Clinical depression resident survival guide

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Clinical depression Resident Survival Guide Microchapters

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

Synonyms and keywords: Approach to depression, Approach to suicide, Suicide workup, Depression workup, Depression management


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 two or more weeks with at least 4 of the following features: sleep disturbances, loss of appetite/increased appetite, feeling guilty/worthless, loss of energy, loss of concentration, psychomotor retardation, or suicidal ideation.The pathophysiology of depression is not completely understood, but it is thought that decreased levels of monoaminergic neurotransmitters Dopamine, Serotonin and Nor-epinephrine are responsible for depressed 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 foster a positive rapport with the patient and help with sensitive matters. If needed, family and friends of the patient may be involved and cultural, social, and situational factors should be considered to diagnose triggering factors.


Life Threatening Causes

Life-threatening causes include conditions includes:

Common Causes


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
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 exaggeratedly 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

❑ 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



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 psychotic features, mania, hypomania

❑ Signs of co-morbid psychiatric conditions

❑ Unable to treat in primary care

❑ Need for psychosocial interventions

❑ Patient preference
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

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



❑ Full remission?

❑Continue current treatment to prevent relapse

❑ Possible long-term maintenance


Mild to Moderate Depression

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

Mild to moderate Depression
No response
No response
Change to anti-depressant
Partial Response
Change to anti-depressant
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


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


Severe Depression

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

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
Mechanism Name Dose Side effects
Selective Serotonin Reuptake Inhibitor
Tricyclic antidepressant
Norepinephrine Serotonin Reuptake Inhibitor

Non adrenaline and Specific Serotonin Inhibitor

Atypical antidepressant

Mono amine oxidase Inhibitors

Selective Serotonin Reuptake Inhibitor 20-40


  • If the patient has any suicidal ideation, the physician should ask if he/she has any plan to execute it or if he/she 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 long term and help them with medication adherence.


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


  1. NJC Andreasen (1972), "The role of religion in depression", Journal of Religion and Health, Springer
  2. Manev R, Manev H (2004). "5-Lipoxygenase as a putative link between cardiovascular and psychiatric disorders". Crit Rev Neurobiol. 16 (1–2): 181–6. doi:10.1615/critrevneurobiol.v16.i12.190. PMID 15581413.
  3. Alian S, Masoudzadeh A, Khoddad T, Dadashian A, Ali Mohammadpour R (2013). "Depression in hepatitis B and C, and its correlation with hepatitis drugs consumption (interfron/lamivodin/ribaverin)". Iran J Psychiatry Behav Sci. 7 (1): 24–9. PMC 3939977. PMID 24644496.
  4. Senior, Kathryn (1999). "Anecdotal link between mononucleosis and depression disproved". The Lancet. 353 (9148): 214. doi:10.1016/S0140-6736(05)77225-1. ISSN 0140-6736.
  5. White PD, Lewis SW (July 1987). "Delusional depression after infectious mononucleosis". Br Med J (Clin Res Ed). 295 (6590): 97–8. doi:10.1136/bmj.295.6590.97-a. PMC 1246972. PMID 3113655.
  6. Dayan CM, Panicker V (September 2013). "Hypothyroidism and depression". Eur Thyroid J. 2 (3): 168–79. doi:10.1159/000353777. PMC 4017747. PMID 24847450.
  7. Jehan S, Auguste E, Pandi-Perumal SR, Kalinowski J, Myers AK, Zizi F, Rajanna MG, Jean-Louis G, McFarlane SI (2017). "Depression, Obstructive Sleep Apnea and Psychosocial Health". Sleep Med Disord. 1 (3). PMC 5836734. PMID 29517078.
  8. Ledochowski M, Sperner-Unterweger B, Widner B, Fuchs D (June 1998). "Fructose malabsorption is associated with early signs of mental depression". Eur. J. Med. Res. 3 (6): 295–8. PMID 9620891.
  9. Marsh L (December 2013). "Depression and Parkinson's disease: current knowledge". Curr Neurol Neurosci Rep. 13 (12): 409. doi:10.1007/s11910-013-0409-5. PMC 4878671. PMID 24190780.
  10. Siegert RJ, Abernethy DA (April 2005). "Depression in multiple sclerosis: a review". J. Neurol. Neurosurg. Psychiatry. 76 (4): 469–75. doi:10.1136/jnnp.2004.054635. PMC 1739575. PMID 15774430.
  11. Skovlund CW, Mørch LS, Kessing LV, Lidegaard Ø (November 2016). "Association of Hormonal Contraception With Depression". JAMA Psychiatry. 73 (11): 1154–1162. doi:10.1001/jamapsychiatry.2016.2387. PMID 27680324.
  12. Abdel-Motleb M (October 2012). "The neuropsychiatric aspect of Addison's disease: a case report". Innov Clin Neurosci. 9 (10): 34–6. PMC 3508960. PMID 23198275.
  13. Paolucci S (February 2008). "Epidemiology and treatment of post-stroke depression". Neuropsychiatr Dis Treat. 4 (1): 145–54. doi:10.2147/ndt.s2017. PMC 2515899. PMID 18728805.
  14. Knouse LE, Zvorsky I, Safren SA (December 2013). "Depression in Adults with Attention-Deficit/Hyperactivity Disorder (ADHD): The Mediating Role of Cognitive-Behavioral Factors". Cognit Ther Res. 37 (6): 1220–1232. doi:10.1007/s10608-013-9569-5. PMC 4469239. PMID 26089578.
  15. Rao TS, Asha MR, Ramesh BN, Rao KS (April 2008). "Understanding nutrition, depression and mental illnesses". Indian J Psychiatry. 50 (2): 77–82. doi:10.4103/0019-5545.42391. PMC 2738337. PMID 19742217.
  16. 16.0 16.1 16.2 Gautam S, Jain A, Gautam M, Vahia VN, Grover S (January 2017). "Clinical Practice Guidelines for the management of Depression". Indian J Psychiatry. 59 (Suppl 1): S34–S50. doi:10.4103/0019-5545.196973. PMC 5310101. PMID 28216784.
  17. Kroenke K, Spitzer RL, Williams JB (September 2001). "The PHQ-9: validity of a brief depression severity measure". J Gen Intern Med. 16 (9): 606–13. doi:10.1046/j.1525-1497.2001.016009606.x. PMC 1495268. PMID 11556941.
  18. "The Mental Status Examination - Clinical Methods - NCBI Bookshelf".

CME Category:Psychiatry