Approach to the Patient with Depression
John J. Worthington III
Scott L. Rauch
Depression is not only a very common condition—estimated prevalence 5.8% in men, 9.5% in women, and a lifetime incidence of 16%—but an important cause of disability and a major risk factor for stroke and death from coronary heart disease. Being a treatable, yet potentially fatal disease, it requires early detection and implementation of an effective management program. Most patients with depression present to primary care physicians rather than psychiatrists, often complaining of somatic symptoms such as fatigue or disturbed sleep. The frequency, treatability, and potentially serious consequences of depression make its diagnosis and management high priorities for the primary care physician. Unfortunately, the diagnosis is often not made. Sometimes, it is not evident because the symptoms may masquerade as a variety of psychiatric or somatic conditions. Moreover, the stigma of psychiatric diagnosis can impede recognition of depressive illness by both patients and physicians. All members of the primary care team need to be vigilant in watching for manifestations of depression. The primary care physician should be prepared to initiate further evaluation and basic treatment when symptoms or signs are encountered. A collaborative care approach to management that engages other members of the primary care team can help improve outcomes.
PATHOPHYSIOLOGY AND CLINICAL PRESENTATION (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17)
Mechanisms
The purported mechanisms of depression include psychodynamic, cognitive, genetic, neuroendocrine, and neurotransmitter determinants. Depression most likely represents a complex combination of these elements. Genetic factors and/or early childhood experiences may render persons more susceptible to depression. Neurotransmitter and neurohumoral elements probably serve as important effector pathways for the development of symptoms.
Psychodynamic origins are believed to involve difficulties with formation and maintenance of self-esteem, which may occur from having hypercritical parents or being abused. In addition, growing up in an emotionally unresponsive environment may compromise learning ways effectively to cope with situational stresses. Suffering loss or failure as an adult is likely to be difficult, poorly responded to, and capable of reawakening prior painful feelings of inadequacy and worthlessness that lead
to depression. Rigid dysfunctional defenses may be erected in an attempt to minimize the chances of loss or failure.
to depression. Rigid dysfunctional defenses may be erected in an attempt to minimize the chances of loss or failure.
The cognitive perspective views depression as the consequence rather than as the origin of negative or distorted thinking. Subscribing to inflexible rules of conduct and unattainable goals can be a setup for failure and loss of self-esteem. Setbacks are viewed as a reflection of one’s unworthiness and inadequacy.
Genetic determinants have been discovered from studies of twins, chromosomes, and pedigrees. In some pedigrees, there appears to be a dominant gene with incomplete penetrance that confers risk. A family history of affective disease is commonly elicited. Major depression is up to three times more common among first-degree relatives of people with the disorder than in the general population.
Neurotransmitter theories of depression began with the finding that reserpine could induce depression and monoamine oxidase inhibitors (MAOIs) could reverse it. This led to the identification of altered neurotransmitter metabolism as an important biochemical concomitant of depression and to the discovery of new antidepressant drugs, each increasing the availability of a major central neurotransmitter (e.g., norepinephrine, serotonin, or acetylcholine), usually by selective inhibition of reuptake. On a neurotransmitter basis, norepinephrine appears to affect energy levels and level of alertness, while serotonin’s sphere of influence is on mood.
Neuroendocrine hypotheses derive from the observation that most neurovegetative manifestations of depression (changes in appetite, libido, diurnal rhythms) involve hypothalamic functions. In addition, links between neurotransmitter release and neurohormonal activity have been identified. Corticotropinreleasing hormone is believed to play an important role, resulting in hypercortisolism. Early-morning awakening, reflecting an abnormal advance in circadian rhythm, may be one consequence.
Psychological and Somatic Manifestations
Depression’s clinical presentation includes a host of psychological and bodily complaints.
Psychological Manifestations
Sadness is a very common symptom. Irritability, discouragement, loss of interest, worry, frustration, and decreased libido are the major dysphoric manifestations and may occur in the absence of overt sadness (Table 227-1). Some patients become preoccupied with physical complaints, such as pain or bowel dysfunction. Others exhibit changes in memory, concentration, or self-image. Diurnal mood variation is characteristic, with symptoms often worse in the morning and improving as the day progresses.
Depressed affect can be subtle, and at times, the patient’s sadness only becomes evident on talking with the physician. As depression worsens, psychomotor abnormalities may appear. Although psychomotor retardation, with slowed speech and a long latency before the patient answers questions, has been thought of as the classic presentation of depression, anxiety is the much more common symptom. Nearly three fourths of patients with a depressive disorder have worry, psychic anxiety, or somatic anxiety as one of their presenting symptoms.
Somatic Manifestations
Distinctive neurovegetative symptoms include disturbed sleep (most commonly early-morning awakening), lack of energy, and decreased appetite. Neurovegetative symptoms are predictive of responsiveness to psychopharmacologic intervention. In what is termed an atypical depression, patients may exhibit increased sleep and increased appetite (hypersomnolence and hyperphagia).
TABLE 227-1 Clinical Presentation of Depressive Syndromes | ||||||||||||||||||||||||||||||||||||||||||||||||||
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Diagnostic Classification
Although no single classification system is universally accepted, the current standard of diagnosis in the United States is the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) (Table 227-2).
Major Depression (Major Depressive Disorder, Unipolar Depression)
This is the DSM-V term for serious depression that is accompanied by neurovegetative symptoms. The lifetime risk of developing a major depression is estimated to be 1 in 4 for women and 1 in 8 for men. Dysphoric mood typically dominates the clinical picture and is persistent. Four or more of the major neurovegetative symptoms dominate the clinical picture and are present for a minimum of 2 weeks, including appetite disturbance, sleep disturbance, psychomotor retardation or agitation, anhedonia, loss of energy, feelings of worthlessness or guilt, decreased concentration, and suicidal thoughts.
Onset is variable. Symptoms usually develop over weeks to months, but they may develop suddenly. Situational factors surrounding the onset of the illness have no bearing on the diagnosis. Historically, distinctions were made between endogenous and reactive depression, but an identifiable precipitant is no longer considered pertinent with respect to diagnosis; the frequency of episodes appears to increase with age. At least half of patients have recurrent episodes. A family history of a major affective disorder (major depression or bipolar disorder) is common. The relationship between alcoholism and depression is controversial. Traumatic brain injury is associated with a high frequency of posttraumatic major depression as well as anxiety.
Major Depression with Psychotic Features
A subclassification of major depression, this disorder has the additional features of delusions, hallucinations, bizarre behavior, or disorganized thinking.
TABLE 227-2 Classification of Depressive Syndromes* | |||||||||||||||||||||||||||||||||||||||||||||||||||
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Major Depression in the Elderly
In the elderly, depression can mimic dementia. The patient may appear withdrawn, unkempt, inattentive, or even confused. The condition may be due to depression alone or to a combination of depression and dementia. Conversely, a clinical presentation consistent with depression is much more likely to be secondary to a medical condition (infarct, brain tumor, etc.) in individuals older than 50 years.
Bipolar Disorder: Depressed Phase
Depression may be a manifestation of bipolar (manic-depressive) illness. The presentation of a depressive episode in a bipolar patient is identical to that of major depression, except that there is a history of a prior manic or hypomanic episode. Mania is manifested by an episode of elation or expansive mood, increased energy, decreased need for sleep, inflated self-esteem, and overinvolvement in activities, accompanied by a decreased concern for the consequences. Its diagnosis requires adequate severity substantially to impair level of functioning. Hypomania refers to the hallmark symptoms of mania in the absence of impaired functioning. Bipolar I disorder involves at least one episode of mania; bipolar II disorder involves at least one episode of hypomania. Prevalence is considerable, with estimates as high as 5% of the adult population (1% for bipolar I disease and 4% for bipolar II). Distinguishing between the depressions of unipolar and bipolar disorders is important because initial treatments differ substantially (see later discussion).
Persistent Depressive Disorder
This category denotes a chronic low-grade depression, characterized by pervasive dysphoric mood for at least 2 years. Some patients complain of lifelong feelings of depression. Symptoms are less severe than are those of major depression, and neurovegetative symptoms are fewer. Depression appears as an integral part of the patient’s personality or character (hence the older term characterologic depression). Such patients can be frustrating to treat because of chronic dysphoria, self-pity, and development of irrational patterns of negative thinking (e.g., “Things always go wrong for me”). The physician typically develops feelings of helplessness and may unconsciously communicate a wish that the patient would go away.
Typically, onset is in adolescence or early adult life and is accompanied by other symptoms of a personality disorder, such as a history of difficulty with interpersonal relationships, manipulativeness, feelings of emptiness, and lack of an identity. A subpopulation of dysthymic patients seems to have an attenuated chronic form of major depression with onset later in life after a period of good functioning. Neurovegetative symptoms may be more prominent.
Dysthymia and major depression can coexist in a given patient (so-called double depression) when a major depressive episode evolves in the context of preexisting dysthymia. However, incomplete recovery from a major depression should be described as major depression in partial remission rather than dysthymia.
Cyclothymic Disorder
This state resembles bipolar illness, but the mood swings are less severe. These patients have a chronic mood disturbance characterized by periods of depression alternating with periods of elevated mood. Neither is of sufficient severity or duration to meet the criteria for major depressive or manic episodes. Interspersed may be periods of normal mood lasting as long as several months.
Seasonal Affective Disorder
This depressive variant is distinguished by its seasonal pattern, characteristically beginning in the fall and ending about 5 months later. It has been linked to a lack of light exposure and is more common in northern latitudes. Alterations in serotonin activity have also been noted. As in other forms of depression, sadness is the dominant affect, and fatigue and decreased libido are common. Atypical features include tendencies to overeat and oversleep. In the United States, women are more commonly affected than are men (ratio, 3:1). The age of onset is typically in the 20s.
Adjustment Disorder with Depressed Mood
This occurs after a significant life stress. Patients usually present with depressed mood associated with feelings of hopelessness, helplessness, worthlessness, and anxiety. Their thoughts are often dominated by the problems that precipitated the episode. Sleep and appetite disturbances are common but are less severe and less persistent than in major depression. The condition is usually self-limited, lasting less than 6 months and improving when the stress is removed or the individual evolves a more adaptive coping mechanism. It is important to note that any patient with symptoms severe enough to meet the criteria for major depression (see prior discussion) should receive that diagnosis regardless of the history of a precipitant. The message that the primary care physician should gather from this chapter is that evaluating the depressive symptoms, regardless of a suspected precipitant, is crucial, and possibly lifesaving, in initiating antidepressant treatment.
Postpartum Depression
Postpartum depression affects more than 10% of new mothers, perhaps as a consequence in susceptible persons of the rapid decline in reproductive hormone levels that occur with childbirth. Those with a prior history of depression, especially postpartum depression, are at greatest risk. Other risk factors include situational stress but not mode of delivery, gender
of the child, breast-feeding, or whether the pregnancy was unwanted. Clinically, symptoms of major depression appear within 4 weeks of delivery and persist for more than 2 weeks (which constitutes the formal definition of the condition); in some instances, onset may be delayed for up to 3 months postpartum. Manifestations are those of major depression, but the consequences to the newborn can be particularly serious, with disruption of normal childhood development leading to cognitive and behavioral problems.
of the child, breast-feeding, or whether the pregnancy was unwanted. Clinically, symptoms of major depression appear within 4 weeks of delivery and persist for more than 2 weeks (which constitutes the formal definition of the condition); in some instances, onset may be delayed for up to 3 months postpartum. Manifestations are those of major depression, but the consequences to the newborn can be particularly serious, with disruption of normal childhood development leading to cognitive and behavioral problems.
TABLE 227-3 Organic Etiologies of Depression | |||||||
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It is important to consider organic causes of depression, including drug-related etiologies, which are among the most common (Table 227-3). Chronic feelings of fatigue and dysphoria are nonspecific symptoms common to multiple medical conditions whose differential diagnosis includes chronic fatigue syndrome, Lyme disease, fibromyalgia, rheumatoid disease, and endocrinopathies (see Chapter 8). Patients experiencing domestic violence may present with frank major depression or multiple bodily complaints (e.g., headache, gastrointestinal symptoms, premenstrual difficulties, sexual dysfunction) mimicking depression. In addition, several psychiatric disorders can masquerade as depression, including uncomplicated bereavement, alcoholism, drug dependence, and personality disorders.
Uncomplicated Bereavement
Symptoms of normal grief may initially be identical to those of depression. The question of a superimposed depression should be raised if mourning continues for more than 6 months, if neurovegetative symptoms are particularly severe, if there is severe impairment in the patient’s ability to function, or if psychotic symptoms emerge.
Alcoholism and Drug Dependence
Many alcoholic patients appear depressed. It is not possible to delineate which symptoms are due to alcohol and which, if any, might be due to a primary affective disorder until the patient has been fully detoxified. Other substance abuse disorders may mimic depression, especially abuse of sedative-hypnotics or withdrawal from psychostimulants.
Personality Disorders
These patients frequently complain of depressive symptoms, with periods of severe dysphoria, but their affective symptoms often fluctuate markedly with environmental changes (especially with changes in interpersonal relationships). Poor impulse control, histories of unstable relationships, and a striking quality of manipulativeness or entitlement are other clues to primarily characterologic pathology.
The possibility of depression should always be considered in patients who present with fatigue, poor sleep, appetite disturbances, multiple bodily complaints, or expressed feelings of hopelessness or poor self-esteem. Screening in the primary care setting is also important and can be accomplished by asking a pair of simple questions about mood and interest during an annual checkup: “In the prior 2 weeks, have you felt down, depressed, or hopeless?” and “Have you noted a lack of interest or pleasure?”
The onset of depressive symptoms and signs in patients with chronic debilitating disorders or chronic pain can be slow and subtle and should not be overlooked. When depression is suspected, specific inquiry into its manifestations is needed. However, before proceeding with the inquiry, it is useful to complete a detailed medical history for “organic” etiologies (including elicitation of specific patient concerns) and to follow later with a detailed physical examination, especially in patients who present complaining of somatic symptomatology. Not to do so risks alienating the patient, who wants his or her medical complaints taken seriously. Also useful are a few words to explain the rationale for considering depression (e.g., “It’s a serious, treatable condition and is listed as one of the important causes of the symptoms bothering you”). These few simple measures facilitate patient understanding and impart a sense of seriousness and thoroughness to the workup. In addition, they help to reduce the stigma of considering a psychiatric diagnosis.
History
The dimensions to explore include neurovegetative symptoms, multiple bodily complaints, psychosocial history, and past psychiatric history of patient and family. It is helpful and often less threatening to ask first about neurovegetative symptoms such as those relating to sleep, appetite, and energy. If the responses suggest depression, one can proceed to inquire about mood and any loss of interest in sex, family, job, and other sources of interest or pleasure. In addition, the patient should be queried about self-opinion and any self-critical feelings. With every depressed patient, it is critical to ask about suicidal thoughts and intentions (see later discussion). Also useful in the exploration of multiple bodily complaints is consideration of systemic illness that might mimic depression.
Checking for Neurovegetative Symptoms
Checking for characteristic neurovegetative symptoms can help in diagnosis and is also useful in screening (see later discussion). Specific inquiry into these characteristic symptoms is facilitated by the validated mnemonic SIG E CAPS (“prescribe an energy capsule”):
S—Is your sleep disturbed?
I—Have you noted a loss of libido or interest in your usual activities?
G—Are you feeling guilty or having self-deprecatory thoughts?
E—Have you noticed a decrease in your energy level?
C—Have you been having trouble concentrating?
A—Have you experienced changes in your appetite and weight?
P—Have you been physically slowed down or sped up (i.e., experienced psychomotor abnormalities)?
S—Have you had thoughts of suicide, feelings of hopelessness, or preoccupation with issues related to death? (See later discussion for more detail.)
Checking for Multiple Bodily Complaints and Ruling Out Organicity
Patients with low energy, dysphoria, and multiple bodily complaints out of proportion to physical findings are likely to have depression, but, as noted earlier, they still require careful consideration of conditions that may present in similar fashion, such as chronic fatigue syndrome, Lyme disease, fibromyalgia, rheumatoid disease, vasculitis, and endocrinopathies (see Chapter 8 for details of workup). In addition, depression or multiple bodily complaints may be the clinical presentation of domestic violence. Screening for this condition can be as straightforward as asking, “At any time, has a partner ever hit you, kicked you, or otherwise physically hurt you?”
Confusion and alterations in level of consciousness strongly suggest organicity, although they are not always present. When they are, drug-induced etiologies are important to consider. Onset is usually temporally related to medication use and should be sought. Worth noting is any use of antiarrhythmics, antihypertensives, sedative-hypnotics, and corticosteroids, as well as over-the-counter agents and substances of abuse. The relation of β-blockers to depression remains inconclusive, but risk appears to be greatest for those that are lipophilic and readily cross the blood-brain barrier. The elderly are particularly susceptible to adverse central nervous system (CNS) effects from drugs that cross the blood-brain barrier.
Primary neuropathology should be sought when depression is accompanied by an alteration of neurologic function. Left frontal lobe involvement by a mass lesion or stroke may trigger a depressive syndrome. Inquiry into focal signs and symptoms helps to differentiate a structural lesion from a functional affective disorder. In some medical illnesses, depression may dominate the early clinical picture. Pancreatic cancer is the archetypal example. Important associated findings should be sought, including profound weight loss, vague upper abdominal discomfort, and onset of painless jaundice (see Chapter 58). HIV infection and emergence of AIDS are frequently associated with depression. In such cases, the diagnosis may be obscured by comorbid medical illness (see Chapter 13). In addition, depressive features may mistakenly be conceptualized as normal grief in response to the medical diagnosis and surrounding tragedy.
Psychosocial History
This should focus on the patient’s current home environment and means of financial and emotional support. Does the patient live alone? If the patient does not, is the family environment accepting or, conversely, contributing to the patient’s discomfort? The availability of responsible family members to observe and supervise the patient might mean the difference between outpatient treatment and hospitalization if the patient is very depressed or debilitated. What are the patient’s daily responsibilities, and what secondary stressors arise if the patient cannot meet these obligations?
Psychiatric History of the Patient and Family
Once the issue of medical etiologies has been put to rest, one should return to eliciting a past psychiatric history. Given depression’s tendency to recur, the patient should always be asked about similar episodes in the past. If there is a history of depressive or manic disease, it is important to obtain the details of treatment and treatment response; a positive family history of manic symptoms or bipolar disease should raise suspicion for bipolar disorder in the patient. A history of prior psychosis or suicidality is also important to elicit because of their risks for recurrence.
Family history can be difficult to elicit because of shame about any mental illness in the family. It helps to explain that depression is believed to run in families because of hereditary biochemical factors, not defects in character. A family history of major depression, bipolar disorder, or suicide supports a diagnosis of depression in the patient. The genetic predispositions for unipolar depression and bipolar illness are distinct.
A family history of other psychiatric diagnoses must be interpreted in the context of changing nomenclature and diagnostic criteria. In the past, mania was frequently misdiagnosed as schizophrenia. “Nervous breakdown” and “going insane” were common nonspecific terms. If family psychiatric history is present, it is worth reviewing symptoms and attempting a tentative retrospective diagnosis.
Physical Examination
The importance of a careful and detailed physical examination cannot be overemphasized, especially because most depressed patients presenting to primary physicians harbor concerns about medical illness. Specific patient concerns elicited during the history should be explicitly checked during the physical examination to facilitate the provision of meaningful reassurance (see Chapter 8 for description of the pertinent physical examination).
Mental Status Examination
Much of the mental status examination can be performed by taking note of the patient’s appearance, affect, behavior, and responses during the history. Has the patient’s condition interfered with grooming and self-care? Is there sadness, tearfulness, despondency, apathy, irritability, anxiety, or anger? Is there psychomotor retardation or agitation? Does the patient offer anything spontaneously, or is there a long period of hesitation before answering (i.e., speech latency)? Is the speech slow? Is normal inflection present?
The patient should also be asked explicitly to describe his or her mood. Thought is assessed for form and content. Is the patient’s thought pattern clear and coherent or is it tangential, circumstantial, or nonsensical? Are there ideas of worthlessness, helplessness, hopelessness, guilt, suicidal thought, or homicidality?
Is the patient able to maintain attention? Distractibility may occur in depression, delirium, dementia, or severe anxiety and will interfere with the patient’s overall cognitive performance. Any inattention is worth documenting by testing the ability to recall a series of random numbers (digit span). Patients should be able to repeat a series of at least five to seven numbers without error. “I don’t know” answers are reflective of apathy or lack of energy associated with depression. Tests of memory, calculation, abstractions, and other higher cortical functions should be performed.
Although psychotic depression is uncommon in primary care settings, it is important not to miss this very serious condition. It should be noted whether the patient appears guarded or expresses paranoid thoughts or delusions. Inquiry into any unusual experiences, such as hearing voices or seeing things that other people do not see, provides further evidence of a thought disorder. However, unusual smells, tastes, and tactile experiences suggest an organic brain syndrome.
Evaluation for Suicidality
Depression is a potentially fatal illness. Assessment of suicide risk is an integral part of the workup of every depressed patient. About 15% of patients with major affective disorders take their lives; diagnosing and treating depression can be a lifesaving medical intervention by the primary care physician.
With proper intervention, most suicides can be prevented. Concurrent conditions that increase the risk of suicide include chronic alcoholism, personality disorders, and both functional and drug-induced psychoses; delusional beliefs or hallucinations may lead to self-destruction. Predicting a suicide attempt is difficult, even among patients who complain of suicidal thoughts. Assessment of risk is facilitated by specific inquiry.
With proper intervention, most suicides can be prevented. Concurrent conditions that increase the risk of suicide include chronic alcoholism, personality disorders, and both functional and drug-induced psychoses; delusional beliefs or hallucinations may lead to self-destruction. Predicting a suicide attempt is difficult, even among patients who complain of suicidal thoughts. Assessment of risk is facilitated by specific inquiry.
Technique.
Assessing risk of suicide requires attention to the patient’s thoughts (ideas, wishes, motives), intent (the degree to which the patient intends to act on the thoughts), and plans. Inquiry necessitates a calm, empathic approach that allows expression of feelings and is free of any implied criticism. On any expression of hopelessness, helplessness, or suffering, one might begin with a rather indirect query (e.g., “Are you feeling so bad that sometimes you would prefer not to go on living?”). A positive response is followed by more direct questions about self-destructive thoughts and plans. A well-worked out, realistic, and potentially lethal plan suggests great risk, as does the act of putting one’s affairs in order.
Asking patients about suicide does not put the idea into their heads. Pitfalls include failure to ask specifically about suicidal thoughts and feelings and premature interruption of the patient who mentions suicide. Any mention of suicide must be taken seriously, and every depressed patient must be asked about suicide. It is an error to avoid the subject for fear of doing so. Truly suicidal patients usually are relieved to be asked about it.
Mental status, especially the patient’s ability to resist suicidal thoughts, is important to consider. An extremely impulsive, psychotic, or intoxicated patient has no meaningful internal controls and requires hospitalization.
Assessment of Risk.
There is no simple formula for precisely assessing suicide risk. Attention to thoughts, intent, and plans is essential, facilitated by consideration of mental status and pertinent psychosocial and demographic predictors (Table 227-4). Patients expressing suicidal thoughts, especially if accompanied by intent and plans, or who lack reliable internal controls to resist suicidal impulses require emergency psychiatric consultation. Such patients should be closely supervised and not allowed to transport themselves. Patients with severe or worsening depression who have thought about suicide but steadfastly deny intent or plans should be given a prompt confirmed appointment with a psychiatrist. Depressed patients with no suicidal thoughts, intent, or plans; a normal mental status examination; and external social supports can be treated by the primary care physician, as long as frequent visits can be arranged and the depression responds to treatment. Patients with suicide potential should never be given more than 1 g or 1 week’s supply of a tricyclic antidepressant (TCA) (see later discussion).
TABLE 227-4 Risk Factors for Suicide | |||||||||||
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Related posts:
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Screening for Hyperlipidemia and Associated Coronary Heart Disease Risk Factors
Evaluation of Arterial Insufficiency of the Lower Extremities
Approach to the Patient with Chronic Congestive Heart Failure
Evaluation and Prevention of Occupational and Environmental Lung Disease
Management of Chronic Obstructive Pulmonary Disease
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