Today we will cover elements of the mental status exam that are particularly important in depressive disorders. These are important clues that will help you with diagnosis as well as gauge treatment response. Let's get started.
Today's Content Level: Beginner; Intermediate
REMINDER OF THE MENTAL STATUS EXAM COMPONENTS
If you need a refresher on the mental status exam and a description of each component including important terms feel free to review here: Intro to Mental Status Exam.
•There is no one-size-fits-all when it comes to appearance and behavior of depressed patients.
•Many patients with depression are suffering on the inside but still able to present themselves as well-kept and presentable. On the other hand some patients with severe depression may lack the motivation and energy to bathe or properly groom and dress themselves or appear disheveled.
•Observe for evidence of self-harm such as cut marks, burns, or scars. This is commonly done on the forearms, however by no means limited to that area.
•Observe for noticeable evidence of weight loss or gain if seeing the patient serially.
•Generalized "psychomotor retardation" is often the most common symptom of depression seen in a mental status exam. What this means is you will see visible generalized slowing of movements and speech.
•Classically, a depressed patient has a stooped posture with few spontaneous movements, and a downcast gaze with minimal eye contact with the interviewer.
•At its most extreme, depression can present as grossly regressed behavior, not bathing, soiling themselves, and mute. Such patients are likely exhibiting catatonic behaviors and should be worked up for and treated as such.
•Some patients may appear slow and numb, however others may appear tearful and visually despondent.
•Some depressed patients present differently and actually have "psychomotor agitation" which is a term used to describe excessive motor activity associated with a feeling of inner tension. Behaviors seen include hand wringing, hair pulling, pulling of clothes, pacing, fidgeting, and inability to sit still.
SPEECH / LANGUAGE
•Many depressed patients have decreased rate and volume and variation in tone of speech. AKA slow, soft, and monotone. This is not always the case.
•Not unlike what can be seen in patients with the negative symptoms of schizophrenia discussed previously, severely depressed patients may have paucity of speech (alogia), which is a lack of unprompted speech. They may respond to questions with single words and exhibit delayed responses to questions. You may have to literally wait over a minute for them to respond to a question.
MOOD / AFFECT
•Patients will sometimes say their mood is "depressed" but just as common they will describe one of the many flavors of depression to include -> numb, hopeless, worthless, guilty, irritable, zombie-like, sad, exhausted, miserable, dark, dejected, paralyzed, drowning, heart-broken, bleak, etc...
•Depressed mood is obviously a key symptom, however it is important to realize that some patients deny depressed feelings and do not appear to be particularly depressed at first glance. Family members or employers often bring or send these patients for treatment because of social withdrawal, generally decreased activity, or other behaviors.
•The emotional range can vary but often tends to be blunted or constricted. Constricted is a mild reduction in the range and intensity of emotional expression. Blunted is a significant reduction and is a greater reduction than constricted. Flat is the complete absence of emotional expression which is more common in schizophrenia but can also be seen in very severe depression.
•While a reduced emotional range is classic in depression, some patients show more lability and have rapid and abrupt shifts in affective expression such as appearing numb one moment and then crying hysterically the next.
•The word dysphoric is used to describe a negative mood state that is less extreme than depression. It is the experience of feeling discontent and, in some cases, indifference to the world. This is commonly seen as a lifelong pattern in patients with persistent depressive disorder (PDD).
•Depressed patients can sometimes be guarded, which means filtering their emotional expression and using caution in disclosing information.
THOUGHT PROCESS / THOUGHT CONTENT
•Depressed patients often have negative views of themselves and of the world.
•Thought content often includes perseverations (non delusional ruminations) about negative themes to include guilt, loss, death, and suicide.
•Clearly described in your documentation the extent of their suicidal (and homicidal) thoughts and include their specific thoughts, their intent, plans, research, preparatory actions, etc... This will weigh heavily in your risk assessment and safety plan. We will discuss this in depth in a later article.
•Not as common as in psychotic or bipolar disorders, but some patients with severe depression have marked symptoms of a thought disorder. According to Kaplan and Sadock about 10% of all depressed patients have marked symptoms of a thought disorder, usually thought blocking and profound poverty of thought. 1
•Depressed patients with delusions or hallucinations are said to have a major depressive episode with psychotic features.
•Mood-congruent delusions/hallucinations are consistent with a depressed mood and include themes of failure, guilt, sinfulness, worthlessness, poverty, persecution, and terminal illnesses. Mood-incongruent delusions/hallucinations might involve grandiose themes, exaggerated power, knowledge, and worth. If this happens then consider a psychotic based illness.
•Commonly obtained through a general sense of cognitive functioning obtained through conversation, however additional tests (MMSE, MoCA) can expand this exam if needed.
•Most depressed patients are oriented to person, place, and time although some may not have sufficient energy or interest to answer questions about these subjects during an interview.
•Over half of patients with depression have a resultant cognitive impairment and can include impaired memory, learning, executive function, concentration, and processing speed. 2 Such patients commonly complain of impaired concentration and forgetfulness.
INSIGHT / JUDGEMENT
•Does the patient attribute their symptoms to a mental disorder? Are they unconvinced of a problem?
•Depressed patients' descriptions of their disorder often overemphasize their symptoms, their disorder, and their life problems. It can be difficult to convince such patients that improvement is possible.
•Judgment is best assessed by reviewing patients' actions in the recent past and their behaviors during the interview.
Nice work today. We covered some important factors regarding the mental status exam in patients with depression. Next lesson will be a review quiz because spaced repetition learning is critical to our success. After that we will provide a framework for the medical/laboratory workup for depression including when and what to order.
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