Week 2 - Depressive Disorders Flashcards
(40 cards)
Symptoms of Major Depressive Disorder
- include timeline and # needed for Dx
5+ of the following sxs, present most of the day nearly every day for 2+ consecutive weeks.
At least 1:
Depressed mood
Loss of interest or please in most or all activities
Plus at least 4: Insomnia or hypersomnia Change in appetite or weight Psychomotor retardation or agitation Low energy Poor concentration Thoughts of worthlessness or guilt Recurrent thoughts about death or suicide
PHQ2 - questionaire (shorter version), PHQ9 - longer
Exclusions of Major Depressive Disorder
History of mania or hypomania –> bipolar
History of substance use or other medical condition that may be causing the depression
Better explained by another disorder
Course and Severity of Major Depressive Disorder - EHR asks you about different presentations
Single episode Recurrent episode In partial remission In full remission Mild Moderate Severe With psychotic features
Dysthymic Disorder
characterized by fewer symptoms than major depression (
Premenstural Dysphoric Disorder
Pronounced mood changes that begin in the week before menses, decrease within a few days after the onset of menses, and abate in the week post-menses.
Include at least one of the following: Marked affective lability Marked irritablity or interpersonal conflicts Marked depressed mood Marked anxiety
At least one of the following must also be present:
Decreased interest in usual activities
Subjective difficulty concentrating
Lethargy, easy fatigability, or marked lack of energy
Marked change in appetite
Hypersomnia or insomnia
Feeling overwhelmed
Physical symptoms such as breast tenderness, joint/muscle pain, bloating, and weight gain
Depression not otherwise specified
includes syndromes without a sufficient number of symptoms (
Seasonal affective disorder
describes depressive symptoms in the winter months and absence of depressive symptoms during the summer months.
Substance/Medication Induced Depression
Alcohol Ask CAGE questionnaire Illicit Drugs Amphetamines Medications Corticosteroids Beta-blockers Antipsychotics (especially in elderly) and reserpine
No medication definitively “causes” depression.
CAGE Questions
C – Have you ever felt like you should cut down on alcohol use?
A – have people annoyed you by criticizing your drinking habits?
G – Do you ever feel guilty about your drinking?
E – eye-opener in the morning?
Depressive Disorders due to another Medical Condition
Parkinson’s Hypothyroidism: Check TSH! Traumatic Brain Injury Huntington’s Cushing’s disease Stroke
Other DDXs
Grief either complicated or uncomplicated Adjustment disorder with depressed mood Bipolar disorder – week 4 Psychotic disorders – week 5 Personality disorders – week 7
Risk Factors for Depression
Prior depressive episode Family history Female gender Childbirth Childhood trauma Stressful life events Poor social support Serious medical illness Dementia Substance abuse
US Preventative Services Task Force recommendation for screening:
ask patients to complete a depression questionnaire during routine appointments.
Rational for this approach include:
- difficult to detect since patients often present with a variety of somatic symptoms and may be reluctant to acknowledge symptoms of depression.
- Untreated depression is associated with decreased quality of life, increased mortality, and increased economic burden.
- Depression can be successfully treated and treatment is more effective when started early in the course.
Screening for Depression
Adult
PHQ-9 or Becks Inventory-Primary Care Version (BDI-PC) are recommended.
PROMIS is a newer scale developed by the American Psychiatric Association.
Adolescents (12-18)
Patient Health Questionnaire for Adolescents (PHQ-A) and Becks Inventory-Primary Care Version (BDI-PC) have been shown to o well in teens in primary care settings.
Children (7-11)
Screening instruments perform less well in younger children.
PHQ-9
Scoring 1-4 minimal depression 5-9 mild depression 10-14 moderate depression 15-19 moderately severe depression 20-27 severe depression
Treatment Assessment
A decrease by 5 points is a clinically significant improvement
A 50% decrease is a treatment response*
Scores below 5 are considered to be in remission*
What does SIG E CAPS stand for?
S: changes in sleep I: loss of interest/pleasure G: thoughts of worthlessness or guilt E: loss of energy C: trouble concentrating A: change in weight or appetitie P: changes in pychomotor activity S: thoughts of death or suicide
PEs for Depression
Always get vitals, including height & weight.
Cardiopulmonary
Anemia screen
Thyroid
Suicide Risk
Assessing for suicide risk is critical.
There is no evidence that asking about suicide precipitates suicidal thinking or acts.
Some useful screening questions are: “Sometimes when a person feels down or depressed, they might think about dying. Have you been having any thoughts like that?”
If the patient answers yes, the next step is to ask: “Do you have a plan?”
If a patient answers yes, inquire about the plan and determine whether they have assembled the materials required, has set a time, and if there are factors that may precipitate or prevent the patient from carrying out the plan.
Major risk factors for suicide include:
Hopelessness
Substance abuse
Previous suicide attempts
High Risk referrals and actions:
Patient at high risk of suicide should be referred for psychiatric evaluation. Those at imminent risk should be evaluated immediately.
Call 911 for an ambulance.
Call Multnomah County Crisis Line at 503-9988-4888.
Always try to get a “warm hand off”.
Classic antidepressant action is to block one or more of the transporters for:
Serotonin
Norepinephrine
Dopamine
Antidepressant Tx Goals
Respond to treatment
Enter and sustain remission
Achieve recovery
Prevent relapse
Define response
A response is when treatment of depression results in at least 50% improvement in symptoms.
Define remission
Remission is when treatment of depression results in removal of essentially all symptoms for several months.
