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

  • Physical symptoms of major severity (eg, anorexia, insomnia, reduced sexual drive, weight loss)

  • 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 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 and worthlessness

• Poor concentration and cognitive dysfunction

• Anxiety

• Chronic fatigue and somatic complaints

• Loss of sexual drive

• Thoughts of death

• 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

• Depression may be a part of any illness, either reactively or as a secondary symptom

• Schizophrenia

• Partial complex seizures

• Organic brain syndromes

• Panic disorders

• Anxiety disorders

• Thyroid dysfunction and other endocrinopathies

• Malignancies

• Strokes, particularly dominant hemisphere lesions

• Mood disorders

  • Bipolar disorder or cyclothymia

  • Adjustment disorder with depressed mood

  • Psychotic major depression

  • Major depression with atypical features

  • Melancholic major depression

  • Persistent depressive disorder (dysthymia)

  • Premenstrual dysphoric disorder

  • Major depression with peripartum onset: occurs during pregnancy or starts up to 4 weeks after delivery

  • Drug-induced depression

  • 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

Treatment

Medications

• See Table 25–6 and Figure 25–2

• SSRIs, SNRIs, 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, ...