Depression
Key Feature 8: In a patient with depression, differentiate major depression from adjustment disorder, dysthymia, and a grief reaction. Skill: Clinical Reasoning, Selectivity Phase: Diagnosis Key Feature 9: Following failure of an appropriate treatment in a patient with depression, consider other diagnoses (ex: bipolar disorder, schizoaffective disorder, organic disease). Skill: Clinical Reasoning Phase: Diagnosis Key Feature 10: In the very young and elderly presenting with changes in behaviour, consider the diagnosis of depression (as they may not present with classic features). Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Elderly Key Feature 5: In older patients with diseases prone to atypical presentation, do not exclude these diseases without a thorough assessment (ex: pneumonia, appendicitis, depression). Skill: Selectivity, Clinical Reasoning Phase: Hypothesis generation, Diagnosis Many patients who present with depressed mood meet the DSM-V diagnostic criteria for Major Depressive Disorder, which are as follows:
NOTE: Responses to a significant loss (ex: bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual's history and the cultural norms for the expression of distress in the context of loss. The DSM-V diagnostic criteria for Major Depressive Disorder provides a footnote on differentiated grief from major depression, as follows: "In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in grief the predominant affect is feelings of emptiness and loss, while in MDE it is persistent depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of grief. These waves tend to be associated with thoughts or reminders of the deceased. The depressed mood of MDE is more persistent and not tied to specific thoughts or preoccupations. The pain of grief may be accompanied by positive emotions and humour that are uncharacteristic of the pervasive unhappiness and misery characteristic of MDE. The thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased, rather than the self-critical or pessimistic rumination seen in MDE. In grief, self-esteem is generally preserved, whereas in MDE feelings of worthlessness and self-loathing are common. If self-derogatory ideation is present in grief, it typically involves perceived failings vis-à-vis the deceased (ex: not visiting frequently enough, not telling the deceased how much he or he was loved). If a bereaved individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly about "joining" the deceased, whereas in MDE such thoughts are focused on ending one's own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression." The DSM-V diagnostic criteria for Persistent Depressive Disorder (Dysthymia) are as follows:
The DSM-V diagnostic criteria for Adjustment Disorders are as follows:
If a patient is diagnosed with depression, but does not respond well to therapy, this could be due to a failure of therapy to treat the depression, or it could also be that the treatment is not effective because the diagnosis is not accurate. Other diseases that can be incorrectly diagnosed as depression include bipolar disorder, schizoaffective disease, and organic disease (see my last blog post), as they may present first with an episode of major depression prior to the onset of other signs and symptoms that suggest an alternative diagnosis. The DSM-V diagnostic criteria for Bipolar Disorder I are as follows:
The DSM-V further states, "For a diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes." The DSM-V diagnostic criteria for Bipolar Disorder II are as follows:
The DSM-V diagnostic criteria for a Manic Episode are as follows:
The DSM-V diagnostic criteria for a Hypomanic Episode are as follows:
The DSM-V diagnostic criteria for Schizoaffective Disorder are as follows:
In summary, while I have outlined diagnostic criteria for multiple psychiatric diagnoses, the most important point here is to know how to diagnose Major Depressive Disorder as it is extremely common, to distinguish it from other common causes for depressed mood, and to consider other diagnoses that may present with depressed mood as part of their symptomatology prior to the emergence of the other symptoms that distinguish them from Major Depression.
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Priority Topic: Depression, Priority Topic: Immigrants, & Priority Topic: Rape/Sexual Assault7/7/2018 Depression
Key Feature 6: In a patient presenting with symptoms consistent with depression, consider and rule out serious organic pathology, using a targeted history, physical examination, and investigations (especially in elderly or difficult patients). Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 7: In patients presenting with depression, inquire about abuse:
Phase: History, Hypothesis generation Immigrants Key Feature 4b: As part of the ongoing care of all immigrants (particularly those who appear not to be coping): Inquire about a past history of abuse or torture. Skill: Clinical Reasoning Phase: History Rape/Sexual Assault Key Feature 7: Enquire about undisclosed sexual assault when seeing patients who have symptoms such as depression, anxiety, and somatization. Skill: Clinical Reasoning Phase: Hypothesis generation, History In my last post, I discussed the messy relationship between medical illness and depressed mood. Even if we will never be able to find a clear relationship that one necessarily preceded the other, and in this setting, whether it necessarily even led to the other, it is always important to rule out other medical conditions when evaluating someone for depressed mood, just as it is important to evaluate mood when providing care for other medical illness. Beyond the focused psychiatric history (including characterising mood, presence of other psychiatric syndromes such as anxiety or psychosis, and inquiring about predisposing, precipitating, perpetuating, and protecting factors*), it is important to do a general review of systems (screening for other symptoms they may be experiencing), review their medical history, the medications they take (including anything over the counter), and any substances they use (consider use or withdrawal from substances as a potential cause of depressed mood). Physical examination will be informed by the history. Consider cardiorespiratory and neurological examinations, among others. According to the UpToDate article, "Unipolar depression in adults: Assessment and diagnosis" the indications to order investigations are as follows:
*A factor that may contribute to depression and other mental health problems is a history of trauma, be it physical, sexual, emotional, or otherwise. This could have been something experienced by the person or a witnessed experience. It is important to ask about this when performing a mental health assessment (including screening for this in well-established primary care relationships, particularly in patients who are at increased risk, even in the absence of depression) along with a screen for other significant psychosocial factors that could be contributing. It is important to be aware of the fact that talking about trauma can be particularly traumatic in and of itself for patients, so patients may choose not to disclose information about a history of abuse. And that is okay. As the clinician, what's most important is that you've created space for the patient to share their experiences of trauma, so that if and when they are ready and want to share, you can try to help in their process of healing. Priority Topic: Depression, Priority Topic: Immigrants, & Priority Topic: Multiple Medical Problems7/6/2018 Depression
Key Feature 2: Screen for depression and diagnose it in high-risk groups (ex: certain socio-economic groups, those who suffer from substance abuse, postpartum women, people with chronic pain). Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 3: In a patient presenting with multiple somatic complaints for which no organic cause is found after appropriate investigations, consider the diagnosis of depression and explore this possibility with the patient. Skill: Clinical Reasoning, Patient Centered Phase: Hypothesis generation, Treatment Immigrants Key Feature 4a: As part of the ongoing care of all immigrants (particularly those who appear not to be coping): Screen for depression (i.e., because they are at higher risk and frequently isolated). Skill: Clinical Reasoning Phase: History Multiple Medical Problems Key Feature 3: In a patient with multiple medical complaints (and/or visits), consider underlying depression, anxiety, or abuse (ex: physical, medication, or drug abuse) as the cause of the symptoms, while continuing to search for other organic pathology. Skill: Clinical Reasoning Phase: Hypothesis generation I was tempted to tack these learning objectives into a previous blog that fit, partly due to the urge to be lazy, but also because they really do mesh with so many patient situations I encounter. In previous blog posts, I have discussed the power of the social determinants of health to influence health status, which of course includes mental health. I have also talked about the bidirectional influence of mood and chronic pain, and I have talked about the importance of screening for postpartum depression. Without being too much of a bummer, depression is really everywhere. Or, without being too heavy, and recognising that I am skewed by seeing a greater proportion of the population who may be at increased risk for mental health concerns given their history medical issues, perhaps it is better to say that it can be anywhere. Certainly not everyone is depressed, but almost every single person in their lives has risk factors for depression or anxiety. On the flip side, some people are extremely resilient, and managing to deke out this omnipresent state despite a significant number of risk factors can be truly remarkable. Nevertheless, I think it is important to recognise, as a family physician, that any of my patients may be at increased risk for poor mental health if they present with ongoing health concerns. I may be the one person in the medical field who they are in contact with to do so. I can't tell you the number of times patients have presented for bodily concerns and, once probed, reveal significant mood disturbance. After appropriate investigation for the other bodily concerns, depression, anxiety, or other psychiatric distress may in fact be the most likely etiology responsible for them. Alternatively, it could be a secondary to chronic physical discomfort, or it could be totally unrelated. In some patients, it may be all too intimately mumble-jumbled to really know. But does it matter? I would argue that it doesn't, and that whether it causes, contributes, results from, or is entirely separate from other somatic complaints, treating mental health concerns may have the possibility to alleviate or lessen the severity of other symptoms, or at the very least increase one's capacity to cope with them, and it deserves treatment as it's own disease process that decreases quality of life. It takes two seconds to ask, and patients are often so very honest. But yet clinicians often don't ask, at least when it is not their domain of care (ex: Emergency Room Physicians, Surgeons, Cardiologists, etc. etc. etc.). Partly, this makes sense. They are there to treat a specific issue and not the rest of the body. I can't imagine practicing medicine like that, although I appreciate specialists' commitment to ameliorating and improving the lives of the patients they serve in their way. As a Family Physician, screening and managing depression and anxiety, and other mental health concerns (ex: abuse, whether physical/emotional/sexual/financial etc. or self-inflicted such as via harmful use of prescribed or non-prescribed substances) is absolutely under my purview, and detecting and providing therapy for these issues could arguably be how I may have the greatest impact in my career given the prevalence of it. It is also intimately related to quality of life at least as much as any other disease process, and helping my patients achieve better quality of life is my purpose for doing what I do. UBC Objectives: Family Medicine, UBC Objectives: Mental Health, & Priority Topic: Depression1/18/2018 By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Key Feature 4: After a diagnosis of depression is made, look for and diagnose other co-morbid psychiatric conditions (ex: anxiety, bipolar disorder, personality disorder). Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 5: In a patient diagnosed with depression, treat appropriately:
Phase: Treatment, Follow-up At this point in my residency, I don't yet have a panel of patients I follow up with regularly. However, because I have a once-weekly callback shift in my home family clinic, I occasionally am lucky enough to be able to follow up with the patients I've seen there previously. Today, on my callback shift, the 19 year old female I previously wrote a previous post about who was having suicidal ideation returned to clinic for her followup appointment. I did not delve into the quality of this patient's depression in that last post, but her depression was largely of the seasonal affective variety. For most depressive disorders, first line treatment is antidepressant medication and/or psychotherapy. This major depressive disorder is of a unique subtype, however, in that first line therapy includes light therapy, a totally different modality of treatment. Other first-line recommendations include going for walks outside (even when cloudy), aerobic exercise, and having good sleep hygiene, the latter two of which would probably be useful first-line recommendations for any subtype of depression. See the UpToDate article, Seasonal affective disorder: Treatment (2017), for more information. This patient was already on a high-dose of an antidepressant and described feeling as though she wasn't getting relief from it (although she had been on it already for 4 years or so, so it was pretty hard to know for sure), I screened her for any other psychiatric symptoms suggesting an alternative diagnosis. She indeed did have anxiety, as she was frequently having panic attacks at night, but she denied ever having elevated or energetic periods in keeping with mania or hypomania, and she denied and on examination did not appear to have any symptoms or signs of psychosis, reducing the likelihood for having disorders associated with this such as schizophrenia or schizoaffective disorder. In my clinical opinion, it seemed as though the anxiety was largely interrelated with the depression, and since the treatment for both depression and anxiety are often similar, this didn't change too much about how we would develop a plan for her treatment. As this patient was characterised as having suicidal ideation in that previous post, you're probably wondering, just as I was when I saw her name on the dayshift, how she was doing in this regard in followup. At this visit, she was still feeling as depressed as at the last, but she was feeling stable in that her mood was not worsening, and she still did not have any intent of acting on her suicidal thoughts. And again, she didn't think she would feel like she was going to consider acting on her suicidal thoughts anytime in the near future. Phewf. And although her energy was low, at this appointment she was feeling open to giving new therapies a chance - she felt she had nothing to lose at this point. So we went as multi-faceted in our therapeutic approach as I can imagine any disease treatment can get. The plan was as follows:
I wrote out the above list with unchecked boxes in front of each item and gave it to her once we drew up this mutually agreed upon plan. I won't get into the details regarding the specifics of each treatment on that list, but the plan was more nuanced than this of course. For example, we came up with a specific plan that was tailored for her in terms of how she was going to include more aerobic exercise in her life over the next month, and we discussed strategies that she could use to promote good sleep hygiene. And they were all agreed upon in in keeping with SMART goal criteria (specific, measurable, achievable, realistic, timely). You may be thinking that this is an extensive to do list for anyone to followup on, let alone someone who is feeling depressed with all of the demotivation that can come along with that. Certainly it is. However, she was already on a high dose of an antidepressant and using light therapy optimally (so she was simply continuing as usual with these two therapies). She also had a previous positive experience with psychotherapy in the past, so the idea of this option was well-received. I would love to know how she is doing at her 4 week follow-up appointment, and if the stars align, I may be in clinic that day to reassess. Until then, it has been a great reminder of the ways in which I can incorporate a multifaceted approach to treatment of illness and restoration of function. By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Crisis Key Feature 2: Identify your patient’s personal resources for support (ex: family, friends) as part of your management of patients facing crisis. Skill: Patient Centered, Clinical Reasoning Phase: History, Treatment Key Feature 3: Offer appropriate community resources (ex: counselor) as part of your ongoing management of patients with a crisis. Skill: Patient Centered, Professionalism Phase: Treatment Key Feature 4: Assess suicidality in patients facing crisis. Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 8: Negotiate a follow-up plan with patients facing crisis. Skill: Clinical Reasoning, Communication Phase: Treatment, Follow-up Depression Key Feature 1a: In a patient with a diagnosis of depression: Assess the patient for the risk of suicide. Skill: Clinical Reasoning, Selectivity Phase: History Key Feature 1b: Decide on appropriate management (i.e., hospitalisation or close follow-up, which will depend, for example, on severity of symptoms, psychotic features, and suicide risk). Skill: Clinical Reasoning, Selectivity Phase: Treatment Suicide Key Feature 1: In any patient with mental illness (i.e., not only in depressed patients), actively inquire about suicidal ideation (ex: ideas, thoughts, a specific plan). Skill: Clinical Reasoning Phase: History Key Feature 2: Given a suicidal patient, assess the degree of risk (ex: thoughts, specific plans, access to means) in order to determine an appropriate intervention and follow-up plan (ex: immediate hospitalization, including involuntary admission; outpatient follow-up; referral for counselling). Skill: Clinical Reasoning, Selectivity Phase: Diagnosis, Treatment Key Feature 3: Manage low-risk patients as outpatients, but provide specific instructions for follow-up if suicidal ideation progresses/worsens (ex: return to the emergency department [ED], call a crisis hotline, re-book an appointment). Skill: Clinical Reasoning Phase: Treatment, Follow-up A 19 year old female presented to clinic for a yearly refill of her antidepressant. When I asked her what she takes it for, she said it was for depression and anxiety. She didn't elaborate. I probed further by asking how her mood has been lately. She said it had been worsening over the past month or so but again was brief in her answer. By around this point I started to clue in to the fact that not only were her answers minimally detailed, she was also slow to speak them (psychomotor retardation). I asked her if she was having thoughts about self-harming or suicide. She responded to say she was having suicidal thoughts. She denied any homicidal ideation. I asked her if she had thought of a plan for committing suicide, and without time to think she answered very matter-of-factly, "Yeah I think about hanging myself. When I was younger I used to think I'd want to drown, but now I think hanging makes the most sense." I asked if she's been thinking about going through with it, and she said, "There are all these deaths that seem to be happening around me, even like celebrities and whatnot, and I think to myself how those people have the courage to do what I haven't been able to. But then I think to myself how that's just a temporary solution to a bigger problem sort of thing." I didn't quite understand what she meant by her last sentence, but I was a little relieved to hear she had a protective thought. Just how at risk was this patient of completing suicide? In patients who endorse having suicidal thoughts, it's important to clarify
SADPERSONS mnemonic for risk-stratifying patients with suicidal ideation (1 pt for each if present)
According to the SADPERSONS suicidal ideation risk stratification mnemonic, this patient was low risk. Note that depression gives one point on the SADPERSONS scale, which is something important to note as it raises the point that suicidal ideation is not a phenomenon that is unique to patients with depression. According to the UpToDate article, "Suicidal ideation and behaviour in adults," "The psychiatric disorders most commonly associated with suicide include depression, bipolar disorder, alcoholism or other substance abuse, schizophrenia, personality disorders, anxiety disorders including panic disorder, posttraumatic stress disorders, and delirium." This article also notes, "Anxiety disorders more than double the risk of suicide attempts (odds ratio 2.2), and a combination of depression and anxiety greatly increases the risk (odds ratio 17). Symptoms of psychosis (delusions, command auditory hallucinations, paranoia) may increase the risk regardless of the specific diagnosis." Once you've got a patient in front of you who endorses suicidal ideation, what are your next steps? My approach to a patient that is risk-stratified for suicidal ideation (SI) as either low, medium, or high risk is as follows:
The 19 year old patient in the office agreed to follow-up in clinic in one week, agreed to avoiding triggers (aka precipitants) for her SI, and agreed to present to the ED or call a suicide crisis line before taking any action if she was having thoughts about completing suicide. The Canadian Association for Suicide Prevention website has a list of local crisis centres organized by province on their home page. I provide both the CSAP website address and the province-wide crisis line (1-800-SUICIDE) to patients at risk of SI. |
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