Major depressive disorder and persistent depressive disorder (dysthymia): Clinical sciences

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Decision-Making Tree
Transcript
Depression is a state of persistent sadness that affects how a person thinks, feels, and behaves. It can cause significant personal distress, strain relationships, and impair daily functioning. Additionally, depression significantly increases the risk of self-harm and suicidality. Depressive disorders include major depression and persistent depressive disorder, also known as dysthymia.
When a patient presents with a chief concern suggesting a depressive disorder, first perform a safety assessment. Assess for features of psychosis like agitation, paranoia, aggression, hallucinations, and other forms of disorganized thoughts, speech, or behavior.
Additionally, look for signs of catatonia, such as slow movements, holding odd poses, and minimal response to external stimuli, which can be accompanied by severe dehydration or malnutrition.
Finally, assess specifically for homicidal and suicidal ideation, paying attention to the intensity and intention, as evidenced by plans and behaviors. If any of these features are present, the patient is at high risk of harm to self and others and requires acute management.
Your management might include psychiatric hospitalization, medical and pharmacologic stabilization, and a one-to-one sitter, if appropriate. In severe, persistent treatment-resistant or life-threatening cases, electroconvulsive therapy might be necessary.
On the other hand, if the patient is at low risk of harm to self and others, your next step is to obtain a focused history and physical exam. History usually reveals persistently sad, depressed, or hopeless mood, with decreased energy, and a lack interest and motivation that is significantly different from their baseline.
On exam, the patient might exhibit poor posture, slow speech and movements, with a flat or tearful affect. Additionally, you might see signs of inattention and memory difficulties affecting focus, recalling information, and performing tasks that require mental effort. These findings should lead you to suspect a depressive disorder.
Here’s a clinical pearl! During the history and exam, look for signs that suggest your patient's depressive symptoms are attributed to a medical condition or substance use. For example, hypothyroidism or a chronic pain disorder can mimic symptoms of depression.
Sources
- "Depressive Disorders" Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (2022)
- "Summary of the clinical practice guideline for the treatment of depression across three age cohorts" Am Psychol (2022)
- "The Management of Major Depressive Disorder: Synopsis of the 2022 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline" Ann Intern Med (2022)
- "Prevention, Diagnosis, and Management of Serotonin Syndrome" American Family Physician (2010)