Diagnosis and Treatment of Depression in the Intensive Care Unit Patient



Diagnosis and Treatment of Depression in the Intensive Care Unit Patient


John Querques

Theodore A. Stern



I. GENERAL PRINCIPLES

A. Major depressive disorder is a psychiatric condition that affects mood and neurovegetative functions (e.g., sleep, appetite).

1. While experiencing a depressed mood transiently can be a normal and expected part of life, having the full constellation of symptoms meeting the criteria for major depressive disorder is never a normal or appropriate reaction to a stressful situation.

2. Left untreated, major depression increases rates of morbidity and mortality, especially from cardiac conditions.

B. Definition.

1. Major depressive disorder is a syndrome characterized by five or more of the symptoms listed in Table 144-1 for 2 weeks or more.

2. One of the five symptoms must be either depressed mood or anhedonia (i.e., an absence of pleasure).

3. The mnemonic SIG: E CAPS (i.e., label: energy capsules) is a helpful guide to remember these defining criteria (Table 144-1).

II. DIAGNOSIS

A. Clinical features. The manifestations of depression include affective, behavioral, and cognitive abnormalities (i.e., the ABCs of depression) (Table 144-2). Though a depressed patient may be psychomotorically slowed and have scant facial expression, his or her sensorium will be intact. This helps to distinguish depression from delirium, in which the patient will have a reduced level of wakefulness, alertness, and/or attentiveness. The hypomanic or manic patient will have an elevated, expansive, or irritable mood rather than a dysphoric one.

B. Differential diagnosis. Depression in the intensive care unit (ICU) can occur as a primary affective disorder (e.g., major depressive disorder), a mood disorder associated with a specific medical condition or its treatment, or a psychological reaction to an acute medical illness.









TABLE 144-1 Mnemonic for the Diagnostic Criteria for a Depressive Episode—SIG: E CAPS







Depressed mood


Sleep (increased or decreased)


Interest (decreased)


Guilt (preoccupation with feeling guilty or worthless)


Energy (decreased)


Concentration (decreased)


Appetite disturbed (increased or decreased) or weight gain or loss


Psychomotor agitation or retardation


Suicidal thinking or thoughts of death


Adapted from American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994.









TABLE 144-2 Affective, Behavioral, and Cognitive Features of Depression—the ABCs




















Affective symptoms



Depressed mood


Hopelessness


Crying


Irritability


Anger


Decreased interest


Behavioral symptoms



Insomnia


Anorexia


Apathy


Increased sleep


Increased appetite


Decreased energy


Psychomotor agitation


Psychomotor retardation


Noncompliance


Deliberate self-harm


Impulsivity


Poor eye contact


Increased or intractable pain


Cognitive symptoms



Guilty rumination


Decreased concentration


Suicidal thinking or thoughts of death


Confusion


Dementia-like symptoms


Somatic preoccupation


Adapted from Geringer ES, Querques J, Kolodziej MS, et al. Diagnosis and treatment of depression in the intensive care unit patient. In: Irwin RS, Rippe JM, eds. Intensive care medicine, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2012:2087-2099.










TABLE 144-3 Selected Medical Conditions Associated with Depression







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Jun 11, 2016 | Posted by in CRITICAL CARE | Comments Off on Diagnosis and Treatment of Depression in the Intensive Care Unit Patient

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