Clinical depression resident survival guide: Difference between revisions

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{{WikiDoc CMG}}; {{AE}} {{RAB}}
{{WikiDoc CMG}}; {{AE}} {{RAB}}


{{SK}}
{{SK}} Approach to depression, Approach to suicide, Suicide workup, Depression workup, Depression management
==Overview==
==Overview==
[[Depression]] often leads to poor quality of life and impaired functioning.[[Clinical depression]] is defined as loss of [[Interest (emotion)|interest]] ([[anhedonia]]) and/or [[Depressed Mood|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|energy,]] loss of [[concentration]],[[psychomotor retardation]], [[suicidal ideation]].The [[pathophysiology]] of [[depression]] is not incompletely understood.But it is thought that decreased  levels of  [[Neurotransmitter|monoaminergic neurotransmitter]]<nowiki/>s like [[Dopamine]], [[Serotonin]] and [[Norepinephrine|Nor-epinephrine]] are responsible for low [[mood]]. When a patient with [[Depression|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 psychology|cultura]]<nowiki/>l, [[Social Practice|social]], and situational factors should be considered to diagnose the triggering factors as well.
[[Depression]] often leads to poor quality of life and impaired functioning. [[Clinical depression]] is defined as loss of [[Interest (emotion)|interest]] ([[anhedonia]]) and/or [[Depressed Mood|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|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  [[Neurotransmitter|monoaminergic neurotransmitter]]<nowiki/>s [[Dopamine]], [[Serotonin]] and [[Norepinephrine|Nor-epinephrine]] are responsible for depressed [[mood]]. When a patient with [[Depression|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 psychology|cultura]]<nowiki/>l, [[Social Practice|social]], and situational factors should be considered to diagnose triggering factors.


==Causes==
==Causes==
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===Common Causes===
===Common Causes===


*[[Genetic|Genetic Predisposition]]
*[[Genetic|Genetic predisposition]]
*Life Experiences
*Life experiences
**[[Divorce]] or the end of a serious relationship
**[[Divorce]] or the end of a serious relationship
**[[Eating disorders]]
**[[Eating disorders]]
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***[[Psychological trauma|Trauma]]
***[[Psychological trauma|Trauma]]
***[[Workplace stress|Work-related stress]]
***[[Workplace stress|Work-related stress]]
*Medical Conditions
*Medical conditions
**[[Cardiovascular disease]]<ref name="pmid15581413">{{cite journal |vauthors=Manev R, Manev H |title=5-Lipoxygenase as a putative link between cardiovascular and psychiatric disorders |journal=Crit Rev Neurobiol |volume=16 |issue=1-2 |pages=181–6 |date=2004 |pmid=15581413 |doi=10.1615/critrevneurobiol.v16.i12.190 |url= |issn=}}</ref>
**[[Cardiovascular disease]]<ref name="pmid15581413">{{cite journal |vauthors=Manev R, Manev H |title=5-Lipoxygenase as a putative link between cardiovascular and psychiatric disorders |journal=Crit Rev Neurobiol |volume=16 |issue=1-2 |pages=181–6 |date=2004 |pmid=15581413 |doi=10.1615/critrevneurobiol.v16.i12.190 |url= |issn=}}</ref>
**[[Hepatitis]]<ref name="pmid24644496">{{cite journal |vauthors=Alian S, Masoudzadeh A, Khoddad T, Dadashian A, Ali Mohammadpour R |title=Depression in hepatitis B and C, and its correlation with hepatitis drugs consumption (interfron/lamivodin/ribaverin) |journal=Iran J Psychiatry Behav Sci |volume=7 |issue=1 |pages=24–9 |date=2013 |pmid=24644496 |pmc=3939977 |doi= |url= |issn=}}</ref>:There is a high prevalence of [[depression]] in patients with [[hepatitis B]] and [[hepatitis C]] infection, especially those who are on [[Interferon]] [[therapy]].
**[[Hepatitis]]<ref name="pmid24644496">{{cite journal |vauthors=Alian S, Masoudzadeh A, Khoddad T, Dadashian A, Ali Mohammadpour R |title=Depression in hepatitis B and C, and its correlation with hepatitis drugs consumption (interfron/lamivodin/ribaverin) |journal=Iran J Psychiatry Behav Sci |volume=7 |issue=1 |pages=24–9 |date=2013 |pmid=24644496 |pmc=3939977 |doi= |url= |issn=}}</ref>:<br>There is a high prevalence of [[depression]] in patients with [[hepatitis B]] and [[hepatitis C]] infection, especially those who are on [[Interferon]] [[therapy]].
**[[Mononucleosis]]<ref name="Senior1999">{{cite journal|last1=Senior|first1=Kathryn|title=Anecdotal link between mononucleosis and depression disproved|journal=The Lancet|volume=353|issue=9148|year=1999|pages=214|issn=01406736|doi=10.1016/S0140-6736(05)77225-1}}</ref><ref name="pmid3113655">{{cite journal |vauthors=White PD, Lewis SW |title=Delusional depression after infectious mononucleosis |journal=Br Med J (Clin Res Ed) |volume=295 |issue=6590 |pages=97–8 |date=July 1987 |pmid=3113655 |pmc=1246972 |doi=10.1136/bmj.295.6590.97-a |url= |issn=}}</ref>
**[[Mononucleosis]]<ref name="Senior1999">{{cite journal|last1=Senior|first1=Kathryn|title=Anecdotal link between mononucleosis and depression disproved|journal=The Lancet|volume=353|issue=9148|year=1999|pages=214|issn=01406736|doi=10.1016/S0140-6736(05)77225-1}}</ref><ref name="pmid3113655">{{cite journal |vauthors=White PD, Lewis SW |title=Delusional depression after infectious mononucleosis |journal=Br Med J (Clin Res Ed) |volume=295 |issue=6590 |pages=97–8 |date=July 1987 |pmid=3113655 |pmc=1246972 |doi=10.1136/bmj.295.6590.97-a |url= |issn=}}</ref>
**[[Hypothyroidism]]<ref name="pmid24847450">{{cite journal |vauthors=Dayan CM, Panicker V |title=Hypothyroidism and depression |journal=Eur Thyroid J |volume=2 |issue=3 |pages=168–79 |date=September 2013 |pmid=24847450 |pmc=4017747 |doi=10.1159/000353777 |url= |issn=}}</ref>
**[[Hypothyroidism]]<ref name="pmid24847450">{{cite journal |vauthors=Dayan CM, Panicker V |title=Hypothyroidism and depression |journal=Eur Thyroid J |volume=2 |issue=3 |pages=168–79 |date=September 2013 |pmid=24847450 |pmc=4017747 |doi=10.1159/000353777 |url= |issn=}}</ref>
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*Dietary
*Dietary
**[[Alcohol]]
**[[Alcohol]]
**Poor [[Diet (nutrition)|diet]]:deficiency of  [[Vitamin|Vitamins]], [[Mineral|minerals]], and [[Omega-3 fatty acids|omega-3 fatty acid]]<nowiki/>s<ref name="pmid19742217">{{cite journal |vauthors=Rao TS, Asha MR, Ramesh BN, Rao KS |title=Understanding nutrition, depression and mental illnesses |journal=Indian J Psychiatry |volume=50 |issue=2 |pages=77–82 |date=April 2008 |pmid=19742217 |pmc=2738337 |doi=10.4103/0019-5545.42391 |url= |issn=}}</ref>
**Poor [[Diet (nutrition)|diet]]:<br>Deficiency of  [[Vitamin|vitamins]], [[Mineral|minerals]], and [[Omega-3 fatty acids|omega-3 fatty aci]]<nowiki/>[[Omega-3 fatty acids|d]]<nowiki/>s<ref name="pmid19742217">{{cite journal |vauthors=Rao TS, Asha MR, Ramesh BN, Rao KS |title=Understanding nutrition, depression and mental illnesses |journal=Indian J Psychiatry |volume=50 |issue=2 |pages=77–82 |date=April 2008 |pmid=19742217 |pmc=2738337 |doi=10.4103/0019-5545.42391 |url= |issn=}}</ref>
*[[Seasonal affective disorder|Seasonal Affective Disorder]]: Due to production of excessive [[melatonin]]
*[[Seasonal affective disorder|Seasonal Affective Disorder]]:
*Due to production of excessive [[melatonin]]
*[[Postpartum Depression]]
*[[Postpartum Depression]]
*Drugs:<ref name="pmid28216784">{{cite journal |vauthors=Gautam S, Jain A, Gautam M, Vahia VN, Grover S |title=Clinical Practice Guidelines for the management of Depression |journal=Indian J Psychiatry |volume=59 |issue=Suppl 1 |pages=S34–S50 |date=January 2017 |pmid=28216784 |pmc=5310101 |doi=10.4103/0019-5545.196973 |url= |issn=}}</ref>
*Drugs:<ref name="pmid28216784">{{cite journal |vauthors=Gautam S, Jain A, Gautam M, Vahia VN, Grover S |title=Clinical Practice Guidelines for the management of Depression |journal=Indian J Psychiatry |volume=59 |issue=Suppl 1 |pages=S34–S50 |date=January 2017 |pmid=28216784 |pmc=5310101 |doi=10.4103/0019-5545.196973 |url= |issn=}}</ref>
**[[Cardiovascular]] drugs:[[ACE inhibitor|ACEI]],[[Calcium channel blocker|Calcium Channel blockers]],[[Digitalis]],[[Clonidine]], [[Hydralazine]],[[Methyldopa|Methyl-dopa]], [[Procainamide]],[[Propranolol|Propanolol]],[[Thiazide]] and [[Diuretic|Zolamide diuretics]], [[Reserpine]]
**[[Cardiovascular]] drugs:<br>[[ACE inhibitor|ACEI]],[[Calcium channel blocker|Calcium Channel blockers]],[[Digitalis]],[[Clonidine]], [[Hydralazine]],[[Methyldopa|Methyl-dopa]], [[Procainamide]],[[Propranolol|Propanolol]],[[Thiazide]] and [[Diuretic|Zolamide diuretics]], [[Reserpine]]
**[[Antiparkinsonian|Anti-parkinsonian]] drugs: [[Levodopa]], [[Amantadine]], [[Bromocriptine]]
**[[Antiparkinsonian|Anti-parkinsonian]] drugs: <br>[[Levodopa]], [[Amantadine]], [[Bromocriptine]]
**[[Anticonvulsants|Anti-convulsants]]:[[Ethosuximide]], [[Phenobarbital]], [[Phenytoin]],[[Vigabatrin]],[[Tiagabine]]
**[[Anticonvulsants|Anti-convulsants]]:<br>[[Ethosuximide]], [[Phenobarbital]], [[Phenytoin]],[[Vigabatrin]],[[Tiagabine]]
**[[Anti-psychotic]]: [[Fluphenazine]],[[Haloperidol]]
**[[Anti-psychotic]]: <br>[[Fluphenazine]],[[Haloperidol]]
**[[Chemotherapeutics]]:[[Azathioprine]], [[Bleomycin]], [[Cisplatin]],[[Cyclophosphamide]], [[Vinblastine]], [[Vincristine]]
**[[Chemotherapeutics]]:<br>[[Azathioprine]], [[Bleomycin]], [[Cisplatin]],[[Cyclophosphamide]], [[Vinblastine]], [[Vincristine]]
**[[Stimulants]]: [[Amphetamine]] [[Withdrawal syndrome|withdrawal]], [[Cocaine]] [[Withdrawal syndrome|withdrawal]]
**[[Stimulants]]: <br>[[Amphetamine]] [[Withdrawal syndrome|withdrawal]], [[Cocaine]] [[Withdrawal syndrome|withdrawal]]
**[[AIDS antiretroviral drugs|Anti-retroviral]]:[[Atazanavir]][[Efavirenz|,Efavirenz]], [[Zidovudine]], [[Saquinavir]]
**[[AIDS antiretroviral drugs|Anti-retroviral]]:<br>[[Atazanavir]][[Efavirenz|,Efavirenz]], [[Zidovudine]], [[Saquinavir]]
**[[Sedative]] and [[anxiolytics]]: [[Barbiturate|Barbiturates]], [[Ethanol]], [[Benzodiazepine|Benzodiazepines]]
**[[Sedative]] and [[anxiolytics]]: <br>[[Barbiturate|Barbiturates]], [[Ethanol]], [[Benzodiazepine|Benzodiazepines]]


==Diagnosis==
==Diagnosis==
Shown below is an algorithm summarizing the diagnosis of [[Clinical depression|Clinical Depression]]<ref name="pmid28216784">{{cite journal |vauthors=Gautam S, Jain A, Gautam M, Vahia VN, Grover S |title=Clinical Practice Guidelines for the management of Depression |journal=Indian J Psychiatry |volume=59 |issue=Suppl 1 |pages=S34–S50 |date=January 2017 |pmid=28216784 |pmc=5310101 |doi=10.4103/0019-5545.196973 |url= |issn=}}</ref><ref name="pmid11556941">{{cite journal |vauthors=Kroenke K, Spitzer RL, Williams JB |title=The PHQ-9: validity of a brief depression severity measure |journal=J Gen Intern Med |volume=16 |issue=9 |pages=606–13 |date=September 2001 |pmid=11556941 |pmc=1495268 |doi=10.1046/j.1525-1497.2001.016009606.x |url= |issn=}}</ref><ref name="urlThe Mental Status Examination - Clinical Methods - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK320/ |title=The Mental Status Examination - Clinical Methods - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
Shown below is an algorithm summarizing the diagnosis of [[Clinical depression|Clinical Depression]]<ref name="pmid28216784">{{cite journal |vauthors=Gautam S, Jain A, Gautam M, Vahia VN, Grover S |title=Clinical Practice Guidelines for the management of Depression |journal=Indian J Psychiatry |volume=59 |issue=Suppl 1 |pages=S34–S50 |date=January 2017 |pmid=28216784 |pmc=5310101 |doi=10.4103/0019-5545.196973 |url= |issn=}}</ref><ref name="pmid11556941">{{cite journal |vauthors=Kroenke K, Spitzer RL, Williams JB |title=The PHQ-9: validity of a brief depression severity measure |journal=J Gen Intern Med |volume=16 |issue=9 |pages=606–13 |date=September 2001 |pmid=11556941 |pmc=1495268 |doi=10.1046/j.1525-1497.2001.016009606.x |url= |issn=}}</ref><ref name="urlThe Mental Status Examination - Clinical Methods - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK320/ |title=The Mental Status Examination - Clinical Methods - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
{{Family tree/start}}
{{Family tree/start}}
{{Family tree | | | | | | | A01 | | | |A01=Patient with Clinical [[Depression]]}}
{{Family tree | | | | | | | A01 | | | |A01=Patient with clinical [[depression]]}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B01 | | | |B01= Take complete history}}
{{Family tree | | | | | | | B01 | | | |B01= Take complete history}}
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{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 10em; width: 30em; padding:1em;"> '''[[Screening]] and ask about previous 2 weeks:'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 10em; width: 30em; padding:1em;"> '''[[Screening]] and ask about previous 2 weeks:'''<br>
----
----
  Over the past 2 weeks how often have you been bothered by any of the following problem?<br>1.Little interest or pleasure in doing things<br>2.Feeling down, [[Depress|depressed]] or hopeless</div>}}
  Over the past 2 weeks how often have you been bothered by any of the following problem?<br>1.Little interest or pleasure in doing things<br><br>2.Feeling down, [[Depress|depressed]] or hopeless</div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | |,|-|^|-|-|-|.| }}
{{Family tree | | | | | |,|-|^|-|-|-|.| }}
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{{Family tree | | | | | |A01| | | |B01 | | |A01=Yes|B01=No| | }}
{{Family tree | | | | | |A01| | | |B01 | | |A01=Yes|B01=No| | }}
{{Family tree | | | | | | | |!| | | |!| }}
{{Family tree | | | | | | | |!| | | |!| }}
{{Family tree | | | | | | | |!| | | |G01|G01= Repeat Screening Annually|| }}
{{Family tree | | | | | | | |!| | | |G01|G01= Repeat screening annually|| }}
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{Family tree/start}}
{{Family tree/start}}
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----
----
❑ Do you feel low/ hopeless or sad? <br><br>❑ Have you lost interest/pleasure in doing things you used to like <br><br>❑ Have you noticed any changes in body [[weight]] recently( [[weight gain]]/ [[weight loss]])<br><br>
❑ Do you feel low/ hopeless or sad? <br><br>❑ Have you lost interest/pleasure in doing things you used to like <br><br>❑ Have you noticed any changes in body [[weight]] recently( [[weight gain]]/ [[weight loss]])<br><br>
❑ Is there any [[sleep disturbances]]? Is there any trouble falling or staying asleep, or sleeping too much<br><br>❑ 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<br><br>❑ Do you feel [[tired]]/ [[Fatigue|fatigued]] most of the time of the day?<br><br>❑ Can you concentrate on usual work? Are you having trouble concentrating on things, such as reading the newspaper or watching television<br><br>❑ Have you noticed any changes in [[appetite]]?<br><br>❑ 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<br><br>❑ Have you had any thoughts of death and/or [[suicide]], [[suicide]] planning, or a [[suicide]] attempt</div>}}
❑ Is there any [[sleep disturbances]]? <br><br>❑ Is there any trouble falling or staying asleep, or sleeping too much<br><br>❑ 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<br><br>❑ Do you feel [[tired]]/ [[Fatigue|fatigued]] most of the time of the day?<br><br>❑ Can you concentrate on usual work? Are you having trouble concentrating on things, such as reading the newspaper or watching television<br><br>❑ Have you noticed any changes in [[appetite]]?<br><br>❑ 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<br><br>❑ Have you had any thoughts of death and/or [[suicide]], [[suicide]] planning, or a [[suicide]] attempt</div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
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{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 10em; width: 30em; padding:1em;"> '''General [[Physical Examination]]:'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 10em; width: 30em; padding:1em;"> '''General [[Physical Examination]]:'''<br>
----
----
  ❑ Look for [[thyroid]] [[swelling]]<br>❑ Look for symptoms of [[malnutrition]] and specific [[nutritional deficiency]]<br></div>}}
  ❑ Look for [[thyroid]] [[swelling]]<br><br>❑ Look for symptoms of [[malnutrition]] and specific [[nutritional deficiency]]<br><br></div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
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{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 15em; width: 30em; padding:1em;"> '''Record the [[Vital signs|vitals]]:'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 15em; width: 30em; padding:1em;"> '''Record the [[Vital signs|vitals]]:'''<br>
----
----
❑ [[Blood pressure]]<br> ❑ [[Weight]] <br>
❑ [[Blood pressure]]<br><br>❑ [[Weight]] <br><br>
❑ [[Body Mass Index]]<br> ❑ [[Waist|Waist circumference]]<br> </div>}}
❑ [[Body Mass Index]]<br><br>❑ [[Waist|Waist circumference]]<br><br> </div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{Family tree/start}}
{{Family tree/start}}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 45em; width: 30em; padding:1em;"> '''Perform [[mental status examination]]:'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 55em; width: 30em; padding:1em;"> '''Perform [[mental status examination]]:'''<br>
----
----
❑ '''Level of [[consciousness]]:''' See if patient reacts to stimuli<br><br> ❑ '''Appearance and general behavior''':Look for patient's physical appearance, grooming (clean/untidy or dishevelled appearance), dress (subdued/riotous), posture ([[erect]]/[[Kyphosis|kyphotic]]) <br><br> ❑'''[[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 <br><br> ❑ '''[[Affect]] and [[mood]]''':Look for restricted, labile, or [[flat affect]] <br><br> ❑ '''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]]<br><br> ❑ '''Attitude and Insight''':See if the patient gets angry, aggressive,hostile, overdramatic,helpless during interview<br> <br>❑ '''Cognitive abilities''':Attention,Language,Memory,Constructional ability and praxis,Abstract reasoning<br></div>}}
❑ '''Level of [[consciousness]]:<br>''' See if patient reacts to stimuli<br><br> ❑ '''Appearance and general behavior''':<br>
Look for patient's physical appearance, grooming (clean/untidy or dishevelled appearance), dress (subdued/riotous), posture ([[erect]]/[[Kyphosis|kyphotic]]) <br><br> ❑'''[[Speech]] and motor activity:<br>
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 <br><br> ❑ '''[[Affect]] and [[mood]]''':<br>
Look for restricted, labile, or [[flat affect]] <br><br> ❑ '''Thought and Perception''':<br>
Evaluate how the patient perceives and responds to stimuli. <br>
Does the patient harbor realistic concerns, or are these concerns elevated to the level of irrational fear? <br>
Is the patient responding exaggeratedly to actual events, or is there no discernible basis in reality for the patient's beliefs or behavior?<br>
Look for [[illusions]], [[hallucinations]]<br><br> ❑ '''Attitude and Insight''':<br>
See if the patient gets angry, aggressive,hostile, overdramatic,helpless during interview<br> <br>❑ '''Cognitive abilities''':<br>
Attention, language, memory, constructional ability and praxis, abstract reasoning<br></div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | A01 | | | |A01=Establish a diagnosis}}
{{Family tree | | | | | | | A01 | | | |A01=Establish a diagnosis}}
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{{Family tree | | | | | | | A01 | | | |A01=Differential diagnosis by ruling out secondary [[depression]]}}
{{Family tree | | | | | | | A01 | | | |A01=Differential diagnosis by ruling out secondary [[depression]]}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | A01 | | | |A01=Rule out [[Bipolar disorder]], [[Premenstrual dysphoric disorder]]}}
{{Family tree | | | | | | | A01 | | | |A01=Rule out [[bipolar disorder]], [[premenstrual dysphoric disorder]]}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{Family tree/start}}
{{Family tree/start}}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 25em; width: 30em; padding:1em;"> '''Assessment:'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 30em; width: 30em; padding:1em;"> '''Assessment:'''<br>
----
----
❑ Assess the severity of the [[disease]]<br>❑ Evaluate if the person can harm himself/herself and others:Current [[Suicidal ideation|suicidal ideations]],Past history of [[Suicidal behavior|suicidal attempts]], Severity of [[suicide]] attempt,Ask if they have any specific plan about [[suicide]] or [[Homicidal ideation|homicide]]<br>❑ Ask about any comorbid drug or [[Substance Abuse|substance use]]/dependence<br>
❑ Assess the severity of the [[disease]]<br><br>❑ Evaluate if the person can harm himself/herself and others:<br>
❑ Assess their personality<br>❑ Assess their level of functioning: Ask if there is any work dysfunction<br>❑ Do detailed Physical examination to rule out any disease that can contribute to [[depression]]<br></div>}}
Current [[Suicidal ideation|suicidal ideations]],past history of [[Suicidal behavior|suicidal attempts]], severity of [[suicide]] attempt.Ask if they have any specific plan about [[suicide]] or [[Homicidal ideation|homicide]]<br><br>❑ Ask about any comorbid drug or [[Substance Abuse|substance use]]/dependence<br><br>
❑ Assess their personality<br><br>❑ Assess their level of functioning: Ask if there is any work dysfunction<br><br>❑ Do detailed physical examination to rule out any disease that can contribute to [[depression]]<br><br></div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{Family tree/start}}
{{Family tree/start}}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 20em; width: 30em; padding:1em;"> '''Do basic investigations:'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 25em; width: 30em; padding:1em;"> '''Do basic investigations:'''<br>
----
----
❑ [[Haemoglobin]]<br>❑ [[Blood sugar]]<br>❑ [[Lipid|Lipid level]]s<br>❑ [[Liver function test]]<br>❑ [[Renal function tests|Renal function test]]<br>❑ [[Thyroid function test]]<br>❑ [[Pregnancy test|Urine pregnancy test]](If required)</div>}}
❑ [[Haemoglobin]]<br><br>❑ [[Blood sugar]]<br><br>❑ [[Lipid|Lipid level]]s<br><br>❑ [[Liver function test]]<br><br>❑ [[Renal function tests|Renal function test]]<br><br>❑ [[Thyroid function test]]<br><br>❑ [[Pregnancy test|Urine pregnancy test]](If required)<br><br></div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
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{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 15em; width: 30em; padding:1em;"> '''Ask about previous treatment history:'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 15em; width: 30em; padding:1em;"> '''Ask about previous treatment history:'''<br>
----
----
❑ Ask if they have any past medical illness<br>❑ Ask if they take any [[medication]]s<br><br>❑ Ask about response to any prior [[treatment]] of [[depression]] (if they recieved any treatment earlier)</div>}}
❑ Ask if they have any past medical illness<br><br>❑ Ask if they take any [[medication]]s<br><br>❑ Ask about response to any prior [[treatment]] of [[depression]] (if they recieved any treatment earlier)<br><br></div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{Family tree/start}}
{{Family tree/start}}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 10em; width: 30em; padding:1em;"> '''Assessment of the caregiver:'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 15em; width: 30em; padding:1em;"> '''Assessment of the caregiver:'''<br>
----
----
❑ Evaluate if they understand the nature of the [[disease]] and have enough knowledge about it <br>❑ Impact of the illness on them<br>❑ Their beliefs regarding [[treatment]]<br></div>}}
❑ Evaluate if they understand the nature of the [[disease]] and have enough knowledge about it <br> <br>❑ Impact of the illness on them<br><br>❑ Their beliefs regarding [[treatment]]<br><br></div>}}
{{familytree/end}}
{{familytree/end}}


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{{Family tree | | | | | | | B01 | | | |B01= Determine the level of severity and functional impairment||}}
{{Family tree | | | | | | | B01 | | | |B01= Determine the level of severity and functional impairment||}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 15em; width: 25em; padding:1em;"> '''Is referral to mental health care indicated?:'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 25em; width: 25em; padding:1em;"> '''Is referral to mental health care indicated?:'''<br>
----
----
❑ Unclear diagnosis <br>❑ Evidence of psychotic features, [[mania]], [[Hypomania|hypomania]] <br>❑ Signs of co-morbid [[psychiatric]] conditions<br>
❑ Unclear diagnosis <br><br>❑ Evidence of psychotic features, [[mania]], [[Hypomania|hypomania]] <br><br>❑ Signs of co-morbid [[psychiatric]] conditions<br><br>
❑ Unable to treat in primary care<br>❑ Need for [[psychosocial]] interventions<br>❑ Patient preference</div>}}
❑ Unable to treat in primary care<br><br>❑ Need for [[psychosocial]] interventions<br><br>❑ Patient preference</div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
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{{Family tree | | | |!| | | | | | | | | | | | | | | | | |!}}
{{Family tree | | | |!| | | | | | | | | | | | | | | | | |!}}
{{Family tree | | | |!| | | | | | | | | | | | | | | | | |!}}
{{Family tree | | | |!| | | | | | | | | | | | | | | | | |!}}
{{Family tree | | | |p09| | | | | | | | | | | | | | | |j09|j09= Refer to Mental health specialty care|p09= Discuss Treatment Options and patient's preferences|}}
{{Family tree | | | |p09| | | | | | | | | | | | | | | |j09|j09= Refer to mental health specialty care|p09= Discuss treatment options and patient's preferences|}}
{{Family tree | | | |!| | | | | | | | | | | | | | | | | |}}
{{Family tree | | | |!| | | | | | | | | | | | | | | | | |}}
{{familytree/start |summary=Sample 9}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=Sample 9}}{{familytree/start |summary=PE diagnosis Algorithm.}}
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<table class="wikitable">
<table class="wikitable">
<tr class="v-firstrow"><th>'''Severity '''</th><th>'''PHQ-9 Score'''</th><th>'''Functional impairment'''</th><th>'''Initial treatment'''</th></tr>
<tr class="v-firstrow"><th>'''Severity '''</th><th>'''PHQ-9 Score'''</th><th>'''Functional impairment'''</th><th>'''Initial treatment'''</th></tr>
<tr><td>Mild</td><td>10-14</td><td>Mild</td><td>'''[[Monotherapy]]-[[Antidepressant]] or [[psychotherapy]]; or possibly combination of both'''</td></tr>
<tr><td>Mild</td><td>10-14</td><td>Mild</td><td>'''[[Monotherapy]]-[[antidepressant]] or [[psychotherapy]]; or possibly combination of both'''</td></tr>
<tr><td>Moderate</td><td>15-19</td><td>Moderate</td><td>'''[[Antidepressant]] or [[psychotherapy]]; or possibly combination of both'''</td></tr>
<tr><td>Moderate</td><td>15-19</td><td>Moderate</td><td>'''[[Antidepressant]] or [[psychotherapy]]; or possibly combination of both'''</td></tr>
<tr><td>Severe</td><td>>/=20</td><td>Severe</td><td>'''May start with [[Antidepressant]] or [[psychotherapy]] but prefer combination of both'''</td></tr>
<tr><td>Severe</td><td>>/=20</td><td>Severe</td><td>'''May start with [[antidepressant]] or [[psychotherapy]] but prefer combination of both'''</td></tr>
</table>}}
</table>}}
{{Family tree | | | |!| | | | | }}
{{Family tree | | | |!| | | | | }}
{{Family tree | | | B01 |-|-|-|.| |B01=<div style="float: left; text-align: left; height: 15em; width: 10em; padding:1em;"> '''Follow up in 2 weeks:'''<br>
{{Family tree | | | B01 |-|-|-|.| |B01=<div style="float: left; text-align: left; height: 25em; width: 10em; padding:1em;"> '''Follow up in 2 weeks:'''<br>
----
----
❑ Symptoms improved <br>❑ Treatment is well-tolerated and no side-effects <br>❑ Patient is adhering to treatment<br>
❑ Symptoms improved <br><br>❑ Treatment is well-tolerated and no side-effects<br><br>❑ Patient is adhering to treatment<br><br>
</div> |}}
</div> |}}
{{Family tree | | | | |!| | | |!| }}
{{Family tree | | | | |!| | | |!| }}
{{Family tree | | | | A01 | | |)|-|p09|-|n09| | n09=<div style="float: left; text-align: left; height: 20em; width: 10em; padding:1em;"> '''Modify treatment:'''<br>
{{Family tree | | | | A01 | | |)|-|p09|-|n09| | n09=<div style="float: left; text-align: left; height: 30em; width: 10em; padding:1em;"> '''Modify treatment:'''<br>
----
----
❑ Increase [[dose]] <br>❑ Augmentation of the [[medication]] <br>❑Switch to another agent<br><br>❑ Combine [[psychotherapy]] and [[pharmacotherapy]]<br>❑ Somatic intervention<br>❑Inpatient/residential treatment
❑ Increase [[dose]] <br>❑ Augmentation of the [[medication]] <br><br>❑ Switch to another agent<br><br>❑ Combine [[psychotherapy]] and [[pharmacotherapy]]<br><br>❑ Somatic intervention<br><br>❑ Inpatient/residential treatment
</div> ||p09=No |A01=Yes}}
</div> ||p09=No |A01=Yes}}
{{Family tree | | | | |!| | | |!| | | | | |!|}}
{{Family tree | | | | |!| | | |!| | | | | |!|}}
{{Family tree | | | | B01 | | |!| | | |b09| |b09=<div style="float: left; text-align: left; height: 25em; width: 15em; padding:1em;"> '''Some indications for inpatient care:'''<br>
{{Family tree | | | | B01 | | |!| | | |b09| |b09=<div style="float: left; text-align: left; height: 25em; width: 15em; padding:1em;"> '''Some indications for inpatient care:'''<br>
----
----
❑ Presence of [[suicidal]] ideation <br>❑ Refusal to eat or drink <br>❑ Severe [[malnutrition]]<br><br>❑ Presence of [[Psychiatric|psychiatric]] conditions or other general medical comorbidity that make outpatient [[treatment]] unsafe or ineffective
❑ Presence of [[suicidal]] ideation <br><br>❑ Refusal to eat or drink <br><br>❑ Severe [[malnutrition]]<br><br>❑ Presence of [[Psychiatric|psychiatric]] conditions or other general medical comorbidity that make outpatient [[treatment]] unsafe or ineffective<br>
<br>❑ [[Catatonia]]<br>
<br>❑ [[Catatonia]]<br><br>
</div> |B01=❑ Continue current [[treatment]]<br>
</div> |B01=❑ Continue current [[treatment]]<br><br>
❑Re-assess in 4-6 weeks||}}
❑Re-assess in 4-6 weeks||}}
{{Family tree | | | | |!| | | |!| | | | | }}
{{Family tree | | | | |!| | | |!| | | | | }}
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{{Family tree | | | | B02 |-|-|'| | | | |B02=<div style="float: left; text-align: left; height: 15em; width: 10em; padding:1em;"> '''Evaluate:'''<br>
{{Family tree | | | | B02 |-|-|'| | | | |B02=<div style="float: left; text-align: left; height: 15em; width: 10em; padding:1em;"> '''Evaluate:'''<br>
----
----
❑ Full [[remission]]? <br>❑Continue current [[treatment]] to prevent [[relapse]]<br>❑ Possible long-term maintenance<br>
❑ Full [[remission]]? <br><br>❑Continue current [[treatment]] to prevent [[relapse]]<br><br>❑ Possible long-term maintenance<br><br>
</div>}}
</div>}}


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{{Family tree | | |!| | | |!| |!| | | | | | |!| |!| | |}}
{{Family tree | | |!| | | |!| |!| | | | | | |!| |!| | |}}
{{Family tree | | |!| | | |!| |!| | | | | | |!| |!| | | }}
{{Family tree | | |!| | | |!| |!| | | | | | |!| |!| | | }}
{{Family tree | | |!| |t09|-|p09        |-|-|-|-|^|-|r07 |r07=Change to [[Anti-depressant]] OR, Switch to [[psychotherapy]]|t09=Change to [[Anti-depressant]]|p09=Partial Response }}
{{Family tree | | |!| |t09|-|p09        |-|-|-|-|^|-|r07 |r07=Change to [[anti-depressant]]<br> OR <br>Switch to [[psychotherapy]]|t09=Change to [[anti-depressant]]|p09=Partial Response }}
{{Family tree | | |!| | | | | | |!| | | | | }}
{{Family tree | | |!| | | | | | |!| | | | | }}
{{Family tree | | |!| | | | | | |!| | | | | }}
{{Family tree | | |!| | | | | | |!| | | | | }}
{{Family tree | | |)|-|-|-|-| b09 | | | | | | | |b09=<div style="float: left; text-align: left; height: 15em; width: 15em; padding:1em;"> '''Optimize the [[treatment]]:'''<br>
{{Family tree | | |)|-|-|-|-| b09 | | | | | | | |b09=<div style="float: left; text-align: left; height: 15em; width: 15em; padding:1em;"> '''Optimize the [[treatment]]:'''<br>
----
----
❑ Increase frequency of [[psychotherapy]]<br>❑Give maximum tolerable doses of the [[Antidepressant|anti depressant]]<br>
❑ Increase frequency of [[psychotherapy]]<br><br>❑ Give maximum tolerable doses of the [[antidepressant|anti depressant]]<br><br>
</div> |}}
</div> |}}
{{Family tree | | |!| | | | | | |!| | | | | }}
{{Family tree | | |!| | | | | | |!| | | | | }}
{{Family tree | | |!| | | | | | |!| | | | | }}
{{Family tree | | |!| | | | | | |!| | | | | }}
{{Family tree | | |!| | | | | b09 | | | | | | | |b09=<div style="float: left; text-align: left; height: 15em; width: 15em; padding:1em;"> '''Change or give Combination therapy:'''<br>
{{Family tree | | |!| | | | | b09 | | | | | | | |b09=<div style="float: left; text-align: left; height: 20em; width: 15em; padding:1em;"> '''Change or give combination therapy:'''<br>
----
----
❑ If patient is getting [[psychotherapy]]: Add [[antidepressant]]<br>❑If patient is recieving [[Antidepressant|antidepressant]]:Add [[psychotherapy]] or Change the [[Antidepressant|anti depressant]]<br>
❑ If patient is getting [[psychotherapy]]: Add [[antidepressant]]<br><br>❑ If patient is recieving [[Antidepressant|antidepressant]]:<br>Add [[psychotherapy]] or change the [[Antidepressant|anti depressant]]<br><br>
</div> |}}
</div> |}}
{{Family tree | | |!| | | | | | |!| | | | | }}
{{Family tree | | |!| | | | | | |!| | | | | }}
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{{Family tree | | |`|-|-|-|-| b09 | | | | | | | |b09=<div style="float: left; text-align: left; height: 15em; width: 15em; padding:1em;"> '''Augmentation/Combination:'''<br>
{{Family tree | | |`|-|-|-|-| b09 | | | | | | | |b09=<div style="float: left; text-align: left; height: 15em; width: 15em; padding:1em;"> '''Augmentation/Combination:'''<br>
----
----
❑ If patient is recieving [[antidepressant]]:Add a second [[Antidepressant|antidepressant]] OR augment the medication depending on tolerability and side effects<br>
❑ If patient is recieving [[antidepressant]]:<br>Add a second [[Antidepressant|antidepressant]] <br>OR<br> augment the medication depending on tolerability and side effects<br><br>
</div> |}}
</div> |}}
{{familytree/end}}
{{familytree/end}}
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{{Family tree | | | | |,|-|-|^|-|-|-|-|-|-|-|.| | }}
{{Family tree | | | | |,|-|-|^|-|-|-|-|-|-|-|.| | }}
{{Family tree | | | | |!| | | | | | | | | | |!| | }}
{{Family tree | | | | |!| | | | | | | | | | |!| | }}
{{Family tree | | | | |p09| | | | | | | | |y09| |y09=<div style="float: left; text-align: left; height: 25em; width: 15em; padding:1em;"> '''Assess the patient:'''<br>
{{Family tree | | | | |p09| | | | | | | | |y09| |y09=<div style="float: left; text-align: left; height: 40em; width: 15em; padding:1em;"> '''Assess the patient:'''<br>
----
----
❑ Ask about patient's preference of [[treatment]]<br>❑ Past history or family history of good response to treatment of [[ECT]]<br>❑ Low  risk of drug interaction<br>❑ High risk of [[suicide]]<br>
❑ Ask about patient's preference of [[treatment]]<br><br>❑ Past history or family history of good response to treatment of [[ECT]]<br><br>❑ Low  risk of [[drug]] interaction<br><br>❑ High risk of [[suicide]]<br><br>
</div> |p09=<div style="float: left; text-align: left; height: 25em; width: 15em; padding:1em;"> '''Assess the patient:'''<br>
</div> |p09=<div style="float: left; text-align: left; height: 25em; width: 15em; padding:1em;"> '''Assess the patient:'''<br>
----
----
❑ Ask about patient's preference of [[treatment]]<br>❑ Past history of good response to treatment of [[ECT]]<br>❑ Recieving other [[treatment]] or high risk of drug interaction<br>❑ High risk of [[suicide]]<br>❑ Refuse to eat or Drink<br>❑ Has [[catatonic]] features<br>❑ Has other features of [[psychosis]]<br>❑ Non responding to any other [[treatment]]
❑ Ask about patient's preference of [[treatment]]<br><br>❑ Past history of good response to treatment of [[ECT]]<br><br>❑ Recieving other [[treatment]] or high risk of drug interaction<br><br>❑ High risk of [[suicide]]<br><br>❑ Refuse to eat or drink<br><br>❑ Has [[catatonic]] features<br><br>❑ Has other features of [[psychosis]]<br><br>❑ Non responding to any other [[treatment]]<br><br>
</div> |}}
</div> |}}
{{Family tree | | | | |!| | | | | | | | | | |!| | }}
{{Family tree | | | | |!| | | | | | | | | | |!| | }}
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{{Family tree | | | | |`|-|-|-|-|-|-|-|-|-|-|p09| |y09| |y09=Partial response |p09=No response }}
{{Family tree | | | | |`|-|-|-|-|-|-|-|-|-|-|p09| |y09| |y09=Partial response |p09=No response }}
{{Family tree | | | | | | | | | | | | | | | | | | | | |!|}}
{{Family tree | | | | | | | | | | | | | | | | | | | | |!|}}
{{Family tree | | | | | | | | | | | | | | | | | | | | |b09 | | | | | | | |b09=<div style="float: left; text-align: left; height: 15em; width: 15em; padding:1em;"> '''Optimize the [[treatment]]:'''<br>
{{Family tree | | | | | | | | | | | | | | | | | | | | |b09 | | | | | | | |b09=<div style="float: left; text-align: left; height: 10em; width: 15em; padding:1em;"> '''Optimize the [[treatment]]:'''<br>
----
----
❑ Give the maximum tolerable doses of the [[antidepressant]]<br>
❑ Give the maximum tolerable doses of the [[antidepressant]]<br>
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{{Family tree | | | | | | | | | | | | | | | | | | | | |!|}}
{{Family tree | | | | | | | | | | | | | | | | | | | | |!|}}
{{Family tree | | | | | | | | | | | | | | | | | | | | |!|}}
{{Family tree | | | | | | | | | | | | | | | | | | | | |!|}}
{{Family tree | | | | | | | | | | | | | | | | | | | | |p09| | p09=<div style="float: left; text-align: left; height: 15em; width: 15em; padding:1em;"> '''No further response:'''<br>
{{Family tree | | | | | | | | | | | | | | | | | | | | |p09| | p09=<div style="float: left; text-align: left; height: 25em; width: 15em; padding:1em;"> '''No further response:'''<br>
----
----
❑ Switch to a different [[antidepressant]] from same or different [[pharmalogical]] class<br>❑ Add [[ECT]]<br>❑ Add a second [[Antidepressant|anti depressant]]<br>❑ Augment the [[medication]]<br>
❑ Switch to a different [[antidepressant]] from same or different [[pharmalogical]] class<br><br>❑ Add [[ECT]]<br><br>❑ Add a second [[Antidepressant|anti depressant]]<br><br>❑ Augment the [[medication]]<br>
</div> ||}}
</div> ||}}
{{familytree/end}}
{{familytree/end}}
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*[[Paroxetine]]
*[[Paroxetine]]
*[[Fluvoxamine]]
*[[Fluvoxamine]]
*[[Sertaline]]
*[[Sertraline]]
*[[Citalopram]]
*[[Citalopram]]
*[[Escitalopram]]
*[[Escitalopram]]
Line 309: Line 320:
*[[Sexual dysfunction]]
*[[Sexual dysfunction]]
*[[Gastrointestinal tract|GI disturbances]]
*[[Gastrointestinal tract|GI disturbances]]
* [[Weight loss]]/gain
*[[Weight loss]]/gain
* [[Insomnia]]
*[[Insomnia]]
* [[Anxiety]]
*[[Anxiety]]
|-
|-
|'''[[Tricyclic antidepressant]]'''
|'''[[Tricyclic antidepressant]]'''
Line 343: Line 354:
|<br>  
|<br>  


* [[Mirtazapine]]
*[[Mirtazapine]]
|<br>15-45
|<br>15-45


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*Mild [[anticholinergic]] effect
*Mild [[anticholinergic]] effect
*[[Drowsiness]]
*[[Drowsiness]]
*[[GI|GI distress]]  
*[[GI|GI distress]]
|-
|-
|'''Atypical antidepressant'''
|'''Atypical antidepressant'''
Line 355: Line 366:


*[[Trazodone]]<br>
*[[Trazodone]]<br>
*[[Nefazodone]]|
*[[Nefazodone]]
|<br>150-300<br>100-300
|<br>150-300<br>100-300
|
|
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|
|
*[[Orthostatic hypotension]]
*[[Orthostatic hypotension]]
* [[Headache]]
*[[Headache]]
*[[Insomnia]]
*[[Insomnia]]
*[[Drowsiness]]
*[[Drowsiness]]
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|
|
*[[Vilazodone]]
*[[Vilazodone]]
|20-40||[[Diarrhea]], [[nausea]], [[vomiting]], [[insomnia]]
|20-40
|
*[[Diarrhea]]
*[[Nausea]]
*[[Vomiting]]
*[[Insomnia]]
|}
|}


==Do's==
==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 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.
*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.
*Be empathetic to the [[patient]] and listen to them.
*Motivate them to continue the [[treatment]] for the long term and help them with medication adherence
*Motivate them to continue the [[treatment]] long term and help them with [[medication]] adherence.


==Don'ts==
==Don'ts==


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


==References==
==References==
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[[Category:Resident survival guide]]
[[Category:Resident survival guide]]
[[Category:Psychiatry]]
[[Category:Psychiatry]]
 
[[Category:Needs English review]]
 
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Latest revision as of 10:07, 13 March 2021

Clinical depression Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts


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

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 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.

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 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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 psychotic 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

 
 
 
 
 
 
 
 
 
 
 

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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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

 
 
 
 
 
 
 
 
 
 
 
 

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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

Medications used to treat Depression:[16]

Medications used to treat Depression
Mechanism Name Dose Side effects
Selective Serotonin Reuptake Inhibitor
20-80
20-60
50-300
50-200
20-40
10-20
Tricyclic antidepressant
50-200
75-300
75-300
75-300
Norepinephrine Serotonin Reuptake Inhibitor

75-300
20-60
50-200
Non adrenaline and Specific Serotonin Inhibitor

15-45
Atypical antidepressant

150-300
100-300
Mono amine oxidase Inhibitors

45-90
30-60
20-60
Selective Serotonin Reuptake Inhibitor 20-40

Do's

  • 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.

Don'ts

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

References

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  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.
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  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.
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  18. "The Mental Status Examination - Clinical Methods - NCBI Bookshelf".

CME Category:Psychiatry