Clinical depression resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S.

Overview

Depression often leads to poor quality of life and impaired functioning.Clinical depression is defined as loss of interest (anhedonia) and/or depressed mood for 02 or more weeks with atleast 4 of the following features such as, sleep disturbances, loss of appetite/increased appetite,feeling guilty/worthless,loss of energy, loss of concentration,psychomotor retardation, suicidal ideation.The pathophysiology of depression is not incompletely understood.But it is thought that decreased levels of monoaminergic neurotransmitters like Dopamine, Serotonin and Nor-epinephrine are responsible for low mood. When a patient with depressed mood comes to primary care a detailed psychiatric interview is important to evaluate the psychiatric symptoms and assess the effect of symptoms on functioning of the patient.A physician is required to give the patient enough time to build a good doctor-patient relationship and to establish an effective therapeutic alliance with the patient and a physician should give attention to matters of a sensitive nature.If needed family and friends of the patient may be involved and cultural, social, and situational factors should be considered to diagnose the triggering factors as well.

Causes

Life Threatening Causes

Life-threatening causes include conditions includes:

Common Causes

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Clinical Depression[16][17][18]

 
 
 
 
 
 
Patient with Clinical Depression
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Take complete history
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Do initial screening
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Screening and ask about previous 2 weeks:

Over the past 2 weeks how often have you been bothered by any of the following problem?
1.Little interest or pleasure in doing things
2.Feeling down, depressed or hopeless
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Repeat Screening Annually
 
 
 
 
 
 
 
Ask the following questions about last 2 weeks:

❑ Do you feel low/ hopeless or sad?

❑Have you lost interest/pleasure in doing things you used to like

❑Have you noticed any changes in body weight recently( weight gain/ weight loss)

❑Is there any sleep disturbances? Is there any trouble falling or staying asleep, or sleeping too much

❑Do you feel guilty about anything?Do you Feel bad about yourself—or that you are a failure or have let yourself or your family down

❑Do you feel tired/ fatigued most of the time of the day?

❑Can you concentrate on usual work? Are you having trouble concentrating on things, such as reading the newspaper or watching television

❑Have you noticed any changes in appetite?

❑ Have you been moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual

❑Have you had any thoughts of death and/or suicide, suicide planning, or a suicide attempt
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
General Physical Examination:

❑ Look for thyroid swelling
❑Look for symptoms of malnutrition and specific nutritional deficiency
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform mental status examination:

Level of consciousness: See if patient reacts to stimuli

Appearance and general behavior:Look for patient's physical appearance, grooming (clean/untidy or dishevelled appearance), dress (subdued/riotous), posture (erect/kyphotic)

Speech and motor activity:Ask them open-ended questions and check if there is any word-finding difficulties, or the rapid and pressured speech, tics or unusual mannerisms,Look for slowness and loss of spontaneity in movement,Look for akathisia or motor restlessness

Affect and mood:Look for restricted, labile, or flat affect

Thought and Perception: Evaluate how the patient perceives and responds to stimuli. Does the patient harbor realistic concerns, or are these concerns elevated to the level of irrational fear? Is the patient responding in exaggerated fashion to actual events, or is there no discernible basis in reality for the patient's beliefs or behavior? Look for illusions, Hallucinations

Attitude and Insight:See if the patient gets angry, aggressive,hostile, overdramatic,helpless during interview

Cognitive abilities:Attention,Language,Memory,Constructional ability and praxis,Abstract reasoning
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Establish a diagnosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Differential diagnosis by ruling out secondary depression
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rule out Bipolar disorder, Premenstrual dysphoric disorder
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assessment:

❑ Assess the severity of the disease
❑Evaluate if the person can harm himself/herself and others:Current suicidal ideations,Past history of suicidal attempts, Severity of suicide attempt,Ask if they have any specific plan about suicide or homicide
❑Ask about any comorbid drug or substance use/dependence

❑Assess their personality
❑Assess their level of functioning: Ask if there is any work dysfunction
❑Do detailed Physical examination to rule out any disease that can contribute to depression
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask about previous treatment history:

❑ Ask if they have any past medical illness
❑Ask if they take any medications

❑Ask about response to any prior treatment of depression (if they recieved any treatment earlier)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assessment of the caregiver:

❑ Evaluate if they understand the nature of the disease and have enough knowledge about it
❑impact of the illness on them
❑Their beliefs regarding treatment
 
 
 


Treatment

Shown below is an algorithm summarizing the treatment of Clinical depression:


Abbreviations: ECT: Electroconvulsive Therapy,MAOI= Monoamine oxidase Inhibitor, TCA= Tricyclic Antidepressant,SSRI= Selective Serotonin Reuptake Inhibitor


 
 
 
 
 
 
Presumptive diagnosis of Clinical Depression
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine the level of severity and functional impairment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is referral to mental health care indicated?:

❑Unclear diagnosis
❑Evidence of psychosit features, mania, hypomania
❑Signs of co-morbid psychiatric conditions

❑Unable to treat in primary care
❑Need for psychosocial interventions
❑Patient preference
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Discuss Treatment Options and patient's preferences
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Refer to Mental health specialty care
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initiate treatment according to severity and follow-up in 1-2 weeks
Severity PHQ-9 ScoreFunctional impairmentInitial treatment
Mild10-14MildMonotherapy-Antidepressant or psychotherapy; or possibly combination of both
Moderate15-19ModerateAntidepressant or psychotherapy; or possibly combination of both
Severe>/=20SevereMay start with Antidepressant or psychotherapy but prefer combination of both
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Follow up in 2 weeks:

❑Symptoms improved
❑Treatment is well-tolerated and no side-effects
❑Patient is adhering to treatment

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
No
 
Modify treatment:

❑Increase dose
❑Augmentation of the medication
❑Switch to another agent

❑Combine psychotherapy and pharmacotherapy
❑Somatic intervention
❑Inpatient/residential treatment

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑Continue current treatment
❑Re-assess in 4-6 weeks
 
 
 
 
 
 
 
Some indications for inpatient care:

❑Presence of suicidal ideation
❑Refusal to eat or drink
❑Severe malnutrition

❑Presence of psychiatric conditions or other general medical comorbidity that make outpatient treatment unsafe or ineffective
Catatonia

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluate:

❑Full remission?
❑Continue current treatment to prevent relapse
❑Possible long-term maintenance

 
 
 
 
 
 
 
 
 
 
 


The algorithm below shows the management plan in brief in case of mild, moderate and severe depression:

 
 
 
 
 
 
Mild to moderate Depression
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Remission
 
Psychotherapy
 
 
 
 
 
 
Pharmacotherapy
 
Remission
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No response
 
 
 
 
 
 
 
 
 
 
 
 
No response
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Change to Anti-depressant
 
Partial Response
 
 
 
 
 
 
 
Change to Anti-depressant OR, Switch to psychotherapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Optimize the treatment:

❑Increase frequency of psychotherapy
❑Give maximum tolerable doses of the anti depressant

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Change or give Combination therapy:

❑If patient is getting psychotherapy: Add antidepressant
❑If patient is recieving antidepressant:Add psychotherapy or Change the anti depressant

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Augmentation/Combination:

❑If patient is recieving antidepressant:Add a second antidepressant OR augment the medication depending on tolerability and side effects

 
 
 
 
 
 
 
 
 
 
 
 

The algorithm below shows the management plan in brief in case of severe depression:


 
 
 
 
 
 
Severe Depression
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess the patient:

❑Ask about patient's preference of treatment
❑Past history of good response to treatment of ECT
❑Recieving other treatment or high risk of drug interaction
❑High risk of suicide
❑Refuse to eat or Drink
❑Has catatonic features
❑Has other features of psychosis
❑Non responding to any other treatment

 
 
 
 
 
 
 
 
Assess the patient:

❑Ask about patient's preference of treatment
❑Past history or family history of good response to treatment of ECT
❑Low risk of drug interaction
❑High risk of suicide

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ECT+Pharmacotherapy
 
 
 
 
 
 
 
 
Pharmacotherapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No response
 
Partial response
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Optimize the treatment:

❑Give the maximum tolerable doses of the antidepressant

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No further response:

❑Switch to a different antidepressant from same or different pharmalogical class
❑Add ECT
❑Add a second anti depressant
❑Augment the medication

 


Medications used to treat Depression:[16]

Medications used to treat Depression
Name Dose Side effects
Selective Serotonin Reuptake Inhibitor
*Fluoxetine
*Paroxetine
*Fluvoxamine
*Sertaline
*Citalopram
*Escitalopram

20-80
20-60
50-300
50-200
20-40
10-20
Sexual dysfuncyion, GI disturbances, Weight loss/gain, insomnia, anxiety
Tricyclic antidepressant
*Amitriptyline
*Doxepin
*Imipramine
Clomipramine

50-200
75-300
75-300
75-300
Sexual dysfunction,Anticholinergic effect,drowsiness,Weight gain,conduction abnormality.
Norepinephrine Serotonin Reuptake Inhibitor
*Venlafaxine
*Duloxetine
*Milnacipran
*Desvenlafaxine

75-300
20-60
50-200
Mild anticholinergic effect,drowsiness,GI distress.
Non adrenaline and Specific Serotonin Inhibitor
*Mitrazapine

15-45
Mild anticholinergic effect,drowsiness,GI distress |
Atypical antidepressant
*Trazodone
*Nefazodone

150-300
100-300
Anticholinergic effect,drowsinessWeight gain,conduction abnormality.
Mono amine oxidase Inhibitors
*Phenelzine
*Isocarboxazid
Tranylcypromine

45-90
30-60
20-60
orthostatic hypotension, headache,insomnia,drowsiness
Vilazodone 20-40 Diarrhoea,nausea,vomiting,insomnia

Do's

  • If the patient has any suicidal ideation, the physician should ask about if he has any plan to execute it or if he has any previous attempts.If they have any specific plan,admit the patient.
  • If any patient tells they want to hurt someone,the physician should inform that person as well as to police authority.
  • Be empathetic to the patient and listen to them.
  • Motivate them to continue the treatment for long term and help them with medication adherence

Don'ts

  • Do not let the patient stay alone and do not keep firearms if they are suicidal.

References

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CME Category:Psychiatry


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