss of spontaneity in movement,look for akathisia or motor restlessness ❑ Affect and mood: Look for restricted, labile, or flat affect ❑ Thought and Perception: Evaluate how the patient perceives and responds to stimuli. Does the patient harbor realistic concerns, or are these concerns elevated to the level of irrational fear? Is the patient responding exaggeratedly to actual events, or is there no discernible basis in reality for the patient's beliefs or behavior? Look for illusions, hallucinations ❑ Attitude and Insight: See if the patient gets angry, aggressive,hostile, overdramatic,helpless during interview ❑ Cognitive abilities: Attention, language, memory, constructional ability and praxis, abstract reasoning

Establish a diagnosis

Differential diagnosis by ruling out secondary depression

Rule out bipolar disorder, premenstrual dysphoric disorder

Assessment: ❑ Assess the severity of the disease ❑ Evaluate if the person can harm himself/herself and others: Current suicidal ideations,past history of suicidal attempts, severity of suicide attempt.Ask if they have any specific plan about suicide or homicide ❑ Ask about any comorbid drug or substance use/dependence ❑ Assess their personality ❑ Assess their level of functioning: Ask if there is any work dysfunction ❑ Do detailed physical examination to rule out any disease that can contribute to depression

Do basic investigations: ❑ Haemoglobin ❑ Blood sugar ❑ Lipid levels ❑ Liver function test ❑ Renal function test ❑ Thyroid function test ❑ Urine pregnancy test(If required)

Ask about previous treatment history: ❑ Ask if they have any past medical illness ❑ Ask if they take any medications ❑ Ask about response to any prior treatment of depression (if they recieved any treatment earlier)

Assessment of the caregiver: ❑ Evaluate if they understand the nature of the disease and have enough knowledge about it ❑ Impact of the illness on them ❑ Their beliefs regarding treatment

Treatment

Shown below is an algorithm summarizing the treatment of Clinical depression:

Abbreviations: ECT: Electroconvulsive Therapy,MAOI= Monoamine oxidase Inhibitor, TCA= Tricyclic Antidepressant,SSRI= Selective Serotonin Reuptake Inhibitor

Presumptive diagnosis of Clinical Depression

Determine the level of severity and functional impairment

Is referral to mental health care indicated?: ❑ Unclear diagnosis ❑ Evidence of psychotic features, mania, hypomania ❑ Signs of co-morbid psychiatric conditions ❑ Unable to treat in primary care ❑ Need for psychosocial interventions ❑ Patient preference

No

Yes

Discuss treatment options and patient's preferences

Refer to mental health specialty care

Initiate treatment according to severity and follow-up in 1-2 weeks Severity PHQ-9 Score Functional impairment Initial treatment Mild 10-14 Mild Monotherapy-antidepressant or psychotherapy; or possibly combination of both Moderate 15-19 Moderate Antidepressant or psychotherapy; or possibly combination of both Severe >/=20 Severe May start with antidepressant or psychotherapy but prefer combination of both

Follow up in 2 weeks: ❑ Symptoms improved ❑ Treatment is well-tolerated and no side-effects ❑ Patient is adhering to treatment

Yes

No

Modify treatment: ❑ Increase dose ❑ Augmentation of the medication ❑ Switch to another agent ❑ Combine psychotherapy and pharmacotherapy ❑ Somatic intervention ❑ Inpatient/residential treatment

❑ Continue current treatment ❑Re-assess in 4-6 weeks

Some indications for inpatient care: ❑ Presence of suicidal ideation ❑ Refusal to eat or drink ❑ Severe malnutrition ❑ Presence of psychiatric conditions or other general medical comorbidity that make outpatient treatment unsafe or ineffective ❑ Catatonia

Yes

Evaluate: ❑ Full remission? ❑Continue current treatment to prevent relapse ❑ Possible long-term maintenance

Mild to Moderate Depression

The algorithm below shows the management plan in brief in case of mild, moderate, and severe depression:

Mild to moderate Depression

Remission

Psychotherapy

Pharmacotherapy

Remission

No response

No response

Change to anti-depressant

Partial Response

Change to anti-depressant OR Switch to psychotherapy

Optimize the treatment: ❑ Increase frequency of psychotherapy ❑ Give maximum tolerable doses of the anti depressant

Change or give combination therapy: ❑ If patient is getting psychotherapy: Add antidepressant ❑ If patient is recieving antidepressant: Add psychotherapy or change the anti depressant

Augmentation/Combination: ❑ If patient is recieving antidepressant: Add a second antidepressant OR augment the medication depending on tolerability and side effects

Severe Depression

The algorithm below shows the management plan in brief in case of severe depression:

Severe Depression

Assess the patient: ❑ Ask about patient's preference of treatment ❑ Past history of good response to treatment of ECT ❑ Recieving other treatment or high risk of drug interaction ❑ High risk of suicide ❑ Refuse to eat or drink ❑ Has catatonic features ❑ Has other features of psychosis ❑ Non responding to any other treatment

Assess the patient: ❑ Ask about patient's preference of treatment ❑ Past history or family history of good response to treatment of ECT ❑ Low risk of drug interaction ❑ High risk of suicide

ECT+Pharmacotherapy

Pharmacotherapy

No response

Partial response

Optimize the treatment: ❑ Give the maximum tolerable doses of the antidepressant

No further response: ❑ Switch to a different antidepressant from same or different pharmalogical class ❑ Add ECT ❑ Add a second anti depressant ❑ Augment the medication

Medications

Medications used to treat Depression:

Medications used to treat Depression

Mechanism	Name	Dose	Side effects
Selective Serotonin Reuptake Inhibitor	Fluoxetine Paroxetine Fluvoxamine Sertraline Citalopram Escitalopram	20-80 20-60 50-300 50-200 20-40 10-20	Sexual dysfunction GI disturbances Weight loss/gain Insomnia Anxiety
Tricyclic antidepressant	Amitriptyline Doxepin Imipramine Clomipramine	50-200 75-300 75-300 75-300	Sexual dysfunction Anticholinergic effect Drowsiness Weight gain Conduction abnormality
Norepinephrine Serotonin Reuptake Inhibitor	Venlafaxine Duloxetine Milnacipran Desvenlafaxine	75-300 20-60 50-200	Mild anticholinergic effect Drowsiness GI distress
Non adrenaline and Specific Serotonin Inhibitor	Mirtazapine	15-45	Mild anticholinergic effect Drowsiness GI distress
Atypical antidepressant	Trazodone Nefazodone	150-300 100-300	Anticholinergic effect drowsiness Weight gain Conduction abnormality
Mono amine oxidase Inhibitors	Phenelzine Isocarboxazid Tranylcypromine	45-90 30-60 20-60	Orthostatic hypotension Headache Insomnia Drowsiness
Selective Serotonin Reuptake Inhibitor	Vilazodone	20-40	Diarrhea Nausea Vomiting Insomnia

Do's

• If the patient has any suicidal ideation, the physician should ask if he/she has any plan to execute it or if he/she has any previous attempts. If they have any specific plan, admit the patient.
• If any patient tells they want to hurt someone, the physician should inform that person as well as to police authority.
• Be empathetic to the patient and listen to them.
• Motivate them to continue the treatment long term and help them with medication adherence.

Don'ts

• Do not let the patient stay alone and do not keep firearms if they are suicidal.