Okay. Today, we’re going to be discussing depression.
Now, depression is something we
see very commonly in primary care.
It's estimated that up to 40% of patients
presenting to primary care practices
have some form of depressive symptoms.
I thought we’d start with a case here just to illustrate
some of the history and
the symptoms of depression.
So, I’ve got a 30-year-old female.
She complains of fatigue and a lack of interest
in her normal activities for the past three months.
It's a very rare patient who comes out and says
I'm depressed as their chief complaint,
but feeling fatigue,
not being – not feeling like yourself,
these vague symptoms,
that's a lot more common in terms of the presentation.
She reports that she's depressed only sometimes
and denies any recent stress.
That’s a good question to ask.
She also has no previous history
of any mental health disorders.
Now, clearly, there's more history to
be obtained from this patient.
But what’s the most critical additional
history to obtain from her?
So, should it be, A, any family history of thyroid disorders;
B, a history of any abnormal bleeding,
thinking about anemia; C,
any history of suicidal ideation;
or D, a family history of mental health disorders?
Which one do you think it is?
The answer is C,
history of suicidal ideation.
Because the question asked the
most critical bit of information.
By far the most critical information in her history
is the risk of suicidal ideation or suicidality,
the worst outcome in depression is suicide.
And depression, of course,
predisposes patients to suicide.
So, it’s better to ask about,
directly bringing out in the open.
So, how do we define major depressive disorder?
So, it’s defined by either depressed
mood or that term anhedonia,
that loss of pleasure in doing your
normal activities, for at least two weeks.
So, it doesn't take a long duration of symptoms
to be defined as a major depressive disorder,
but it does require impairment in function as well.
And then five of the following nine symptoms
should be present nearly every day.
So, it's not like just one or two days you feel the blues
and therefore you have major depressive disorder.
This has to be pervasive,
causes impairment in function
and has to be present on most days.
Those nine symptoms can include depressed mood,
anhedonia as we mentioned,
weight change or change in appetite,
change in sleep,
change in activity,
feelings of guilt, or worthlessness,
difficulty in concentrating on things,
and suicidal thoughts.
So, five of these nine have to be present
for at least two weeks along with either
the depressed mood or anhedonia
and that's how we define major depressive disorder.
What about screening for depression?
I mentioned how common it is in primary care.
Should we be looking for it in everybody?
Actually, the United States Preventive Services
Task Force (or USPSTF) suggests that, yes,
we should be screening for depression among adults
as long as there’s capacity for follow-up.
That means that we can continue to see
the patients for the depression and treat it proactively.
How do we screen?
The patient health questionnaire is nine items
and it has a good sensitivity and
specificity for diagnosing depression.
But there's another scale called the
Patient Health Questionnaire 2,
which is just two items
related to depression or anhedonia in the past month.
That's very sensitive for diagnosing depression.
And if it’s negative,
the risk of the patient having depression is very,
very small and they don't need more screening.