Download The Recognition and Management of Depression

Provider Education Tool
Looking Beyond the Obvious:
The Recognition and
Management of Depression
T
he purpose of this newsletter is to
provide a brief overview of depression,
including diagnosis and available treatment
options. Depression can affect people of
any age, race, religion, or gender. It can
present as a one-time occurrence or can
be a persistent condition throughout a
patient’s life. This often debilitating disease
affects not only the patient but also family
members, co-workers, and care givers.
This newsletter will briefly touch upon
some of the more important topics related
to depression, including symptoms and
treatment. The overall goal is to provide
the physician with the knowledge and
awareness needed to improve outcomes for
patients with depression.
The Burden of Depression
Every year, depression affects approximately
14.8 million Americans over the age of 18.1 It
also affects a large number of people under
the age of 18, and it is the leading cause
of disability among Americans between the
ages of 15 and 44 years of age.2 Depression
affects not only the patient but also the
patient’s family, loved ones, and care takers.
According to the most recent version of the
Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR), depression is more
common in women (prevalence of 10%
to 25%) than in men (prevalence of 5% to
12%).3 As the primary care physician may
be a patient’s only contact with the health
care system, it is important for the physician
to be able to effectively diagnose and treat
depression in adults.
Depression & Chronic Disease
Studies have found an increased risk of
depression among patients with chronic
diseases, such as diabetes, heart disease,
and COPD.4 Furthermore, depression can
have a negative impact on the severity and
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disability associated with a chronic illness.
It can be quite easy for a primary care
physician to miss the signs and symptoms of
depression when the main focus of an office
visit is the treatment of the chronic illness
itself. For the patient, depression can lead to
unnecessary pain and suffering, as well as
increased mortality and morbidity.
Diagnostic Criteria for Major
Depression
The diagnostic criteria for a single episode
of major depression requires that at least 5
of the following symptoms be present for at
least 2 weeks, and symptoms 1 or 2 must
be present.3
abuse or medication), a bipolar episode, or
bereavement.
Screening Instruments
There is a multitude of depression screening
instruments available that are both
sensitive and specific. Many are short, selfadministered questionnaires that can be
filled out by patients in the waiting room. In
general, they take 5-10 minutes to complete
and can be used as an initial screen or to
monitor patients for depression during
ongoing care. Several commonly used, selfadministered screening questionnaires
include:
`The
` Beck Depression Inventory (BDI)5
1. Depressed mood
`The
` Zung Self-Rating Depression Scale6
2. Diminished interest or pleasure in
all or almost all activities
`The
` Center for Epidemiologic Studies
Depression Scale, Revised (CES-DR)7
3. Significant change in appetite or
weight
4. Insomnia or hypersomnia
Additionally, a much briefer method used
to screen patients for depression is to ask
them the following 2 questions8:
5. Psychomotor agitation or
retardation
`Over
`
the past month, have you felt
down, depressed, or hopeless?
6. Fatigue or loss of energy
`Over
`
the past month, have you had little
interest or pleasure in doing things?
7. Feelings of worthlessness or
excessive guilt
8. Diminished ability to concentrate
9. Recurrent thoughts of death or
suicidal ideations, or a suicide
attempt
A diagnosis of depression also requires
that these symptoms occur for most of
the day, close to every day for a 2 week
period. Typically, these symptoms should
be associated with clinically significant
impairment of daily functioning, including
the ability to work or socialize. In addition,
these symptoms should not be associated
with any general medical disease (Graves’
disease), use of a substance (eg, drugs of
Utilization of these 2 questions can be a
stepping-off point from which a more indepth assessment and/or diagnosis of
depression can be made. A 3rd question that
has been shown to increase the detection
of depression when used with the above
mentioned 2 questions is: “Is this something
you feel you need help for?” It should be
noted that there are also assessment
tools available specifically designed for
adolescents and geriatric patients.
Differential Diagnosis
Symptoms of depression can overlap with
medical conditions, such as hypothyroidism
or dementia, as well as other psychiatric
illnesses. Furthermore, depression can be
associated with infections (eg, HIV/AIDS);
drug toxicity (eg, beta blockers); and vitamin
deficiencies (eg, niacin and B­12). Depression
is a component of bipolar disorder and
as such, additional assessments may
be necessary, since the two are treated
differently. A self-reported assessment tool
utilized for bipolar disorder is the Mood
Disorder Questionnaire.
Disease Severity
The severity of depression, like many
psychiatric illnesses, can vary across a wide
spectrum of clinical presentations from mild
to severe. The Hamilton Depression Rating
Scale (HAMD-7) is an assessment tool used
by clinicians to assess severity of disease
in patients with depression. It is also useful
in determining the efficacy of treatment or
incidence of remission when assessment is
conducted prior to and during treatment.
The HAMD previously consisted of 17
factors related to depression; however, a
modified version consisting of 7 factors
has been found to be just as efficient as
the lengthier version.9 The 7 factors of the
HAMD-7 include:
1. Depressed mood
2. Feelings of guilt
3. Interest, pleasure, and levels of
work
4. Tension or nervousness
5. Physical symptoms of anxiety
6. Energy levels
7. Suicidal thoughts, plans, or
attempts
Each category has several levels of severity
with an accompanying score (usually 0-4).
Total scores can range from 0 to 26; the
higher the total score, the more severe the
depression. A score of ≤ 3 indicates full
remission and a score of ≥ 4 represents a
non- or partial-responder.
Treating Depression
There are several types of treatment
available for depression, including antidepressant medications, psychotherapy,
exercise, and electroconvulsive therapy
(ECT). These treatment options can be
used alone or in combination to provide an
Provider Education Tool
Looking Beyond the Obvious:
The Recognition and
Management of Depression
Class of Anti-depressants Examples
Common Side Effects
Selective serotonin reuptake
inhibitors (SSRIs)
Fluoxetine
Paroxetine
Ecitalopram
Nausea, dry mouth, sexual dysfunction, anxiety
Serotonin-norepinephrine
reuptake inhibitors (SNRIs)
Venlafaxine
Duloxetine
Fatigue, dry mouth, constipation, nervousness
Norepinephrine/dopamine
reuptake inhibitors (NDRIs)
Bupropion
Agitation, insomnia, headache, nausea.
Tricyclics
Amitriptyline
Imipramine
Dizziness, dry mouth, constipation, weight gain
Monoamine oxidase inhibitors
(MAOIs)*
Selegiline
Rasagiline
Weakness, dizziness, headaches, tremor
* Used to treat atypical or tricyclic-resistant depression
individualized treatment regimen to meet
the needs of various patients. There are
several classes of anti-depressants that
affect different neurotransmitters within
the brain and are associated with varying
side effects.
side effects. As primary care physicians
are possibly the only contact some people
have with the health care system, it is
important that physicians have the tools and
knowledge needed to recognize, diagnose,
and treat depression.
Psychotherapy can be used alone or
in combination with anti-depressant
medications to promote remission and
prevent relapses from occurring. By
teaching patients coping skills and methods
for changing their negative thought patterns,
psychotherapy can enhance the effects
of medications to bring about improved
outcomes.
Additional Resources
While ECT is still utilized for the treatment
of depression, it is reserved for the most
difficult to treat or treatment-resistant
forms of depression.
National Institute of Mental Health (NIMH)
www.nimh.nih.gov/
Conclusions
Depression affects millions of Americans
every year and is associated with poor
outcomes in patients with chronic conditions
or if left untreated. The severity of depression
can range from mild forms that have only
a slight impact on a patient’s functioning,
to very severe debilitating forms that can
even result in suicide. In recent years,
pharmaceutical treatments for depression
have become more specific with fewer
The Beck Depression Inventory II (BDI)
http://www.harcourtassessment.com
Zung Self-Rating Depression Scale
http://healthnet.umassmed.edu/mhealth/
ZungSelfRatedDepressionScale.pdf
Hamilton Depression Rating Scale
http://healthnet.umassmed.edu/mhealth/
HAMD.pdf
References
1. Kessler RC, et al. Archives of General Psychiatry , 2005
Jun;62(6):617-27.
2. The World Health Organization. The World Health Report 2004:
Changing History, Annex Table 3: Burden of disease in DALYs by
cause, sex, and mortality stratum in WHO regions, estimates for
2002. Geneva: WHO, 2004.
3. Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision (DSM-IV-TR). Arlington, VA. American Psychiatric
Publishing, Inc.; 2000.
4. Egede LE. Gen Hosp Psychiatry. 2007;29:409–416.
5. Beck AT, Guth D, Steer RA, et al. Behav Res Ther.1997;35:785–
791.
6. Zung WW. Arch Gen Psychiatry. 1965;2:63–70.
7. Radloff LS. Appl Psychol Meas. 1977;1:385–401.
8. Arroll B, Khin N, Kerse N. BMJ. 2003;327:1144–1146.
9. McIntyre RS, et al. CMAJ. 2005;173:1327-1334.
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