Priority Topic: Depression, Priority Topic: Immigrants, & Priority Topic: Rape/Sexual Assault

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:

1. Sexual, physical, and emotional abuse (past and current, witnessed or inflicted).
2. Substance abuse.

Skill: Clinical Reasoning, Patient Centered
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:

1. New onset depression (especially if the psychosocial context or precipitant is not clear)
2. Severe depression (particularly patients with melancholic or psychotic features)
3. Treatment-resistant depression

Commonly performed investigations in the otherwise asymptomatic person are as follows:

• Complete blood count
• Serum chemistry panels
• Urinalysis
• TSH
• B-hCG
• Urine tox screen
• Others as indicated by the history and physical examination

More extensive testing (ex: vitamin B12, folate, ECG) may be warranted based on an individual's risk factors, including having chronic medical conditions or being at increased risk for medical illnesses (this includes elderly or institutionalized patients and patients with self-neglect or substance use disorders). UpToDate also states, "Neuroimaging studies are typically reserved for patients whose evaluation suggests an increased likelihood of structural brain disease. These include focal neurologic signs on physical examination or persistent cognitive impairment. However, it is reasonable to obtain neuroimaging in older depressed patients, especially patients with new onset depression in later life."

*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.