The word depression is both a psychiatric diagnosis and a common term used to describe varying degrees of unhappiness. It is important for the GMO to be able to distinguish common anger, frustration, disgruntlement, dysphoria, or fatigue from clinical depression with attendant neurovegetative signs and symptoms. Patients may present complaining of depression who are merely reacting temporarily to environmental stressors such as long work hours, separation from their families, personal illness, etc. Another group of patients who complain of depression have chronic, intermittent depressive symptoms of a characteristic nature; their habitual feelings of boredom, emptiness, worthlessness, low self-esteem, or irritability are due to personality disorders, which are Axis II diagnoses.

Patients may present with depressive symptoms while taking medications or other substances that cause depression (alcohol, propranolol, clonidine, benzodiazepines, antihistamines, illicit drugs) or who are withdrawing from stimulants (caffeine, nicotine, OTC cold/flu preparations, amphetamines, other illicit drugs, etc.). Finally, depressive feelings may be related to an underlying organic factor such as hypothyroidism or another endocrinologic disorder, occult malignancy, or early dementia or another organic brain syndrome.

Diagnosis of Major Depressive Episode (MDE)

To make a presumptive diagnosis of MDE, at least 5 of the following must be present most or all of the time during the same 2-week period.

• Depressed mood

• Inability to experience pleasure

• Significant weight loss or gain (>5 percent of body weight) or significant change in appetite

• Insomnia or hypersomnia (significantly changed from the patient's normal sleep pattern)

• Psychomotor agitation or retardation (observed by you or others)

• Decreased libido

• Feelings of worthlessness, hopelessness, helplessness, or guilt

• Decreased concentration

• Suicidal thoughts or ruminations about death

To qualify for the diagnosis of MDE, these symptoms must not be the direct physiological effect of substances (intoxications or withdrawal) or of a general medical condition (such as hypothyroidism). They must also not be experienced only in the first 2 months following the loss of a loved one, as in bereavement. Patients sometimes exaggerate their depressive symptoms in order to gain sympathy or some desired change in their environment. Your best criterion for ruling out exaggerated depressive symptoms as well as those due to characterologic or situational factors, is noting the unremitting presence of the symptoms. If a patient’s depressive symptoms remit while on liberty or leave, or when removed from the source of distress, then he or she probably does not have MDE.

Physical Exam and lab studies

Focus the mental status examination on the following areas:

• Hygiene and grooming

• Psychomotor agitation or retardation

• Presence or absence of hallucinations and/or delusions

• Mood and affect

• Quality of speech/thought content centered on feelings of hopeless, helpless, guilt, and suicidal or homicidal thoughts

The general physical exam should include a neurologic examination and should focus on signs consistent with hypothyroidism, intoxication, withdrawal, and occult malignancy. Routine screening labs should include Chem 1, CBC, RPR, UA, urine toxicology screen, and thyroid function tests (TFTs). A baseline EKG may be indicated for patients over age 40.

Simple supportive measures should be prescribed for those patients not meeting criteria for MDE: discontinuation of stimulants or depressants, regular sleep, eating regular healthy meals, relaxation, regular exercise, and obtaining social support from peers, friends, and family members. Patients who meet criteria for MDE, who are suicidal, or who continue to complain of depression despite implementation of conservative measures as described, should be referred for psychiatric evaluation. In cases in which referral to a psychiatrist will be delayed, or when symptoms are so severe that initiating an antidepressant is judged to be prudent, the GMO is advised to begin treatment with a selective serotonin reuptake inhibitor (SSRI) such as Prozac, Zoloft, or Paxil.

When evaluating a patient referred for depression, document the presence or absence of concomitant psychotic thought processes, such as delusions, and the presence or absence of suicidal or homicidal ideation. If a patient expresses suicidal or homicidal ideation with a workable plan and intent, he or she should be placed on a 1:1 watch until evaluated by psychiatry or until the intent clearly resolves. Treat psychoses with neuroleptics such as Haldol.

1. The American Psychiatric Press Synopsis of Psychiatry, edited by Robert Hales and Stuart