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Depression               nishitarumizu 2000.9.1

Overview:

Lifetime risk 7% to 12% for men, 20% to 25% for women.
As many as two-thirds of the people suffering from depression do not realize that they have a treatable illness and do not seek treatment.
Clinical depression commonly occurs concurrently with other medical illnesses and worsens the prognosis for these illnesses.

Tip-offs for depression in a primary care setting:

May include fatigue, somatic complaints (such as headache, backache, chest pain,
dyspepsia, and limb pain), anxiety symptoms, depressed mood, or insomnia.

Risk factors

female (especially post partum), history of depressive illness in
first-degree relatives, prior episodes of major depression, prior suicide attempts,
age <40 years, medical comorbidity, decreased social support, stressful life events,
and current substance or alcohol abuse.

Symptoms can be divided into:

  1. Emotional. Dysphoria, irritability, anhedonia, withdrawal.
  2. Cognitive. Self-criticism, sense of worthlessness or guilt, hopelessness,
    poor concentration, memory impairment, delusions or hallucinations.
  3. Vegetative. Fatigue, decreased energy, insomnia, hypersomnia, anorexia,
    psychomotor retardation or agitation, impaired libido.

Diagnosis:

Depression is often difficult to diagnose because it can manifest in many different forms. Depression is a holistic disorder, affecting body, feelings, thoughts and behaviors.

In addition to Depressed mood or Anhedonia ( loss of interest or pleasure ),
five or more of the following symptoms have been present during the same
two week period: ESCAP-GS

E nergy decreased
S leep disturbance (classically , early awakening ; or may sleep longer than usually)
C oncentration disturbance
A ppetite disturbance (increased or decreased; with or without weight loss)
P sychomotor changes
G uilt (self-deplication, feelings of worthlessness)
S uicidal thinking

Depressed mood is neither necessary nor sufficient for a diagnosis of depression.

Barriers to diagnosis:

  Patient Barriers
   Somatic Presentations
   Stigma
  Clinician barriers
   Pandora’s Box
   Normal feature
At least 50% of depressed patients are either undetected or are not adequately
treated by primary care providers.

Evaluation:

History:
  May use Beck Depression Scale , Zung Depression Scale, or Geriatric Depression   
  Scale to screen for high-risk patients. If depressive symptoms are present,    
  determine:
a. Time course and severity.
b. Any prior episodes and level of recovery.
c. Any history of manic or hypomanic episodes. 
d. If other major psychiatric disorders are present.
e. Any suicidal ideation, plan, or intent.
Examination:
  Evaluate for possible related medical conditions: anemia, hypothyroidism, chronic infection,
  substance abuse, or medication side effects (oral contraceptives,antihypertensives, etc.).

Causes of organic depressions
 Type                     Specific  Cause
   Drugs                 corticosteroids,contraceptives,reserpine, antibiotics
                                alpha-methyldopa,anticholinestherase, cimetidine
                                ranitidine, indomethacin, phenothiazines, thallium
                                mercury, cyclosporine, vincristine, vinblastine
   Drug withdrawal  amphetamine, cocaine
   Infection            Tertiary syphillis, influenza, AIDS, viral pneumoniae
                                Viral hepatitis, infectious mononucleosis, Tb
   Endocrine            Hypothyroidism, apathetic hyperthyroidism,
                                Hyperparathyroidism, postpartum and menses-related,
                                Cushing’s disease, adrenal insufficiency
   Collagen             SLE, RA, vasculitis
   Neurologic           MS, Parkinson’s disease, head trauma
                                Complex partial seizures, CNS tumors, stroke,
                                Early dementia, sleep apnea
   Nutritional          Vitamine deficiencies (B12, C, folate, niacin, thiamine)
   Neoplastic           Pancreatic cancer, disseminated carccinomatosis
   Others                Renal Failure,Liver Failure, Alcohol/Substance Abuse

Lab tests:

  Screen for medical causes of depression (if suspected by Hx or Pex)
  Complete blood count (CBC)
  Electrolytes, including calcium, phosphate, magnesium
  BUN and Creatinine
  Calcium
  Serum toxicology screen
  TSH level
  CT or MRI of brain
  Electrocardiogram (ECG), Electroencephalogram (EEG)

Physical:

Psychomotor retardation or agitation, such as slowed speech, sighs, and long pauses
Slowed body movements, even to the extent of motionlessness or catatonia
Pacing, handwringing and pulling on hair
Preoccupation
Lack of eye contact
Tearfulness
Self-deprecatory manner
Memory loss, poor concentration and poor abstract reasoning

Consultations:

  Psychiatry should be consulted after a screening evaluation is complete and all acute medical
  complications are addressed.

Treatment :

Treatment is effective in at least 70% of cases.

 Communicating with depressed patients
   Empathy
 Presenting the diagnosis
   “These symptoms indicate to me that you are suffering from depression.”
   It can be helpful to then add a couple of additional symptoms not mentioned by the patient.
   It is helpful to explain depression as a common biological disorder.
   Drawing a picture of a synapse and neurotransmitters may be helpful.
   Depression is a curable illness.
 Counseling by the physician
  SPEAK approach
    Schedule
    Pleasurable activities
    Exercise
    Assertiveness
    Kind thoughts about onself
 Psychotherapy cognitive therapy behavioral therapy
 Medication:
    Most antidepressants believed to be equally effective in equivalent therapeutic doses.
    Expect a 2- to 6- week latent period before the full effect is seen at therapeutic doses.
    To prevent relapse, continue medication for at least 4 to 9 months after patient becomes
    asymptomatic. For recurrent depression, consider chronic prophylactic therapy.
    If at 6 weeks a patient shows no response or a poor response to an adequate dose of
    antidepressant medication , treatment should be changed.
  Tricyclic antidepressants (TCAs).
     Choose between them based on patient's sedation requirements and ability to tolerate
     orthostatic hypotension, weight gain, and anticholinergic adverse effects TCAs are usually
     given QHS to take advantage of sedating effects. All TCAs may cause slowing of cardiac
     conduction. May be fatal in overdoses around 2000 mg or more in adults. A therapeutic trial
     usually is considered >100 mg/day of amitriptyline or its equivalent for at least 3 weeks.
     Note: Nortriptyline (Pamelor) has a "therapeutic window" plasma level of 50 to 150 ng/ml for
        optimal efficacy. It has the lowest risk for orthostatic hypotension of all TCAs making it
        a safe choice in the geriatric patient.
  Selective serotonin reuptake inhibitors (SSRIs)
     Much safer in overdose than TCAs. Expensive in contrast to generic TCAs. Initial dose often
     an effective dose. May need to start at lower doses in the elderly of others sensitive to side
     effects. Side effects vary and may include nausea, anorexia, insomnia or mild sedation,
     sweating, headache, tremor, sexual dysfunction, and nervousness. Fluvoxamine is
     contraindicated with astemizole and terfenadine. All SSRIs contraindicated with MAOIs. If
     switching from a SSRI to a MAOI, need a drug-free period of 14 days for paroxetine,
     sertraline or fluvoxamine or 5 weeks for fluoxetine.
  Monoamine oxidase inhibitors (MAOIs)
     Sometimes used in depression refractory to the other treatments. Consider consulting
     psychiatrist before starting because of the serious adverse effect potential.
  St. John’s wort
     For short-term treatment of mild acute depression. Equally effective.
     Induction of the cytochrome P450 system.
  Psychostimulants
     Methylphenidate(Ritalin)
       They take effect very quickly(<24h)
       Provide a relatively quick test of whether antidepressants are likely to be effective.
  Electroconvulsive therapy.
    ECT is the most effective, rapid method of treating severe major depressive disorder (MDD).
    Indicated for patients with poor response to medications, poor tolerance of usual
    antidepressants, severe vegetative symptoms, or psychotic features. The decision to
    administer ECT should be made by a psychiatrist.



Figure. Adverse effects of selective serotonin reuptake inhibitors (striped bars) and tricyclic antidepressants (white bars).

REFERENCE

Pharmacologic Treatment of Acute Major Depression and Dysthymia  Ann Intern Med. 2000; 132: 738-742
Behavioral Medicine in Primary Care A Practical Guide 1st.ed.
Assessing and Managing Depression in the Terminally ill Patients. Ann Intern Med. 2000; 132: 209-218