Depression: guide to detection and recommended management

Pharmacotherapy of Bipolar Disorders

Diagnostic criteria DSM-IV Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Copyright 2000 American Psychiatric Association Criteria for Major Depressive Episode A. 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. Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations. (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 account or observation made by others) (3) signifi cant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: in children, consider failure to make expected weight gains. (4) insomnia or hypersomnia nearly every day (5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) (6) fatigue or loss of energy nearly every day (7) feelings of worthlessness or excessive 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 specifi c plan, or a suicide attempt or a specifi c plan for committing suicide B. The symptoms do not meet criteria for a Mixed Episode. C. The symptoms cause clinically signifi cant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

2014

Psychiatric Clinics of North America, 1987

Physical illness-especially chronic, serious illness-may cause distress, dysphoria, and demoralization. At times, these feelings become so severe and persistent that the diagnosis of "major depression" must be entertained. 72 This diagnosis is often difficult to make because the clinician must decide whether a patient's sadness is a "normal" response to the physical illness or represents a symptom of a distinct syndrome, that is, major depression, requiring treatment by itself. In addition, some of the patient's symptoms, such as fatigue and anorexia, may be attributable either to major depression or to the physical illness itself. This article will discuss these diagnostic difficulties and review the biologic treatments for depression in the context of physical illness. The word depression is used in so many different ways that diagnostic confusion often arises from imprecise language usage itself. Depression is used commonly as a synonym for sadness, a normal affect that people experience at many points in their lives. It is also used rather loosely as a substitute for any one of a number of psychiatric disorders, ranging from milder forms of adjustment and dysthymic disorders, to more severe major depressions and melancholia. For the purposes of this article, we will focus on the diagnostic entity, major depression, and we will restrict our use of the term depression to that syndrome. DIAGNOSTIC ISSUES The diagnosis of major depression, according to DSM-111, 4 requires a patient to demonstrate either a relatively persistent dysphoric mood (sad,

Practical Neurology

Psychosomatics, 1990

BMJ, 2002

Depressive illness is usually treatable. It is common and results in marked disability, diminished survival, and increased healthcare costs. As a result, it is essential that all doctors have a basic understanding of its diagnosis and management. In patients with physical illness depression may x Be a coincidental association x Be a complication of physical illness x Cause or exacerbate somatic symptoms (such as fatigue, malaise, or pain). Clinical features and classification The term depression describes a spectrum of mood disturbance ranging from mild to severe and from transient to persistent. Depressive symptoms are continuously distributed in any population but are judged to be of clinical significance when they interfere with normal activities and persist for at least two weeks, in which case a diagnosis of a depressive illness or disorder may be made. The diagnosis depends on the presence of two cardinal symptoms of persistent and pervasive low mood and loss of interest or pleasure in usual activities. Adjustment disorders are milder or more short lived episodes of depression and are thought to result from stressful experiences. Major depressive disorder refers to a syndrome that requires the presence of five or more symptoms of depression in the same two week period. Dysthymia covers persistent symptoms of depression that may not be severe enough to meet the criteria for major depression, in which depressed mood is present for two or more years. Such chronic forms of depression are associated with an increased risk of subsequent major depression, considerable social disability, and unhealthy lifestyle choices such as poor diet or cigarette smoking. Manic depressive (bipolar) disorder relates to the occurrence of episodes of both major depression and mania.

JAMA, 2002

Comprehensive Psychiatry, 1996

Current classification systems (ICD-10 and DSM-IV) require a quantitative criterion for differentiating depressive states, suggesting a correlation between the number of symptoms, i.e., the pervasiveness of the syndrome, and the subtype of the illness. All the symptoms (within those contained in the diagnostic lists) are assumed to have comparable value. To investigate the relevance of the number and the type of symptoms reported by 196 patients suffering from depression, we compared the symptoms using independent indicators of severity such as the Clinical Global Index (CGI) and the social functioning subscale of the Global Assessment of Functioning (GAF). A second comparison using the same indicators was made between qualitatively distinct categories of DSM-IV and ICD-IO (i.e., melancholic v nonmelancholic, somatic v nonsomatic, and psychotic v nonpsychotic). There was evidence that increasing numbers of symptoms actually reflect higher levels of severity, but the categorizations that were mainly based on qualitative criteria (e.g., melancholia, somatic syndrome, etc.) usually attained better discrimination compared with those based on the number of symptoms. Moreover, certain symptoms (usually those indicated as endogenous) were more likely to be associated with greater severity and pervasiveness. Finally, the results clearly showed that different symptoms had different weight in establishing the gradient of severity.

The International Journal of Psychiatry in Medicine, 1990

The diagnosis of depression in patients presenting with both depressive and physical symptoms is potentially confounded and problematic. The present study of 271 patients with four types of illness all with prominent physical symptoms-end-stage renal disease (n = 99), irritable bowel syndrome (n = 21), post-infectious neuromyasthenia (n = 25) and eating disorders (n = 126)-investigates if there are a group of symptoms on the Beck Depression Inventory (BDI) which redict the diagnosis of major depressive episode (MDE) made using the hagnostic Interview Schedule 01s). Discriminant function analysis of BDI responses yielded a four item function-self-hate, indecisiveness, loss of appetite and suicidal thoughts-which maximally discriminated between patients with and without a current MDE and correctly classified 75 percent of subjects.