Clinical depression resident survival guide

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. Dementia is defined as a decline in cognition which is significant enough to interfere with independent, daily functioning.It is characterized by a decline in one or more cognitive domains like learning and memory, executive function, language, complex attention, perceptual-motor, social cognition.

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
  • Ongoing major health problems
    • Rape
    • Sexual difficulties
    • Trauma
    • Work-related stress
• 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.
  • Mononucleosis
  • Hypothyroidism
  • Sleep apnea
  • Fructose malabsorption
  • Parkinson disease
  • Multiple Sclerosis
  • Hormonal contraception
  • Steroids
  • Addison's disease
  • Syphilis
  • Post- stroke
  • Thyrotoxicosis
  • Diabetes Mellitus
• Attention-Deficit/Hyperactivity Disorder (ADHD)
• Dietary
  • Alcohol
  • Poor diet:deficiency of vitamins, minerals, and omega-3 fatty acids
• Seasonal Affective Disorder:Due to production of excessive melatonin
• Postpartum Depression
• Drugs:
  • 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

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

Record the vitals: ❑ Blood pressure ❑ Weight ❑Body Mass Index ❑ Waist circumference

Perform mental status examination: ❑Level of consciousness: See if patient reacts to stimuli ❑ Appearance and general behavior:Look for patient's physical appearance, grooming (clean/untidy or dishevelled appearance), dress (subdued/riotous), posture (erect/kyphotic) ❑Speech and motor activity:Ask them open-ended questions and check if there is any word-finding difficulties, or the rapid and pressured speech, tics or unusual mannerisms,Look for slowness and loss of spontaneity in movement,Look for akathisia or motor restlessness ❑Affect and mood:Look for restricted, labile, or flat affect ❑ Thought and Perception: Evaluate how the patient perceives and responds to stimuli. Does the patient harbor realistic concerns, or are these concerns elevated to the level of irrational fear? Is the patient responding in exaggerated fashion to actual events, or is there no discernible basis in reality for the patient's beliefs or behavior? Look for illusions, Hallucinations ❑ Attitude and Insight:See if the patient gets angry, aggressive,hostile, overdramatic,helpless during interview ❑Cognitive abilities:Attention,Language,Memory,Constructional ability and praxis,Abstract reasoning

Establish a diagnosis

Differential diagnosis by ruling out secondary depression

Rule out Bipolar disorder, Premenstrual dysphoric disorder

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

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 ❑Evidence of psychosit features, mania, hypo-mania ❑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 Score Functional impairment Initial treatmentt Mild 10-14 Mild Monotherapy-Antidepressant or psychotherapy; or possibly combination of both Moderate 15-19 Moderate Antidepressant or psychotherapy; or possibly combination of both Severe >/=20 Severe May start with Antidepressant or psychotherapy but prefer combination of both

Do's

• The content in this section is in bullet points.

Don'ts

• The content in this section is in bullet points.