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Chief Complaint
Although depression is one of the more common illnesses in outpatient medicine, it is often overlooked. A high degree of suspicion is essential in clinical evaluation.
Very few patients will present with a straightforward complaint of depression. The majority will be seen for other complaints and may never mention depressed mood unless questioned specifically for the symptoms. Vague somatic complaints or numerous complaints that do not fit any clear clinical pattern should prompt consideration of the diagnosis of depression.
Review of Systems
Investigation into depressive symptoms should begin with inquiries of the neurovegetative symptoms. These include changes in sleeping patterns, appetite, and energy levels. Positive responses should elicit further questioning.
Common Symptoms of Depression:
SIG E CAPS: Give energy capsules Sleep disturbance Interest/pleasure reduction Guilt feelings or thoughts of worthlessness Energy changes/fatigue Concentration/attention impairment Appetite/weight changes Psychomotor disturbances Suicidal thoughts Plus depressed mood
These are the nine symptoms listed in the DSMIV for depressive disorder. Five of these nine must be present to make the diagnosis (see below).
All patients with depression should be evaluated for suicidal risk. Questioning should begin with the assessment of thoughts of hurting self. If the response is positive, the patient should be questioned on whether they have a specific plan and intent and emergent admission must be considered.
Some assessment of the degree of risk for suicide can be attempted by evaluating the apparent lethality of the plan and the chance of rescue. Many suicide attempts are apparently made with the hope of the rescue, which can be useful in assessing how receptive the patient may be to therapy. However even poorly conceived plans can have a fatal outcome and any suicide risk must be given prompt attention.
Keep alert to the risk of suicide even after treatment has begun. Some patients will take action once their energy level has increased in response to therapy but before further improvement has had time to occur.
Past Medical History/Family Medical History
Patients with a history of depressive episodes have an increased risk of suffering a subsequent episode. The family medical history may be positive for depression, substance abuse, and/or suicidal attempts.
Chronic medical problems are often associated with depressive symptoms.
Current Medications
Various medications can contribute to depressive symptoms. Examples include reserpine, beta-blockers, alpha-methyldopa, levodopa, and estrogens.
Abusive use of alcohol, prescription drugs, or illegal substances can be either a risk factor for development of depression or the result of attempts at self-medication.
Social History
Discussion of the emotional and mental stressors in the patient's life can give the physician invaluable clues to the patient's state of mind. Outlining the patient's family and/or social support structures is important in determining the patient's prognosis. Lack of support structures in the patient's life can increase the risk of suicide and may undermine effective therapy of depression.
The patient should be questioned directly for personal use of alcohol or other mood and/or mind-altering substances. In some cases the patient may have been self-medicating prior to diagnosis. Also keep alert to the danger that use of such substances may significantly increase the risk of suicide. If the use is continued after treatment begins, the chances for successful treatment are diminished.
Physical Examination
A thorough history and physical examination is indicated to rule out organic causes of depression. Some of the more common organic causes are listed in the table below.
| Organic Causes of Depression | Examples |
| Medications | Reserpine, beta-blockers, alpha-methyldopa, levodopa, estrogens |
| Abusive drug use | Alcohol, sedative-hypnotics, cocaine |
| Toxic-metabolic | Hyperthyroidism, hypothyroidism, Cushing's syndrome, hypercalcemia, hyponatremia, diabetes mellitus |
| Neurologic disorder | Stroke, subdural hematoma, multiple sclerosis, brain tumors (especially frontal), Parkinson's disease, Huntington's disease, uncontrolled epilepsy, syphilis, dementias |
| Nutritional disorder | Vitamin B12 deficiency, pellagra |
| Other | Viral infection, carcinoma |
Testing
Adults diagnosed with depression and with negative findings on physical examination do not routinely need further testing. You may consider a complete blood count, basic metabolic panel and thyroid function tests to rule out anemia and thyroid disease and to assess general nutritional status.
| When evaluating a child for possible depression, consider: | |
| CBC | rule out anemia |
| Electrolytes | electrolyte abnormalities |
| Creatinine/BUN | renal dysfunction |
| LFTs | rule out hepatitis and drug effects |
| TFTs | rule out thyroid disease |
| EKG | as a baseline if pharmacotherapy with a tricyclic antidepressant is being considered |
| EEG | rule out seizure disorder |
| Son, Sung E. and Jeffery T. Kirchner. Depression in Children and Adolescents. American Family Physician. November 15, 2000. Vol 62, no 10. Pp 2303 | |
Depressive symptoms and severity are often evaluated with screening questionnaires either in the physician's waiting room or during the visit with the physician. Examples of screening tools are:
Becks's Depression Inventory (BDI)
Zung Self-Rating Depression Scale
Hamilton Depression Scale (Ham-D)
Diagnosis
Depression is a clinical diagnosis. The criteria for diagnosis are clearly stated in the DSMIV.
For a diagnosis of major depression five of the nine (SIGECAPS) must be present for at least two weeks and one of those five must be loss of interest or pleasure or depressed mood.
Appropriate Therapy
Psychotherapy/Counseling
First line therapy for depression in adolescents and children is psychotherapy, not pharmacotherapy. Counseling is essential in all age groups but often access is limited. Some counseling can be done in routine office visits but time is a concern. One method of addressing patient concerns is the BATHE technique. This is by no means a substitute for professional counseling but it may be helpful to your patients when other options are limited.
BATHE is an easy and quick means of allowing patients to express their concerns and expressing empathy with them. It is important to remember that you are not expected to be able to solve all of your patient's problems. It takes perhaps five to ten minutes to complete the questions and ancedotal evidence shows that patients' satisfaction with their physician is greatly increased.
| B | Bother/Background | What is Bothering you the most right now? | This question is meant to elicit any history of current problems. Some will use an alternate form such as "Tell me what is happening right now." This may result in a seeming avalanche of problems. Do not let this overwhelm you. Listen patiently for 3 to 5 minutes and then ask the next question. Asking the patient to identify the most troubling aspect of numerous problems/stressors can be therapeutic in and of itself for the patient. |
| A | Affect | How is that Affecting you? | This question is aimed at clarifying the patient's emotional state. An alternative form would be "How do you feel about that?" For some patients this may be the first time they consciously admit that they are affected. |
| T | Trouble | What is it about this that Troubles you the most? | With this question we hope to further focus and clarify the patient's reaction to stressors and identify major areas of concern. |
| H | Handle | How are you Handling that? | Note the manner of this question. It carries an implicit belief that the patient is handling the situation in some manner. This assists in establishing a working rapport with the patient and may allow opportunity for brief discussion of alternative coping strategies or resources. |
| E | Empathy | Express Empathy/understanding of the patient's concerns | For some physicians this can be the most difficult portion of the technique. At the same time it is the most simple. Common statements might be "I can see how that would make you angry." Or "That must be very frustrating." The important point to remember here is that genuine concern can be as therapeutic as offering a detailed plan of care. |
Medications
It is beyond the scope of this chapter to detail all the medications that may be used to treat depression. In the table below, I've listed some of the more common prescriptions written in the clinics of LSUHSC.
| Class | Examples | Indications | Common Usage | Side Effects (Not all side effects are listed here. Always review the possible side effects prior to prescribing a medication.) |
| Selective Serotonin Reuptake Inhibitors (SSRIs) |
Sertraline (Zoloft) Fluoxetine (Prozac) Paroxetine (Paxil) Citalopram (Celexa) |
Depression Some SSRIs have indications for conditions that may be comorbid with depression such as anxiety, panic disorder, bulimia nervosa, or obsessive-compulsive disorder. |
Possibly the most popular class for treatment of depression with or without anxiety. Maximize benefits by considering possible comorbid conditions. Fluoxetine has a weekly dosing which may improve compliance in some patients |
May be associated with undesirable behavioral changes (nervousness/anxiety, increased energy, restlessness/akathisia, insomnia, irritability/agitation, silliness/euphoria, disinhibition). Sexual dysfunction may occur and can be extremely distressing to the patient. |
| Tricyclic Antidepressants (TCAs) | Amitriptyline (Elavil) | Depression |
Rarely used as single therapy in our clinics. Available in a generic form if cost is an issue. Highly sedating and often used in patients with sleep disturbance. |
Avoid use in patients with cardiovascular disorders. Multiple possible side effects and interactions with medications limits usefulness. Overdosage is potentially fatal. Avoid use in patients with significant suicidal risks. |
| Aminoketone | Bupropion (Welbutrin, Zyban) |
Depression Smoking cessation |
Consider for patients who express a desire to stop smoking. |
Do not use in patients with a history of seizure disorder, bulimia or anorexia nervosa. More common side effects include insomnia, dry mouth, dizziness, and constipation. |
| Triazolopyridine derivative | Trazodone (Desyrel) | Depression |
Sedating property utilized for sleep disturbance or anxiety in some patients. Available in generic form. |
Use cautiously in patients with cardiovascular disorders. Has a risk of priapism, nausea, dry mouth, dizziness, postural hypotension, and constipation. |
| Piperazino-azepine | Mirtazapine (Remeron) | Depression | Has some sedative properties and may be useful in patients with anxiety or insomnia. |
Agranulocytosis has been reported to develop in patients - watch for symptoms of sore throat, fever, stomatitis. May case elevations in lipids and/or liver enzymes. Use cautiously in patients with significant suicide risk. |
| Serotonin and Norepinephrine reuptake inhibitor | Nefazodone (Serzone) | Depression | Consider with comorbid anxiety or insomnia. |
Use cautiously in patients with cardiovascular disorders. Has a risk of priapism, nausea, dry mouth, dizziness, postural hypotension, and constipation. |
| Venlafaxine | Effexor |
Depression Generalized Anxiety Disorder |
Consider with comorbid anxiety or insomnia. |
Monitor blood pressure closely - may cause sustained increases. Risks include sweating, nausea, constipation, anorexia, sexual dysfunction, and dream disturbance. |
Goals of Therapy
Appropriate Follow-up
Patients with severe depression and possible suicidal risk should be considered for admission while initiating therapy. If admission is not necessary, initial outpatient follow-up would be in 1-2 weeks depending on the severity of the patient's symptoms. It can take several (possibly 8-10) weeks for therapy to have an impact and patients may benefit from close follow-up and encouragement while awaiting relief of symptoms.
If the patient does not have access to psychotherapy or counseling, close follow-up in the clinic may be even more important to provide support and encouragement.
Once symptoms have begun to remit, follow-up can be scheduled at intervals of 2 to 4 months.
Referral
Consider referral for:
References/Links
Sung, E. Son. Depression in Children and Adolescents. Am Fam Physician. 2000;62(10):2297 - 2308.
Screening tools:
Monograph - Diagnosis and Management of Depression; Monograph #2 2000; Michele R. Webb; AAFP
McCulloch J, Ramesar S, Peterson H. Psychotherapy in primary care: the BATHE technique. Am Fam Physician. 1998;57(9):2131-4.
http://lib-sh.lsumc.edu/fammed/intern/antidepr.html
Lieberman J, Stuart M, Robinson S. Enhance the Patient Visit With Counseling and Listening Skills. Fam Pract Manag (United States), Nov/Dec 1996. 3(10)
PDR Monthly Prescribing Guide. June 2002. vol 1, no 6. pp 256-262, 268-275.
Nease, Don. Anxiety and Depression. In: Sloane, P, et al., eds. Essentials of Family Medicine. 4th ed. Lippincott Williams & Wilkins. 2002. pp 345-355.
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