Day # 24: Clinical Pearls for Depression

Welcome back to our current theme of depressive disorders. Up to this point we have covered core features of depressive disorders, diagnostic criteria, epidemiology, risk factors, and pathogenesis. Today we are going to have a discussion on clinical pearls for depression which will include tips on the clinical interview, validated questionnaires, differential diagnosis, and tips on management. Let's get started.


Today's Content Level: Beginner; Intermediate



Clinical Criteria Refresher


Before we start our discussion it will be helpful to review the symptom criteria for major depressive disorder (MDD) and persistent depressive disorder (PDD).


MDD = SIG-E-CAPS.

  • Depressed mood: Subjective (feels sad, empty, hopeless) or observation.

  • Sleep: Insomnia or hypersomnia nearly every day.

  • Interest: Markedly diminished interest in all or almost all activities. Aka Anhedonia.

  • Guilt: Feelings of worthlessness or excessive or inappropriate guilt nearly every day.

  • Energy: Fatigue or loss of energy nearly every day.

  • Concentration: Diminished ability to think or concentrate.

  • Appetite: Increase or decrease. Significant weight loss or weight gain.

  • Psychomotor: Agitation or retardation nearly every day (observable by others).

  • Suicidality: Recurrent thoughts of death, suicidal ideation, with or without plan.


PDD = CHASES.

  • Concentration: poor, or difficulty making decisions

  • Hopelessness

  • Appetite: poor or overeating

  • Sleep: insomnia or hypersomnia

  • Energy: low, fatigue

  • Self-esteem: low



Clinical Interview



•Patients experiencing depression may or may not disclose this up front in a clinical interview. Patients who are help-seeking, are comfortable with identifying and sharing emotions, and are health-literate may be able to coherently discuss their depressed mood and related symptoms. Other patients may, for a variety of reasons, have difficulty expressing what they are experiencing. Some reasons can include difficulty identifying and sharing emotions (alexithymia), amotivation, distrust or anxiety towards doctors, paranoia, and a number of other reasons.


•When screening for depression it is best to ask direct questions that have been shown to be sensitive screeners for depression. This can be very simple. Here are some examples:

  • Do you have little interest or pleasure in doing things? (PHQ-9 #1)

  • Have you been feeling down, depressed, or hopeless? (PGQ-9 #2)

  • Has there been any change in your self-esteem?


•Clarify onset/duration of symptoms with patient and family.

Identify life stressors (recent or historical). Stressful life events often precede first episode of mood disorders (less correlated to subsequent episodes). Examples include divorce/separation, death of a family member, unemployment, childhood trauma, losing a parent, etc...

Substance use - determine if this is substance/medication induced.

Medical and family history.

•Carefully document amount of episodes lasting at least two weeks and determine pattern of episodes. Example: pattern more consistent with MDD or PDD or MDD with seasonal pattern or Adjustment disorder, etc...

•Risk assessment for suicide and aggression - will cover risk/safety assessments in significant detail in later lessons, but remember that patients with depression have a higher risk of suicide than the non-depressed general population. 21:1 for males. 27:1 for females.


•New learners often ask how they can improve their approach to the clinical interview. One way to further develop your technique is to read through the clinically validated screening questionnaires and use some of those questions in your interview. You don't necessarily need to use the questions verbatim (although it is helpful to perform these periodically to track treatment response), but it can help you better formulate your questioning style. Examples:

  • Patient Health Questionnaire-9 (PHQ-9)

  • Beck's Depression Inventory (BDI)

  • Hamilton Rating Scale for Depression (HAM-D)

  • Geriatric Depression Scale (GDS)

  • Center for Epidemiologic Studies Depression Scale (CESD-R)

  • Quick Inventory of Depression Symptomatology (QIDS-C)

  • SAD PERSONS Depression Scale



Differential diagnosis


•Before making any psychiatric diagnosis it is important to consider other related disorders and appropriately determine the best fit according to the patients symptoms, biological, psychological, and social factors.


•Not every patient with depressed mood and anhedonia are going to have a major depressive disorder. Consider other psychiatric and medical causes of depressed mood.


Psychiatric Differential Diagnosis for Depression

  • Depression can be a feature of virtually any mental disorder, but the following deserve particular consideration in the differential diagnosis.

  • Bipolar depression: determine if patient has also had episodes of mania-like symptoms which would change the diagnosis to bipolar I, bipolar II, or cyclothymia.

  • Anxiety disorders: generalized anxiety disorder (GAD), panic disorder, PTSD, and OCD can all have a significant mood component. Carefully screen for anxiety disorders, but remember these are not mutually exclusive. You can have a depressive and anxiety disorder. In fact, it is more common than not!

  • Adjustment disorder with depressed mood: does the presentation meet full criteria for a major depressive episode or is this more consistent with a difficulty adjusting to a recent life stressor.

  • Post-traumatic stress disorder (PTSD): one of the criteria for PTSD, among others, is negative cognitions to include depressed mood, difficulty concentration, decreased energy, etc...

  • Seasonal affective disorder (MDD with seasonal pattern): important to determine the pattern of depressive episodes.

  • Substance (such as alcohol) induced mood disorder: it is critical to determine if the current depressive disorder is secondary to known substance use. Chronic alcohol, benzodiazepines, and opioid use as well as withdrawal from stimulants are all known causes of intense depressive episodes.

  • Early neurocognitive disorder: discussed below.

  • Personality disorder: there is a large mood dysregulation component to many personality disorders. Based on the patients presentation consider screening for personality disorders such as borderline, histrionic, narcissistic, and avoidant personality disorder. Much more on personality disorders in a later theme.

  • Psychotic disorder prodrome: as discussed in the psychotic theme, there is often a prodromal period before frank psychosis that presents as gradual social withdrawal, depression, and decreased cognition.

  • Grief / bereavement: uncomplicated bereavement is not considered a mental disorder even though about one-third of all bereaved spouses for a time meet the diagnostic criteria for MDD. The diagnosis is not made unless no resolution of the grief occurs and is based on the symptom severity and length.


Medical Differential Diagnosis for Depression

  • Mood disorder due to a general medical condition must be considered. Failure to obtain a good clinical history can lead to diagnostic errors.

  • Medications: classical association on board exams include steroids, benzodiazepines, and beta-blockers, however many medications are associated with depressive symptoms, so always do a thorough medication review. Other known associations include cardiac drugs, antihypertensives, sedatives, hypnotics, antipsychotics, antiepileptics, antiparkinsonian drugs, analgesics, antibiotics, and antineoplastics.

  • Thyroid and adrenal dysfunction: hypothyroidism and adrenal insufficiency are known endocrine causes of depressive disorders.

  • Neurological disorders: most common neurological causes of depressive symptoms are neurocognitive disorders (eg, Alzheimer's), Parkinson's disease, seizure disorder, cerebrovascular disease (strokes, TIA's), multiple sclerosis, cancer, and Hungtington's disease. Of note, depression is sometimes called "pseudo dementia" due to the similarity of depressed mood and cognitive deficits.

  • Infection: causes include infectious mononucleosis, influenza, coronavirus, HIV, syphillus, viral pneumonia, and more. Consider screening in at-risk groups (example: screen for mono in an adolescent who is depressed and fatigued).

  • Delirium: hypoactive delirium can manifest as depressed mood. Much more on this in a later theme.

  • Obstructive sleep apnea (OSA): patients may have depressed mood, day time fatigue, sleep disturbance, difficulty concentrating, etc... These patients need CPAP not an antidepressant.

  • More. The above are just some high yield examples.


•It is important to realize that in some cases the depressed mood is occurring directly due to another condition and if you correct that underlying condition then the depression will potentially resolve (fingers crossed). For example, if you treat hypothyroidism or the OSA or the substance use then hopefully the depressed mood resolves/improves.


However, it is equally important to understand that depressive disorders frequently coexist with other conditions. For example: this should go without saying but you can have hypothyroidism but also have a major depressive disorder. This is particularly apparent in co-morbid psychiatric conditions. Co-occuring depressive disorders with anxiety disorders, alcohol use disorder, and other substance-related disorders are very common. One study found that, overall, more than 75% of patients diagnosed with depression in a primary care setting suffer from a current anxiety disorder. 1



Management Based on Severity



•Treatment of depressive disorders is not a one size fits all algorithm. The severity of presentation and symptoms should serve as a guide for the treatment of a major depressive disorder. The following is a very simple guideline for management decisions.


Mild

  • Presentation: Minimum required symptoms are met for the diagnosis. The symptoms are distressing but manageable. There is minor impairment in functioning.

  • Management: Provide active monitoring (with PCM). Individual guided self-help interventions. Exercise, healthy diet, sleep hygiene, therapy.


Moderate

  • Presentation: The number, intensity, and functional impairment of symptoms is between mild and severe.

  • Management: Options include therapy alone, meds alone, or both depending on patient preference. Better evidence for combined psychotherapy and pharmacotherapy than either alone. 2


Mild-moderate depression can be treated by a PCP IF there is a collaborative care setting such as case management and a consulting mental health specialist. This model has improved outcomes as compared with usual care from PCP. 3


Severe:

  • Presentation: The number of symptoms are in substantial excess of the minimum required for diagnosis. Symptoms are distressing and unmanageable and has marked interference with functioning.

  • Management: Recommend antidepressant + psychotherapy. If refractory to multiple medication and psychotherapy trials consider medical augmentation strategies for treatment resistant depression, electroconvulsive therapy (ECT), or transcranial magnetic stimulation therapy (TMS). More in medication strategies and treatment resistant depression in the coming lessons.



Conclusion


I hope you enjoyed these clinical pearls. Today's lesson was geared towards a beginner/intermediate audience, but I hope all of the readers got something out of today's topic. Next we are going to cover mental status exam elements that are relevant to depressive disorders to improve your evaluation of patients as well as your documentation.


Resources for today's post include: Kaplan and Sadock's Synopsis of Psychiatry, DSM-V, and Pocket Psychiatry.



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