DEPRESSION   57A

A 57-year-old woman presents to her primary care clinician complaining of insomnia for 4 months. She reports that she can often fall asleep but awakens very early in the morning and cannot get back to sleep. She has a lack of interest in things that she previously enjoyed, frequent feelings of guilt and hopelessness, decreased energy, and occasional thoughts of “ending it all.” Her symptoms are making it hard for her to perform well at her place of employment. She denies any drug or alcohol use. A physical examination, including thyroid examination, is normal. Laboratory test results, including a thyroid-stimulating hormone (TSH), are normal.

What are the salient features of this patient’s problem? How do you think through her problem?

Salient features: Sleep disturbance with early awakening; anhedonia; decreased energy; guilt and hopelessness; suicidal ideation; functional disturbance; normal examination and laboratory results; no substance use disorder

How to think through: The prevalence of depression is high; unaddressed depression is a significant cause of morbidity and impediment to successful management of other chronic diseases. This patient’s initial complaint is sleep disturbance, which is common. What are her other symptoms and signs of depression? (Loss of interest, dysphoria, decreased energy, suicidal ideation.) When considering depression, what are the other crucial psychiatric diagnoses to consider? (Bipolar disorder, adjustment disorder, dysthymia, seasonal affective disorder, and substance abuse or dependence.) What medical disorder most commonly causes symptoms that mimic depression? (Hypothyroidism.) What are the treatment options? (Psychotherapy and pharmacotherapy are equivalent in efficacy; a combination of the two is superior to either alone.) What are the classes of pharmacotherapy? (Selective serotonin reuptake inhibitors [SSRIs], tricyclics, and monoamine oxidase inhibitors [MAOIs].) What is most serious potential adverse effect of these medications? (Serotonin syndrome may occur when taken in conjunction with MAOIs or selegiline or with other serotonergic agents.) What are the common side effects of SSRIs? (Headache, nausea, tinnitus, insomnia, nervousness, and sexual dysfunction.) While monitoring treatment, one must screen for suicidal ideation.

DEPRESSION   57B

What are the essentials of diagnosis and general considerations regarding depression?

Essentials of Diagnosis

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

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, anxiety, and disrupted sleep

    Loss of energy, appetite, and sex drive

In some severe depressions, psychomotor disturbance, delusions, withdrawal from activities, or suicidal ideation may manifest.

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.

Dysthymia is a chronic depressive disturbance with milder symptoms than major depression.

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