Clinical depression resident survival guide: Difference between revisions
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The algorithm below shows the management plan in brief in case of severe depression: | The algorithm below shows the management plan in brief in case of severe depression: | ||
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{| class="wikitable" style="margin: 1em auto 1em auto" | {| class="wikitable" style="margin: 1em auto 1em auto" | ||
|+ '''Medications used to treat Depression''' | |+'''Medications used to treat Depression''' | ||
! Name || Dose || Side effects | !Name||Dose||Side effects | ||
|- | |- | ||
|'''Selective Serotonin Reuptake Inhibitor'''<br> *Fluoxetine <br> *Paroxetine<br>*Fluvoxamine<br> *Sertaline<br> *Citalopram <br>*Escitalopram|| <br> 20-80<br>20-60<br>50-300<br>50-200<br>20-40<br>10-20<br> || Sexual dysfuncyion, GI disturbances, Weight loss/gain, insomnia, anxiety | |'''Selective Serotonin Reuptake Inhibitor'''<br> *Fluoxetine <br> *Paroxetine<br>*Fluvoxamine<br> *Sertaline<br> *Citalopram <br>*Escitalopram||<br> 20-80<br>20-60<br>50-300<br>50-200<br>20-40<br>10-20<br>||Sexual dysfuncyion, GI disturbances, Weight loss/gain, insomnia, anxiety | ||
|- | |- | ||
| '''Tri-cyclic antidepressant'''<br>*Amitriptyline<br>*Doxepin<br>*Imipramine<br>Clomipramine|| <br>50-200<br>75-300<br>75-300<br>75-300<br> ||Sexual dysfunction,Anticholinergic effect,drwosiness,Weight gain,conduction abnormality. | |'''Tri-cyclic antidepressant'''<br>*Amitriptyline<br>*Doxepin<br>*Imipramine<br>Clomipramine||<br>50-200<br>75-300<br>75-300<br>75-300<br>||Sexual dysfunction,Anticholinergic effect,drwosiness,Weight gain,conduction abnormality. | ||
|- | |- | ||
| '''Norepinephrine Serotonin Reuptake Inhibitor'''<br>*Venlafaxine<br>*Duloxetine<br>*Milnacipran<br>*Desvelnafaxine|| <br>75-300<br>20-60<br>50-200 ||Mild anticholinergic effect,drwosiness,GI distress. | |'''Norepinephrine Serotonin Reuptake Inhibitor'''<br>*Venlafaxine<br>*Duloxetine<br>*Milnacipran<br>*Desvelnafaxine||<br>75-300<br>20-60<br>50-200||Mild anticholinergic effect,drwosiness,GI distress. | ||
|- | |- | ||
| '''Non adrenaline and Specific Serotonin Inhibitor'''<br> *Mitrazapine|| <br>15-45 ||Mild anticholinergic effect,drwosiness,GI distress| | |'''Non adrenaline and Specific Serotonin Inhibitor'''<br> *Mitrazapine||<br>15-45|| Mild anticholinergic effect,drwosiness,GI distress | | ||
|- | |- | ||
| '''Atypical antidepressant'''<br>*Trazodone<br>*Nefazodone || <br>150-300<br>100-300 ||Anticholinergic effect,drowsiness,Weight gain,conduction abnormality. | |'''Atypical antidepressant'''<br>*Trazodone<br>*Nefazodone||<br>150-300<br>100-300||Anticholinergic effect,drowsiness,Weight gain,conduction abnormality. | ||
|- | |- | ||
| '''Mono amine oxidase Inhibitors'''<br>*Phenelzine<br>*Isocarboxazid<br>Tranylcypromine || <br>45-90<br>30-60<br>20-60 || orthostatic hypotension, headache,insomnia,drowsiness | |'''Mono amine oxidase Inhibitors'''<br>*Phenelzine<br>*Isocarboxazid<br>Tranylcypromine||<br>45-90<br>30-60<br>20-60||orthostatic hypotension, headache,insomnia,drowsiness | ||
|- | |- | ||
|'''Vilazodone''' || 20-40 || Diarrhea,nausea,vomiting,insomnia | |'''Vilazodone'''||20-40||Diarrhea,nausea,vomiting,insomnia | ||
|} | |} | ||
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*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 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. | *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== | ==Don'ts== |
Revision as of 10:32, 25 September 2020
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S.
Overview
The first sentence of the overview must contain the name of the disease.
Causes
Life Threatening Causes
Life-threatening causes include conditions includes:
- Major depressive disorder with suicidal ideation
Common Causes
- 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[1]
- Ongoing major health problems
- Medical Conditions
- Cardiovascular disease[2]
- Hepatitis[3]:There is a high prevalence of depression in patients with hepatitis B and hepatitis C infection, especially those who are on interferon therapy.
- Mononucleosis[4][5]
- Hypothyroidism[6]
- Sleep apnea[7]
- Fructose malabsorption[8]
- Parkinson disease[9]
- Multiple Sclerosis [10]
- Hormonal contraception[11]
- Steroids
- Addison's disease[12]
- Syphilis
- Post- stroke[13]
- Thyrotoxicosis
- Diabetes Mellitus
- Attention-Deficit/Hyperactivity Disorder (ADHD)[14]
- Dietary
- Seasonal Affective Disorder:Due to production of excessive melatonin
- Postpartum Depression
- Drugs:[16]
- 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
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? ❑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 ❑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 | |||||||||||||||||||||||||
Do basic investigations: ❑ Haemoglobin ❑Blood sugar ❑ Lipid levels ❑Liver funstion test ❑Renal function test ❑Thyroid function test ❑Urine pregnancy test(If required) | |||||||||||||||||||||||||
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 treatrment, | |||||||||||||||||||||||
Treatment
Shown below is an algorithm summarizing the treatment of Clinical depression:
Presumptive diagnosis of Clinical Depression | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Determine the level of severity and functional impairment | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Is referral to mental health care indicated?: ❑Unclear diagnosis ❑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
| |||||||||||||||||||||||||||||||||||||
Follow up in 2 weeks: ❑Symptoms improved | |||||||||||||||||||||||||||||||||||||
Yes | No | Modify treatment: ❑Increase dose | |||||||||||||||||||||||||||||||||||
❑Continue current treatment ❑Re-assess in 4-6 weeks | Some indications for inpatient care: ❑Presence of suicidal ideation | ||||||||||||||||||||||||||||||||||||
Yes | |||||||||||||||||||||||||||||||||||||
Evaluate: ❑Full remission? | |||||||||||||||||||||||||||||||||||||
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 | |||||||||||||||||||||||||||||||||||||||||||||
Change or give Combination therapy: ❑If patient is getting psychotherapy: Add antidepressant | |||||||||||||||||||||||||||||||||||||||||||||
Augmentatio/Combinationn: ❑If patient is recieving anti depressant:Add a second anti depressant 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 | Assess the patient: ❑Ask about patient's preference of treatment | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
ECT+Pharmacotherapy | Pharmacotherapy | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No response | Partial response | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Optimize the treatment: ❑Give the maximum tolerable doses of the anti depressant | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No further response: ❑Switch to a different anti depressant from same or different pharmalogical class | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Medications used to treat Depression:[16]
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 |
Tri-cyclic antidepressant *Amitriptyline *Doxepin *Imipramine Clomipramine |
50-200 75-300 75-300 75-300 |
Sexual dysfunction,Anticholinergic effect,drwosiness,Weight gain,conduction abnormality. |
Norepinephrine Serotonin Reuptake Inhibitor *Venlafaxine *Duloxetine *Milnacipran *Desvelnafaxine |
75-300 20-60 50-200 |
Mild anticholinergic effect,drwosiness,GI distress. |
Non adrenaline and Specific Serotonin Inhibitor *Mitrazapine |
15-45 |
|
Atypical antidepressant *Trazodone *Nefazodone |
150-300 100-300 |
Anticholinergic effect,drowsiness,Weight gain,conduction abnormality. |
Mono amine oxidase Inhibitors *Phenelzine *Isocarboxazid Tranylcypromine |
45-90 30-60 20-60 |
orthostatic hypotension, headache,insomnia,drowsiness |
Vilazodone | 20-40 | Diarrhea,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
- ↑ NJC Andreasen (1972), "The role of religion in depression", Journal of Religion and Health, Springer
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Dayan CM, Panicker V (September 2013). "Hypothyroidism and depression". Eur Thyroid J. 2 (3): 168–79. doi:10.1159/000353777. PMC 4017747. PMID 24847450.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 16.0 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.
- ↑ 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.
- ↑ "The Mental Status Examination - Clinical Methods - NCBI Bookshelf".