Major depression: Screening and treatment

■ Screen for depression in all patients using simple questions or tools.

■ Address comorbid medical conditions that may mimic or worsen depressive symptoms.

■ Initiate pharmacotherapy and behavioral therapies when appropriate, and ensure sufficient length of treatment.

■ Follow-up should be scheduled within 6 weeks and then at regular intervals to assess progress and consider more intensive therapies.

■ Behavioral therapies can be very effective alone and in conjunction with pharmacotherapy.

■ Refer to appropriate specialists when patient symptoms are severe to suicidal, difficult to control, or complicated by multiple competing disease processes.

■ More information on guidelines can be obtained from the American Psychiatric Association.¹¹

WHO SHOULD READ THIS?

Major depressive disorder (MDD) can complicate the care of patients in any clinical setting and is an issue for any PA practicing in primary care, as well as for those working in many specialty settings where depression may be common but poorly recognized. As many as 6% of pediatric patients and 16% of adult patients will meet the diagnostic criteria for MDD.^1,2 Screening may be as simple as asking two questions and can provide a basis for improving the outcomes from this debilitating disorder.^3-5

WHAT ARE THE SYMPTOMS OF DEPRESSION?

MDD in adults is defined by the persistence for 2 weeks or more of five or more of the following symptoms:6

• Depressed mood for most of the day, every day

• Diminished pleasure from or interest in almost all activities

• Weight loss, weight gain, or a change in eating habits

• Hypersomnia or insomnia

• Excessive or diminished physical movement/expression (psychomotor agitation or psychomotor retardation)

• Loss of energy and fatigue

• Feelings of worthlessness or inappropriate guilt

• Impaired decisiveness or inability to concentrate

• Intrusive thoughts of death or suicide.⁶

Alcohol or drug abuse must be ruled out as a contributing factor. Other secondary causes of behavioral changes, including grief, medication, or an organic metabolic imbalance, should be addressed. In the absence of these, depression should be diagnosed and treatment should be planned.

Patients with depression may complain of mood disturbances but attribute their problems to stress or difficulties in their personal or business lives. They may schedule multiple visits to discuss vague symptoms, such as GI complaints.⁷ The history should include questions about previous episodes of depression or depressive symptoms, other mood disorders, psychotic disorders, substance abuse, and other behavioral disorders, as well as other risk factors (Table 1).

Children can experience depressive symptoms similar to those in adults,8 including feelings of hopelessness and loss of pleasure or interest in activities. Children may become anxious and exhibit turmoil in their lives.^8,9 The prevalence of depression increases from 3% among children to 6% in adolescents, with up to a 20% lifetime MDD prevalence among adolescents.2 Depression affects a child's cognitive, physical, and behavioral function and manifests as feelings of isolation and helplessness; these can lead to a sense of guilt, preoccupation with death, or thoughts of suicide.⁹

Children and adolescents, like adults, may demonstrate changes in eating or sleeping behaviors. They may appear sluggish, easily agitated, or fidgety. The history should include questions about the child's withdrawal from daily activities and whether the child is clinging, more demanding, or more dependent on others. Children may also appear out of control or engage in excessive or reckless behaviors, including activities that produce harm or pain.¹⁰ Comorbid substance abuse should be considered in childhood depression, particularly in adolescence. Preoccupation with morbid thoughts and impulsive, angry, or irritable behavior can all be warning signs.^8-10

HOW DO I SCREEN PATIENTS IN PRIMARY CARE?

Screening for depression can have a significant impact,^3,5 and, in adults, can be accomplished by asking the patient two simple questions:^4,5

• During the past month, have you often been bothered by feeling down, depressed, or hopeless?

• During the past month, have you been bothered by having little interest or pleasure in doing things?

A positive response to either of these questions was both sensitive and specific for MDD, while a negative response to both questions virtually ruled out MDD.5 Significantly more cases of depression will be identified if patients are screened in a primary care setting.4 In addition to these two questions, other screening tools and resources are available.^2-5,11

Depression screening instruments for children and adolescents are limited in number, and their validity is limited as well. The clinician should seek information about recent changes in the child's behavior from the patient as well as from parents, teachers, and others in a position to observe the child.