Clinical depression resident survival guide
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.
Life Threatening Causes
Life-threatening causes include conditions includes:
- Genetic Predisposition
- Life Experiences
- Divorce or the end of a serious relationship
- Eating disorders
- Financial difficulties or poverty
- Gambling addiction
- Grief over the death of a child, spouse, other family member or friends.
- Job loss or unemployment
- Loss of religious faith
- Ongoing major health problems
- Medical Conditions
- Cardiovascular disease
- Hepatitis:There is a high prevalence of depression in patients with hepatitis B and hepatitis C infection, especially those who are on Interferon therapy.
- Sleep apnea
- Fructose malabsorption
- Parkinson disease
- Multiple Sclerosis 
- Hormonal contraception
- Addison's disease
- Post- stroke
- Diabetes Mellitus
- Attention-Deficit/Hyperactivity Disorder (ADHD)
- Seasonal Affective Disorder:Due to production of excessive melatonin
- Postpartum Depression
- Cardiovascular drugs:ACEI,Calcium Channel blockers,Digitalis,Clonidine, Hydralazine,Methyl-dopa, Procainamide,Propanolol,Thiazide and Zolamide diuretics, Reserpine
- Anti-parkinsonian drugs: Levodopa, Amantadine, Bromocriptine
- Anti-convulsants:Ethosuximide, Phenobarbital, Phenytoin,Vigabatrin,Tiagabine
- Anti-psychotic: Fluphenazine,Haloperidol
- Chemotherapeutics:Azathioprine, Bleomycin, Cisplatin,Cyclophosphamide, Vinblastine, Vincristine
- Stimulants: Amphetamine withdrawal, Cocaine withdrawal
- Anti-retroviral:Atazanavir,Efavirenz, Zidovudine, Saquinavir
- Sedative and anxiolytics: Barbiturates, Ethanol, Benzodiazepines
|Patient with Clinical Depression|
|Take complete history|
|Do initial screening|
|Repeat Screening Annually|
Ask the following questions about last 2 weeks:
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
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|
❑ Assess the severity of the disease
❑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
|Presumptive diagnosis of Clinical Depression|
|Determine the level of severity and functional impairment|
|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|
Follow up in 2 weeks:
|❑Continue current treatment|
❑Re-assess in 4-6 weeks
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 OR, Switch to psychotherapy|
The algorithm below shows the management plan in brief in case of severe depression:
Assess the patient:
❑Ask about patient's preference of treatment
|No response||Partial response|
- 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
- Do not let the patient stay alone and do not keep firearms if they are suicidal.
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