Background
The word depression is both a psychiatric diagnosis and a common term used to
describe varying degrees of unhappiness. It is important for the GMO to be able to
distinguish common anger, frustration, disgruntlement, dysphoria, or fatigue from clinical
depression with attendant neurovegetative signs and symptoms. Patients may present
complaining of depression who are merely reacting temporarily to environmental stressors
such as long work hours, separation from their families, personal illness, etc. Another
group of patients who complain of depression have chronic, intermittent depressive
symptoms of a characteristic nature; their habitual feelings of boredom, emptiness,
worthlessness, low self-esteem, or irritability are due to personality disorders, which
are Axis II diagnoses.
Medications and Organic Conditions
Patients may present with depressive symptoms while taking medications or other
substances that cause depression (alcohol, propranolol, clonidine, benzodiazepines,
antihistamines, illicit drugs) or who are withdrawing from stimulants (caffeine, nicotine,
OTC cold/flu preparations, amphetamines, other illicit drugs, etc.). Finally, depressive
feelings may be related to an underlying organic factor such as hypothyroidism or another
endocrinologic disorder, occult malignancy, or early dementia or another organic brain
syndrome.
Diagnosis of Major Depressive Episode (MDE)
To make a presumptive diagnosis of MDE, at least 5 of the following must
be present most or all of the time during the same 2-week period.
To qualify for the diagnosis of MDE, these symptoms must not be the
direct physiological effect of substances (intoxications or withdrawal) or of a general
medical condition (such as hypothyroidism). They must also not be experienced only in the
first 2 months following the loss of a loved one, as in bereavement. Patients sometimes
exaggerate their depressive symptoms in order to gain sympathy or some desired change in
their environment. Your best criterion for ruling out exaggerated depressive symptoms as
well as those due to characterologic or situational factors, is noting the unremitting
presence of the symptoms. If a patients depressive symptoms remit while on liberty
or leave, or when removed from the source of distress, then he or she probably does not
have MDE.
Physical Exam and lab studies
Focus the mental status examination on the following areas:
-
Quality of speech/thought content centered on feelings of hopeless, helpless, guilt, and
suicidal or homicidal thoughts
The general physical exam should include a neurologic examination and
should focus on signs consistent with hypothyroidism, intoxication, withdrawal, and occult
malignancy. Routine screening labs should include Chem
1, CBC, RPR, UA, urine toxicology
screen, and thyroid function tests
(TFTs). A baseline EKG may be indicated for patients
over age 40.
Treatment
Simple supportive measures should be prescribed for those patients not meeting
criteria for MDE: discontinuation of stimulants or depressants, regular sleep, eating
regular healthy meals, relaxation, regular exercise, and obtaining social support from
peers, friends, and family members. Patients who meet criteria for MDE, who are suicidal,
or who continue to complain of depression despite implementation of conservative measures
as described, should be referred for psychiatric evaluation. In cases in which referral to
a psychiatrist will be delayed, or when symptoms are so severe that initiating an
antidepressant is judged to be prudent, the GMO is advised to begin treatment with a
selective serotonin reuptake inhibitor (SSRI) such as Prozac, Zoloft, or Paxil.
Homicidal or Suicidal Ideation
When evaluating a patient referred for depression, document the presence
or absence of concomitant psychotic thought processes, such as delusions, and the presence
or absence of suicidal or homicidal ideation. If a patient expresses suicidal or homicidal
ideation with a workable plan and intent, he or she should be placed on a 1:1 watch until
evaluated by psychiatry or until the intent clearly resolves. Treat psychoses with
neuroleptics such as Haldol.
Reference
-
The American Psychiatric Press Synopsis of Psychiatry
, edited by Robert Hales and
Stuart
Yudofsky, published by American Psychiatric Press, Washington, DC, 1996.