Download Clinical Reasoning 2, Multiple Sclerosis

Clinical Reasoning 1
Running head: MULTIPE SCLEROSIS
Clinical Reasoning 2, Multiple Sclerosis
Margaret Heidenreich
Clinical Management III
University of Akron
Clinical Reasoning 2
Soap Note
Demographics: Caucasian 38yrs female on social security, single
CC: Fatigue
HPI: Jane Doe presents with a month long history of fatigue. She has history of MS for 5 years.
Jane doe states, “it seems like I have a lot less energy than normal, I’ve been sleeping more often
sometimes 12 hours a day, and by the end of the day I’m really exhausted especially if I did
something like cleaned or went to the store.” Jane Doe states does have some loss of interest in
activities she normally enjoys but denies any thoughts of suicide.
PMH: hyperlipidemia 2011, MS 2008
SH: none
FH: mother- MS, htn, hyperlipid, deceased at 65 yrs, Father- htn, living 72yrs
Allergies: None, environmental, drug or food
Social History: No smoking history, drinks alcohol rarely, on special occasions
Health Maintenance: Up to date with pap smears, flu vaccine
ROS:
General: No n/v, fevers, Positive unintended weight loss 5 lbs
NEURO: Denies LOC, denies memory problems, denies muscle weakness, denies parasthesias
HEENT: Negative for frequent headaches, no vision changes or disturbances, no hearing
changes, no nose bleeds or other nasal discharge
NECK: Negative for lumps, goiter, pain, negative for significant swelling
Respiratory: Negative for Cough, SOB, or wheezing
Cardiovascular: Negative for chest pain, palpitations, swelling
ABD: Negative for pain, changes in bowel patterns, red/black in stools, or heart burn
Skin: negative for rash or itching.
All other reviewed and negative other than HPI
Physical Exam
Vitals: B/P: 123/72 Pulse 68, SpO2 100%, Ht: 5’5”, WT 145 lbs,
General Appearance: Middle aged white female Alert in no apparent distress
Head: Normacephalic, no contusions, ecchymosis, or masses noted
Eyes: pupils are round and reactive to light. Extraocular movements are intact.
Ears external ears normal, canals clear, TM’s normal.
Nose/sinuses: negative
Oropharynx : lips, mucosa, and tongue pink and moist, teeth and gums normal
Clinical Reasoning 3
Neck: supple no adenopathy: thyroid symmetric no nodules palpated, no bruits
Lungs: Clear to Auscultation no adventitious sounds
Heart: RRR without murmur, gallop or rubs. No ectopy
ABD: Soft, not tender, no pain with palpation, BS positive in all quadrants
Neuro: CNS II-XII grossly intact, full sensations intact.
Co-Morbidities
Optic Neuritis
One Co-Morbidity found in up to 20% of MS patients is optic neuritis (Goroll & Mulley,
2009). Optic neuritis is defined as inflammation of the optic nerve (Goroll & Mulley, 2009). It
has been found that 20-50% of patient who present with this symptom will eventually be
diagnosed with multiple sclerosis (Goroll & Mulley, 2009). Signs and symptoms are progressive
loss of eyesight usually in one eye that happens in hours to days. There is pain with movement of
the eye and vision will begin to improve after two to three weeks (Goroll & Mulley, 2009).
Physical exam findings will include an afferent papillary defect, large vein congestion, blurred
disc margins, decreased color vision, visual field problems and globe tenderness (Goroll &
Mulley, 2009, Buttaro). The optic nerve often looks normal in these cases (Goroll & Mulley,
2009). Treatment includes immediate referral to ophthalmology (Buttaro, Trybulski, Basiled, &
Sandberg-Cook, 2008).
Depression
Depression is another Co-morbidity of MS that Jane Doe is at risk for. Depression is very
common in MS patients. Some studies even suggest that MS patients are up to 7.5x more likely
to suffer from depression than the general population (National Multiple Sclerosis Society
(NMSS), 2013). Depression is a multi system disease affecting psychological, cognitive,
neuroendocrine and neurotransmitter systems (Goroll & Mulley, 2009). Signs and symptoms
Clinical Reasoning 4
include sadness, loss of interest, decreased libido, sleep changes, frustration, worry, and thoughts
of death and suicide (Goroll & Mulley, 2009).
Several lab tests should be done to rule out other causes of depression. A TSH level
should be taken because hypothyroid and hyperthyroid can cause depression (Goroll & Mulley,
2009). A BMP should be taken as well because hypercalcemia, hypnoatermia and diabetes can
also cause depression (Goroll & Muelly, 2009). Last, vit B12 and vitamin D levels should be
drawn because deficiency of these vitamins can also cause depression (Goroll & Mulley, 2009).
NICE guidelines suggest that diagnosis of depression should include asking two
depression questions: “During the last month, have you often been bothered by feeling down,
depressed or hopeless?” and “During the last month, have you often been bothered by having
little interest or pleasure in doing things” (2004). If the patient answers yes to either of these
questions a formal mental assessment should be done and validated tools should be used such as
the Patient Health Questionnaire-9, Becks Depression Inventory, or the Hospital Anxiety and
Depression Scale (Louch, 2009). Also, evaluation of suicide should always be done in every
patient with known or suspected depression on every visit.
Treatment for depression depends on the severity of the disease. NICE recommends for
mild to moderate depression to offer sleep hygiene, self-help guided by cognitive behavioral
therapy, computerized cognitive behavioral therapy, and referral to psychology or counseling.
Medications should not be given to patients with mild depression unless they have a history of
major depression, mild depression for two years or more, or the depression continues because of
failure of other suggested interventions (2004). Drugs of choice should depend on other
medications currently being used by the patient and potential side effects. First line suggestions
Clinical Reasoning 5
include generic SSRI’s including fluoxetine (20-40mg daily), sertraline (50mg daily to start 100250mg daily for maintenance), paroxetine (20-60mg daily), fluvoxamine 50mg to start, 100250mg daily for maintenance), citalopram (20-40mg daily) and escitalopram (10-20mg daily)
can be given as initial treatment starting with the lowest dose (goroll & Mulley, 2009). The
patient should always be educated that it can take 3 to 4 weeks to be effective (Goroll & Mulley,
2009). Side effects include increased agitation, insomnia, and anxiety, tremor, insomnia,
sedation, mild weight gain, nausea, headache, and diarrhea (Goroll & Mulley, 2009). Fluoextine,
paroxetine, and fluvoxamine interact with cytochrome P450 enzymes and should not be used in
patients taking coumadin, phenytoin, or other drugs that interact with this system (Goroll &
Mulley, 2009).
Intention Tremor
Another common Co-morbidity of multiple sclerosis is cerebellar deficits such as
intention tremor (Goroll & Mulley, 2009). Cerebellar deficits include intention tremor, limb
weakness, and lack of muscle coordination (Goroll & Mulley, 2009). Intention tremor is defined
as “rhythmic oscillations with motion” (Butarro, et al., 2008). Signs and symptoms may include
patient complaints of involuntary or strange body movements, problems getting started or
stopping movements, and these may worsen with increased stress or fatigue (Butarro, et al.,
2008). A thorough drug and alcohol history should be taken as some medications and drugs can
worsen symptoms while alcohol can sometimes improve them (Butarro, et al., 2008). In addition,
aggravating and alleviating symptoms should be discussed as well as time of onset, duration of
symptoms, and when the symptoms first started (Butarro, et al., 2008). Physical exam should
include a complete neurological exam and other systems involved (Butarro, et al, 2008). In
addition, a detailed description of the movements as well as whether the movement is present at
Clinical Reasoning 6
rest or with movements is crucial (Butarro, et al., 2008). Deep tendon reflxes, Babinski and
Romberg’s signs may be decreased (Butarro, et al., 2008). Rapid movement testing and finger to
nose testing should be done which may show rhythmic tremor or jerky and overcorrected
movements (Butarro, et al., 2008). Diagnosis includes a CT scan or MRI of the brain to rule out
tumors and lesions, EMG for diagnosis of the tremor that is present, and a thyroid panel should
be drawn (Goroll & Mulley, 2009). Medications that can help intention tremor include low dose
beta-blockers, primidone, baclofen, gabapentine, and benzos (Goroll & Mulley, 2009). Using
wrist weights sometimes help with tremor as a non-pharmacological intervention (Goroll &
Mulley, 2009).
Urge Incontinence
Urge incontinence is a last Co-Morbidity that is found in patients with MS. Urinary
problems occur including urgency, frequency, and incontinence from nerve injury in the upper
spinal cord (Goroll & Mulley, 2009). Urge incontinence results from decreased bladder capacity
and from cortical inhibition of the detrusor muscles working improperly (Goroll & Mulley,
2009). Signs and symptoms include warning sensation of need to urge only seconds before
incontinence. This incontinence can be of various volumes, and sometimes while sleeping
(Goroll & Mulley, 2009). History questions should include frequency of events, when events
occur, amount of urine lost, and what medications are being taken (Goroll & Mulley, 2009).
Physical exam should include palpation of the bladder post voiding, as well as having the patient
do a Valsalva maneuver to evaluate stress incontinence (Goroll & Mulley, 2009). Superficial
vaginal exam and the bulbocaverosus reflux should both be checked, and last, perineal sensation
should also be checked to rule out autonomic reflex arc, sphincter tone changes, and lesions in
the spinal cord (Goroll & Mulley, 2009).
Clinical Reasoning 7
Labs should include urinalysis and C&S to rule out infection. Treatments exist including
restricting fluids, and natural diuretics like coffee, tea and alcohol (Groll & Mulley, 2009).
Patients should try to avoid caffeine products, use absorbent pads, and avoid catherization (goroll
& Mulley, 2009). Patients should be taught bladder-training programs learning to frequently
empty their bladders to avoid urge incontinence. Kegel exercises should also be taught, and the
use of bedside commodes and urinals can be useful (Goroll & Mulley, 2009). Medication that
can be trialed include tricyclics with anticholinergic properties like imipramine (10mg 1 to 4
times daily), smooth-muscle relaxants like oxybutynin (2.5mg three times daily), or selective
bladder smooth-muscle relaxants like tolterodine (1mg twice daily) (Goroll & Mulley, 2009).
Presumed Diagnosis
The presumed diagnosis for Jane Doe is depression secondary to MS. Jane doe presents
with several features of depression including fatigue, weight loss, loss of interest in hobbies and
changed sleep pattern. Depression is a common Co-Morbidity of MS because of several
different factors including stress from disease diagnosis and progression or damage to the
emotion centers of the brain directly causing these changes (NMSS, 2013). Another reason for
depression in MS includes disease related changes in the immune and neuroendocrine systems
(NMSS, 2013). The patient has some negative risk factors for depression including no familial
history of depression and no history of drug or alcohol abuse (Goroll & Mulley, 2009). At this
time Jane Doe presents with remitting MS disease that is common in younger patients. This
disease course is hallmarked by attacks that are followed by complete or near complete remission
(Goroll & Mulley, 2009). Co-Morbidities or residual problems usually stay stable between
episodes (Goroll & Mulley, 2009). Jane presents with no other Co-Morbidities of MS at this time
including those described above.
Clinical Reasoning 8
Plan of Care
Multiple Sclerosis (340) – Condition Stable
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Give Jane Doe education regarding multiple sclerosis and disease progression, helpful
tips (Appendix A)
Referral to support group through Multiple Sclerosis Foundation or Facebook
Encourage patient to continue healthy diet and exercise to maintain strength (UCSF,
2013)
Depression/Major Depressive Affective Disorder Single Episode unspecified degree (V79.0)Condition Stable
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Labs: TSH, CBC, BMP, vitamin D 25hydroxy, Vitamin b12
Screening for Depression (V79.0)- Patient Health Questionnaire-9
Give education regarding depression (Appendix B)
Referral to psychologist specializing in depression in MS patients
Fluoexetine 20mg daily #30, no refills
Follow up Appointments
1. Follow up in 1 week to go over lab results, make sure patient has made appointment with
psychologist, evaluate medication adherence, re-evaluate dperession and problems or
concerns the patient may be having at this time.
a. Primary Prevention- Tdap booster
b. Secondary Prevention- Screening for hyperlipidemia
c. Tertiary Prevention- Evaluate medication adherence, educate patient not to
stop medication “cold turkey”
2. Follow up 4-6 weeks to evaluate medication effect, re-evaluate patient mood. Adjust
medication dosage as needed.
a. Primary Prevention- pneumonia vaccine
b. Secondary Prevention- Screening for hypertension
c. Tertiary Prevention – referral to psychiatrist if unable to regulate mood.
Research Question
Is yoga a beneficial exercise technique for multiple sclerosis patients? Yoga seems to
have many different applications both for you young fit individuals, athletes and the elderly in
nursing homes. In addition it has some relaxation benefits and would be helpful for the patient
Clinical Reasoning 9
with depression as well. Yoga has in fact been studied on patients with MS while looking at
affects it has on different symptoms including neurogenic bladder, stress, and spasticity
(Velikonja, Curic, Ozura, & Jazbec, 2010). Studies suggest that yoga may have positive effects
on these situations and may be possibly considered in the future as an adjunct to therapy,
however more studies are needed before this could become an evidenced based
recommendations (Rahnama, et. al., 2011; Prichard, Elison-Bowers, & Birdsall, 2010).
Soap Critique
Jane Doe came in with the initial complaint of fatigue. An in depth history of the patients
symptoms was gathered and the patient’s physical exam was grossly negative except for weight
loss. I asked the two initial screening questions of loss of interest in activities and suicide plans
and then discussed the patient with my preceptor. No screening tool for depression was used at
this point however I would’ve preferred to use one. I did not think the use of an anti-depressant
was needed at this time, however my preceptor offered it to the patient who accepted it. I do
agree with the use of an SSRI however I would’ve preferred to refer the patient to a psychologist
since her situation is more complex and since psychotherapy can be as effective as medication
(Goroll & Mulley, 2009). Fluoexetine is a good medication choice because it can help both with
fatigue from MS in addition to underlying depression (Goroll & Mulley, 2009). Perhaps the dual
use of psychotherapy and medications would be the best solution however a psychologist would
be proficient at making this decision especially one that specializes with MS patients.
I suggested the labs to be drawn that would rule out organic causes of the depression. I
was not fully aware of the implications of MS on depression and the multitude of ways that the
disease process can cause depression. However after further research it would be hard to
distinguish what is specifically causing the depression in this type of patient so the plan of care
Clinical Reasoning 10
for diagnostics was sufficient. The patient previously had MRI scans due to her MS so these
ruled out any tumors in the brain that could cause depression. A new lesion could be causing the
depression but using a MRI for diagnosis would not change the treatment plan and would not be
beneficial for the cost.
The patient has had MS for five years with two exacerbations during this time. She has
had no residual problems at this point. She was somewhat educated on the topic, however no
new educational material was given to her at the time. I wish I would’ve had more time to
research and give her more education as this is proven to help the patient have a better feeling of
control over their lives with the more knowledge they have (Goroll & Mulley, 2009). This could
also help reduce any anxiety and perhaps helped the depressive characteristics as well.
Clinical Reasoning 11
References
Buttaro, T. M., Trybulski, J., Bailey, P., & Sandberg-Cook, J. (2008). Primary Care: A
collaborative practice. (3rd ed). St Louis, MI: Mosby
Goroll, A.H., Mulley, A.G. (2009). Primary care medicine: Office and evaluation of the adult
patient. Philadelphia, PA: Lippinicott Williams & Wilkins.
Louch, P. (2009). Diagnosing and treating depression. Practice Nurse, 37(10).
National Institute for Health and Clinical Excellence (NICE). (2011). Donepezil,
galantamine, rivastigmine, and memantine for the treatment of Alzheimer’s disease.
Retrieved from http://guidance.nice.org.uk/TA217.
National Institute of Mental Health (NIMH) (2013). Depression. National Institute of Health
(NIH). Retreived from http://www.nimh.nih.gov/health/topics/depression/index.shtml.
National Multiple Sclerosis Society (NMSS) (2013). Depression. Retrieved from
http://www.nationalmssociety.org/about-multiple-sclerosis/what-we-know-aboutms/symptoms/depression/index.aspx.
Prichard, M., Elison-Bowers, P., & Birdsall, B. (2010). Impact of integrative restoration (iRest)
medidation on perceived stress levels in multiple sclerosis and cancer outpatients. Stress
& Health: Journal of the International Society for the Investigation of Stress, 26(3), 233237. Doi:10.1002/smi.1290.
Rahnama, N., Namazizadeh, M., Etemadifar, M., Babaeichi, E., Arbabzadeh, S., & Sadegipour,
H. (2011). Effects of yoga on depression in women with multiple sclerosis. Journal of
Isfahan Medical School, 29(136), 1-8.
University of California San Francisco Medical Center (UCSF) (2013). Living with multiple
sclerosis. Retrieved From: http://www.ucsfhealth.org/education/living_with_ multiple_
Clinical Reasoning 12
sclerosis/index.html.
Velikonja, O., Curic, K., Ozura, A., Jazbec, S. (2010). Influence of sports climbing and yoga on
spasticity, cognitive function, mood, and fatigue in patients with multiple sclerosis.
Clinical Neurology and Neurosurgery. 112, 597-601. Doi:
10.1016/j.clineuro.2010.03.006.
Clinical Reasoning 13
Appendix A
Living With Multiple Sclerosis
If you have multiple sclerosis (MS), exercise can help retain flexibility and balance, promote
cardiovascular fitness and a sense of well-being, and prevent complications from inactivity.
Exercise also helps regulate appetite, bowel movements and sleep patterns.
Jogging, walking and aerobic exercises are helpful when strength and coordination are not
affected. Stationary bicycle riding may be more practical if walking or balance is impaired.
Swimming is helpful for stretching and cardiovascular fitness. Yoga and Tai Chi are most useful
for stretching and promoting a sense of well-being. Your physical and occupational therapists
will assist you in selecting the best exercise program for you to follow.
Stress Reduction
Although stress cannot be totally eliminated from our lives, we can learn to manage it more
effectively. Any reduction in stress will be associated with an improved sense of well-being and
increased energy. A psychologist or social worker may be helpful in developing a stress
management program that is tailored to your needs. The following are some useful stress
reduction techniques:
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Identify causes of stress in your life and share your thoughts and feelings.
Simplify your responsibilities by setting priorities.
Try relaxation and meditation exercises.
Manage your time and conserve your energy.
Ask for help when needed.
Set both short-term and life goals for yourself.
Keep as active as possible both physically and mentally.
Recognize the things that you cannot change and don't waste your time trying.
Make time for fun activities and maintain your sense of humor.
Nutrition
Good nutrition maximizes your energy, general sense of well-being and healing capacities. A
dietary routine also contributes to regular bowel habits. Although no specific diet has been
demonstrated to conclusively improve the natural history of MS, most people do report an
improved sense of well-being when following a carefully planned diet. Several published diets
are healthful and easy to follow. Others are more restrictive and less practical.
Vitamin and Mineral Supplements
Unless there is a specific vitamin deficiency found by your doctor there is no scientific proof that
supplementary doses of vitamins or minerals, alone or in combination, favorably affect the
course of the disease. Be careful not to take excessive doses of vitamin B6 because excessive
Clinical Reasoning 14
doses of this vitamin can produce sensory symptoms similar to those seen in MS. High doses of
vitamin A and D are toxic.
Oleic and Linoleic Acids
These fatty acids have been reported to be deficient in MS patients. There is an unconfirmed
suggestion that supplementary feeding of these fatty acids may slightly reduce the frequency of
MS attacks. These fatty acids are contained in sunflower seed oil and primrose oil. The former is
much cheaper and readily available in grocery stores. Two tablespoons of sunflower seed oil
each day will provide you with these fatty acids and give you the added benefit of a laxative.
Skin Care
If you have problems with mobility, muscle contractures or are confined to a wheelchair, you
should check your skin regularly for sores, pressure spots, infections and abrasions. Regular skin
care will minimize the chances of skin breakdown and help you to avoid complications such as a
decubitus ulcer. Be sure to check the pressure points on your body including your heels, knees,
hips, buttocks and elbows. Remember to protect against skin cancer by wearing sunscreen and
protective clothing when outdoors, whether it is sunny or not. Get familiar with your skin and
examine it frequently.
Urinary Tract Infections
Vitamin C helps to acidify the urine and prevent the growth of bacteria. Orange juice or vitamin
C tablets are both useful. Cranberry juice also will acidify the urine and is available as a sugar
free juice for those who count calories. If you develop new urinary frequency, burning when you
urinate or have difficulty passing your urine, you should call your doctor and be seen for the
possibility of a urinary tract infection.
Vaccinations
There has traditionally been a concern that immunizations could worsen MS by stimulating the
immune system. With the exception of transient worsening associated with fever or rare
neurological complications known to be associated with certain vaccines, there is no convincing
evidence that immunizations make MS patients worse. If immunizations are recommended by a
doctor, they can probably be undertaken safely. In general, immunizations should be delayed if
the person is experiencing an acute MS attack. However, in some circumstances, such as when
urgent vaccinations for tetanus or rabies are required, immunizations should be given
immediately. If questions arise, you should discuss them further with your neurologist.
Physical Therapy
Physical Therapy (PT) focuses on ways to preserve or improve safety and independence with
functional mobility. This may be accomplished through a variety of approaches including:
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Mobility technique training
Clinical Reasoning 15
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Home exercise programs
Caregiver training
Effective use of adaptive equipment
The following are examples of PT therapeutic strategies that help everyday management of
mobility-related symptoms.
Exercise Categories
You and a physical therapist should develop an individualized exercise program that is based on
your current needs and future goals. This may include yoga, exercises in a gym, tai chi or
Feldenkrais, as well as traditional forms of exercise such as running, walking, biking, swimming
or water aerobics. In some cases, exercises can be carried out independently, with or without
modification. In other instances, certain more challenging exercises may require some assistance.
Stretching
Frequently, persons with MS have spasticity, especially in their lower extremities. This can cause
the legs to stiffen if a regular stretching program is not incorporated into the daily routine of
activities. Stretching exercises help to maintain or improve muscle length to allow greater
flexibility.
Coordination
Coordination exercises are done to improve balance and ease of purposeful movement. The
degree of skill required to perform the exercises varies. An appropriate program will be
discussed with the individual MS patient.
Strengthening
Strengthening exercises are designed to build weakened muscles to aid in moving and walking.
While being beneficial, discretion is advised when carrying out a strengthening program. For
instance, if one has undergone a vigorous session of exercising but is too tired to prepare dinner
or do chores that ordinarily can be done without difficulty, it may be necessary to modify the
program or space the activity more evenly throughout the day.
Upper Body Exercises
These simple exercises are designed to promote flexibility and muscle balance as well as to
enhance upper extremity function. If done correctly, they are appropriate for all stages of MS.
Stretches are to be done slowly, generally being held for approximately five to 10 seconds. These
exercises can be performed either seated or lying on your back. Repeat each exercise five to 10
times on each side as tolerated. You can do one side at a time or both sides at the same time.
(University of California San Francisco Medical Center, 2013)
Clinical Reasoning 16
Appendix B
What Is Depression?
Everyone occasionally feels blue or sad. But these feelings are usually short-lived and pass
within a couple of days. When you have depression, it interferes with daily life and causes pain
for both you and those who care about you. Depression is a common but serious illness.
Many people with a depressive illness never seek treatment. But the majority, even those with
the most severe depression, can get better with treatment. Medications, psychotherapies, and
other methods can effectively treat people with depression.
What are the different forms of depression?
There are several forms of depressive disorders.
Major depressive disorder, or major depression, is characterized by a combination of
symptoms that interfere with a person's ability to work, sleep, study, eat, and enjoy oncepleasurable activities. Major depression is disabling and prevents a person from functioning
normally. Some people may experience only a single episode within their lifetime, but more
often a person may have multiple episodes.
Depression is a common but serious illness. Most who experience depression need treatment to
get better.
Dysthymic disorder, or dysthymia, is characterized by long-term (2 years or longer) symptoms
that may not be severe enough to disable a person but can prevent normal functioning or feeling
well. People with dysthymia may also experience one or more episodes of major depression
during their lifetimes.
Minor depression is characterized by having symptoms for 2 weeks or longer that do not meet
full criteria for major depression. Without treatment, people with minor depression are at high
risk for developing major depressive disorder.
Some forms of depression are slightly different, or they may develop under unique
circumstances. However, not everyone agrees on how to characterize and define these forms of
depression. They include:
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Psychotic depression, which occurs when a person has severe depression plus some
form of psychosis, such as having disturbing false beliefs or a break with reality
(delusions), or hearing or seeing upsetting things that others cannot hear or see
(hallucinations).
Postpartum depression, which is much more serious than the "baby blues" that many
women experience after giving birth, when hormonal and physical changes and the new
Clinical Reasoning 17
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responsibility of caring for a newborn can be overwhelming. It is estimated that 10 to 15
percent of women experience postpartum depression after giving birth.1
Seasonal affective disorder (SAD), which is characterized by the onset of depression
during the winter months, when there is less natural sunlight. The depression generally
lifts during spring and summer. SAD may be effectively treated with light therapy, but
nearly half of those with SAD do not get better with light therapy alone. Antidepressant
medication and psychotherapy can reduce SAD symptoms, either alone or in combination
with light therapy.2
Bipolar disorder, also called manic-depressive illness, is not as common as major depression or
dysthymia. Bipolar disorder is characterized by cycling mood changes—from extreme highs
(e.g., mania) to extreme lows (e.g., depression). More information about bipolar disorder is
available.
What are the signs and symptoms of
depression?
People with depressive illnesses do not all experience the same symptoms. The severity,
frequency, and duration of symptoms vary depending on the individual and his or her particular
illness.
Signs and symptoms include:
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Persistent sad, anxious, or "empty" feelings
Feelings of hopelessness or pessimism
Feelings of guilt, worthlessness, or helplessness
Irritability, restlessness
Loss of interest in activities or hobbies once pleasurable, including sex
Fatigue and decreased energy
Difficulty concentrating, remembering details, and making decisions
Insomnia, early-morning wakefulness, or excessive sleeping
Overeating, or appetite loss
Thoughts of suicide, suicide attempts
Aches or pains, headaches, cramps, or digestive problems that do not ease even with
treatment.
I started missing days from work, and a friend noticed that something wasn't right. She talked to
me about the time she had been really depressed and had gotten help from her doctor.
What illnesses often co-exist with depression?
Clinical Reasoning 18
Other illnesses may come on before depression, cause it, or be a consequence of it. But
depression and other illnesses interact differently in different people. In any case, co-occurring
illnesses need to be diagnosed and treated.
Anxiety disorders, such as post-traumatic stress disorder (PTSD), obsessive-compulsive disorder,
panic disorder, social phobia, and generalized anxiety disorder, often accompany depression.3,4
PTSD can occur after a person experiences a terrifying event or ordeal, such as a violent assault,
a natural disaster, an accident, terrorism or military combat. People experiencing PTSD are
especially prone to having co-existing depression.
In a National Institute of Mental Health (NIMH)-funded study, researchers found that more than
40 percent of people with PTSD also had depression 4 months after the traumatic event.5
Alcohol and other substance abuse or dependence may also co-exist with depression. Research
shows that mood disorders and substance abuse commonly occur together.6
Depression also may occur with other serious medical illnesses such as heart disease, stroke,
cancer, HIV/AIDS, diabetes, and Parkinson's disease. People who have depression along with
another medical illness tend to have more severe symptoms of both depression and the medical
illness, more difficulty adapting to their medical condition, and more medical costs than those
who do not have co-existing depression.7 Treating the depression can also help improve the
outcome of treating the co-occurring illness.8
(NIMH, 2013)