Download Criteria for Depressive Disorder (summary of the guideline)

Criteria for Depressive Disorder (summary of the guideline)
Five (or more) of the following symptoms have been present during the same 2-week period and
represent a change from previous functioning; at least one of the symptoms is either (1)
depressed mood or (2) loss of interest or pleasure.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective
report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
Note: In children and adolescents, can be irritable mood.
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day,
nearly every day (as indicated by either subjective report or observation made by others).
3. Significant weight loss when not dieting, or weight gain (e.g., a change of more than 5%
of body weight in a month), a decrease or increase in appetite. Nearly every day. Note: In
children, consider failure to make weight gains.
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely
subjective feeling of restlessness or being slowed down)
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or inappropriate guilt (which may be delusional) nearly every
day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by
subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for committing suicide.
Diagnostic Guidelines
Allow plenty of time for the anamnesis, accept lulls in the conversation and silences, take note of
behavior and psychomotor agitation. Consider a depressive disorder when:

Depressed mood or moody impression because of little eye contact, monotonous speech
and slow motor system.

Frequent doctor visits with varying complaints.

Continuing fatigue of complaints with no physical basis.

Chronic pain.

Complaints of nervousness, or insomnia. Requests for sleeping pills or tranquillizers.
At high risk are those patients with a depressive disorder or attempted suicide in their history, or
with close family members suffering from depressive disorder or having attempted suicide. Also,
patients with a severe illness, alcohol or drug problems or anxiety disorders..
Anamnesis
Ask for and evaluate:

Moodiness, melancholy feelings, or having a negative take on things.

Loss of interest and not being able to feel joy.
If answered affirmatively, continue with:

Indecisiveness, lack of concentration.

Feelings of worthlessness or guilt.

Agitation, irritation, restlessness.

A sense of everything moving slowly.

Fatigues, loss of energy, sleep problems.

A change in appetite or weight.

Thoughts of death and suicide.
Then:

Evaluate suicide risk, if entertaining thoughts of death, by looking into the death wish,
compulsory suicidal thoughts, elaborated suicide plans, earlier attempted suicides,
suicide attempts in the immediate family.

Look for emotional events in the past.

Ask about work conditions, living conditions, and possible associated problems.

Look into possible hallucinations, delusions, and manic episodes.

Look into anxiety or panic attacks, alcohol and drugs problems.

Exclude physical causes, in particular Hypothyroidism, Dementia, or Parkinson’s disease.
Physical Examination:


Only necessary in case of suspected other physical causes
Evaluation: Diagnose the patient with Depressive Disorder if the criteria in the first section are
met and estimate the amount of suffering and dysfunction. Take note of a possible
combination with anxiety disorders and alcohol and drug problems. Please refer to the
Guidelines for Anxiety Disorders and Problematic Alcohol Use.
Policy guidelines:

Together with the patient choose either treatment by the general practitioner,
psychological intervention in the first line, or a multidisciplinary treatment in a mental
health centre?. A prime condition for combined treatment is good synchronization
between the medical professionals.
Information for the patient:

Depressive disorder occurs frequently. The disorder can be considered a disease and is
not a weakness or deficiency of character.

The disorder usually takes a positive course; half of the patients recover in three to four
months.

Don’t demand too much of yourself, focus on the present, structure your days, exercise
regularly, visit your social circle, stay on the job and avoid heavy use of alcohol.
Supervision:

Initially every 2 weeks appointments, decreasing the frequency later on. Keep evaluating
the course on which the disorder is developing.

Advice patient: Informing important people in the patients life is advised.

Pay attention to disappointments, grief, hurt, or anger and other possible causes.

Set realistic daily goals and encourage the patient to do the things that still bring joy.
Pharmaceutical treatment:
Add medicine depending on the amount of suffering, dysfunction, and the patient’s preference.
Explain that the effect of the medicine on their mood will only be noticeable after two to four
weeks and that, initially, side effects may occur. The choice of TCA or SSRI will be influenced not
only by contra-indication, but also by potential side effects and previous experience.

TCA is preferable when extrapiramidal effects occur, and when NSAID or anti-psychotic
medication is taken: amitriptyline, nortriptyline 75 mg before bed, to be gradually
increased to 150 mg over the course of two weeks. Elderly people are to start with 25
mg, to be increased to 75 mg. For all categories of patients, if results are insufficient
increase the dosage by 25 mg every two to three days, after the initial 4 to 6 weeks, until
effects are noticeable. Maximum dosage of 300 mg; possible side effects are dizziness,
constipation, dry mouth, blurry vision, and sweating.

SSRIs are preferable when the patient has had a recent heart attack, heart failure,
arrhythmia, XXX or untreated glaucoma: fluoxetine 20 mg in the morning, paroxetine 20
mg in the morning, or sertraline 50 mg once a day. If effects are unsatisfactory, double
the dose after 4 to 6 weeks, maximum dosage 80 mg, 60mg and 200 mg per day
respectively. Possible side effects are nausea, diarrhea, anxiety, agitation, nervousness,
insomnia, and headaches.

If no effects are noticeable, or if side effects are unacceptable, phase out medication and
possibly try one of the other groups.

Treat the patient for 6 months after the depressive disorder disappears and phase out
medication over 4 weeks.

In case of anxiety and agitation, prescribe benzodiazepines as needed, for a maximum of
2 to 6 weeks.

If the depression is recurrent or chronic consider prolonged/life-long treatment
Referral:
Refer for psychological intervention or psychotherapy:

If this is the primary treatment, as agreed to by the patient.

If treatment and supervision by the general practitioner are insufficient.

If anti-depressants cause unacceptable side effects.

If serious psychological problems occur.

In case of personality disorders that impede recovery.
Refer to a psychiatrist:

In case of seriously social dysfunction, despite treatment and supervision.

In case of seriously elevated suicide risk.

In case of bipolar or psychotic depression.