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A 58-year-old woman comes to you complaining of difficulty sleeping. She reports that her sleep problems began about 2 months ago, and since that time, she has felt "drained, weak, and not like my usual self." Over the past 2 months, she also acknowledges having gained 12 lbs. The patient appears visibly lethargic to you, as evidenced by her slumped posture, sluggish movement, delayed replies to your questions, and difficulty sustaining attention.

  • Based on the patient's initial presentation, what are likely diagnostic possibilities?
  • What additional history would you want to obtain?
  • How might the past medical history guide your diagnostic decision making?
  • How can you determine what might be causing her symptoms?
  • Are there any questions that are crucial to ask before the patient leaves your office?

Clinical depression is a syndrome characterized by the following cardinal symptoms: depressed mood or anhedonia, additional psychological (eg, decreased concentration) or somatic symptoms (eg, insomnia), and impaired functioning. Depressed mood is very common. In settings where primary care patients are screened systematically, 10% to 30% report depressed mood. The US Preventive Services Task Force recommends a brief 2-item depression screen,1the Patient Health Questionnaire-2 (PHQ2), for use in settings where staff-assisted depression care supports are available.2 Although depressed mood is a cardinal feature of depression, most patients actually present with physical complaints. If systematic screening is not being employed, clinicians should consider clinical depression in patients who present with a "red flag" such as insomnia, fatigue, chronic pain, recent life changes or stressors, fair or poor self-rated health, and unexplained physical symptoms.3

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AnhedoniaMarkedly diminished interest or pleasure in almost all activities most of the day, nearly every day.
Appetite or weight changeSubstantial change in appetite nearly every day or unintentional weight loss or gain (eg, ≥ 5% of body weight in 1 month).
Decreased concentrationDiminished ability to think or concentrate, or indecisiveness nearly every day.
Decreased energyFatigue or loss of energy nearly every day.
Depressed moodDepressed mood most of the day, nearly every day.
Guilt or feelings of worthlessnessFeelings of worthlessness or excessive guilt nearly every day.
Increased or decreased psychomotor activityPsychomotor agitation or retardation nearly every day.
Sleep disturbanceInsomnia or hypersomnia nearly every day.
Suicidal ideationRecurrent thoughts of death or suicide.

Female gender, prior depression, chronic medical illness, and depression in a first-degree relative are risk factors for clinical depression. Among patients with depressed mood or a positive depression screen (eg, PHQ2), the prevalence of clinically significant depressive disorders varies depending on the clinical setting and patient characteristics. In primary care settings, approximately 25% to 50% of such patients will have transient dysphoria (eg, feeling down because their sports team lost the big game) or more persistent but mild symptoms that do not impair function and hence do not meet formal criteria for a psychiatric diagnosis. ...

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