Depression

Key Features

Essentials of Diagnosis

• In most depressions

  • Mood varies from mild sadness to intense guilt, worthlessness, and hopelessness

  • Difficulty in thinking and concentration, with rumination and indecision

  • Loss of interest, with diminished involvement in activities

  • Somatic complaints

  • Disrupted, reduced, or excessive sleep

  • Loss of energy, appetite, and sex drive

• In some severe depressions

  • Psychomotor disturbance: retardation or agitation

  • Delusions of a somatic or persecutory nature

  • Withdrawal from activities

  • Suicidal ideation

General Considerations

• Sadness and grief are normal responses to loss; depression is not

• Unlike grief, depression is marked by a disturbance of self-esteem, with a sense of guilt and worthlessness

• Persistent depressive disorder (dysthymia) is a chronic depressive disturbance with symptoms generally milder than in a major depressive episode

Demographics

• Up to 30% of primary care patients have depressive symptoms

• The COVID-19 pandemic has undoubtably increased the risk of depression

• One meta-analysis of studies of community-based prevalance of depression found a seven-fold increase in depression in some heavily impacted communities in Europe and Asia

• US national surveys show a three-fold increase in the prevalence of depressive symptoms, with risk factors including lower income, < $5000 in savings, and exposure to stressors

Clinical Findings

Symptoms and Signs

• Anhedonia

• Withdrawal from activities

• Feelings of guilt

• Poor concentration and cognitive dysfunction

• Anxiety

• Chronic fatigue and somatic complaints

• Diurnal variation with improvement as the day progresses

• Vegetative signs

  • Insomnia

  • Anorexia

  • Constipation

• Occasionally, severe agitation and psychotic ideation

• Atypical features

  • Hypersomnia

  • Overeating

  • Lethargy

  • Mood reactivity

Differential Diagnosis

• Bipolar disorder or cyclothymia

• Adjustment disorder with depressed mood

• Dysthymia

• Premenstrual dysphoric disorder

• Major depression with postpartum onset: usually 2 weeks to 6 months postpartum

• Seasonal affective disorder

  • Carbohydrate craving

  • Lethargy

  • Hyperphagia

  • Hypersomnia

Diagnosis

Laboratory Tests

• Complete blood count

• Serum thyroid-stimulating hormone

• Serum folate

• Toxicology screen may be indicated

• Blood tests to diagnose depression and predict antidepressant response are being developed

Treatment

Medications

• See Table 25–7 and Figure 25–2

• Selective serotonin reuptake inhibitors (SSRIs) and atypical antidepressants

  • Generally lack anticholinergic or cardiovascular side effects

  • Most are activating and should be given in the morning

  • Some patients may experience sedation with paroxetine, fluvoxamine, and mirtazapine

  • Clinical response varies from 2 to 6 weeks

  • Common side effects are headache, nausea, tinnitus, insomnia, nervousness

  • Sexual side effects (eg, erectile dysfunction) are very common and may respond to sildenafil

  • "Serotonin syndrome" may occur when SSRIs are taken in conjunction with monoamine oxidase inhibitors or selegiline

  • With the exception of paroxetine, SSRIs should be tapered over weeks to months to avoid ...