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Updated 5/1/11
DEPRESSION
DIAGNOSIS
& MANAGEMENT:
(Steps in evaluation and
management)
Step #1)
Screen for depression
Step
#2) Diagnose depression
Step
#3) Differentiate from
specialized causes
of mood disorders that require
psychiatric care:
1) Bipolar disorder
2) Psychotic depression
Step #4) Evaluate for :
cause or co-morbid
medical & neurologic conditions
Step
# 1) DIAGNOSIS (assess two main areas for diagnosis)
a) Mood
and Loss of Interest or Pleasure
b) Vegetative
signs remembered by : “SIG-E-CAPS”
|
Symptoms* |
Major Depression |
Minor Depression |
Dysthymia |
Depressed mood
or loss of
interest/pleasure** |
> 2 weeks |
> 2 weeks |
> 2 years with symptoms
present > 50% of days |
|
"SIG-E-CAPS"* |
|
|
|
|
S
leep changes |
FOUR |
THREE |
OFTEN |
|
I
nterest changes |
OF |
OF |
some |
|
G
uilt (worthless) |
|
|
symptoms |
| |
EIGHT
"SIG-E-CAPS" |
EIGHT
"SIG-E-CAPS" |
are present |
|
E
nergy (lack) |
NEEDED |
NEEDED |
but not |
| |
|
|
enough |
C
ognition/C
oncentration |
FOR
DIAGNOSIS |
FOR
DIAGNOSIS |
to meet |
|
A
ppetite (wt loss) |
|
|
criteria for |
|
P
sychomotor |
|
|
Major or Minor |
S
uicide/death
preocp. |
|
|
depression |
*Symptoms
must cause dysfunction and have no direct physiologic cause.
**"Gateway" sx's: Depressed mood or loss of interest or pleasure
are required for diagnosis.
(Gateway sx's avoid overlap with medical illness)
Step # 2) EVALUATION FOR CAUSE or
CO-MORBID CONDITIONS
1)
H
& P, full neurologic exam & MMSE
(similar to dementia
work up)
2)
Lab
evaluation (similar evaluation as in dementia and
delirium)
| BASIC LABS |
INDICATION DEPENDENT LABS |
| CBC |
VDRL |
ANA |
| Chemistry Profile |
HIV |
Ammonia |
| ESR |
Lumbar Puncture |
|
| TSH |
Lymes Titer |
EEG |
| B12 Level |
CT/MRI (only
if neurologic symptoms are present) |
Neuropsychological testing |
| Folic Acid |
| UA |
| DRUG
|
“NICHE” |
ADVANTAGES
|
| SSRI’s |
-Effective
in
most
depressions.
-Safe in cardiac
conduction
problems,
glaucoma, & BPH
|
low
amount of anti-cholinergic
side effects |
|
Mirtazapine
(Remeron) |
insomnia,
anorexia |
+
weight gain, sleep |
|
Bupropion
(Wellbutrin) |
-Effective for
lethargy &
apathy. If
poor response to
other classes &
in CHF |
Stimulating
or in smoking cessation |
|
|
-Effective
for
apathy in
medically ill
with depressed
mood.
-Can
combine
with other
antidepressants
short term
|
-Rapid
onset
-Low
risk
addiction
-Minimal
side
effects
|
|
Venlafaxine
(Effexor) |
Severe
depression, generalized anxiety or neuropatic pain |
Efficacious
for severe depression |
Duloxetine
(Cymbalta) |
Diabetic neuropathy
Urge Incontinence |
|
******************TREATMENT***************
A)
Target symptoms (don’t only rely on “Are you better”?)
e.g.
follow vegetative signs
B) Non-pharmacologic
| |
1)
Become a care-giver |
|
2) Prescribe
activity |
| |
3)
Consider psychotherapy |
|
4)
Correct all co-morbid factors |
|
5)
Enhance all sensory systems ( i.e. vision and hearing.) |
DRUG DOSING:***************************************
|
DRUG |
INITIAL
DOSE |
MAINTENANCE
DOSE |
|
SSRI’s |
|
Sertraline
(Zoloft) |
25
mg q d |
50-200
mg q d |
|
Citalopram
(Celexa) |
10
mg q d |
20-40
mg q d |
| Escitalopram (Lexapro) |
10 mg q d |
10-20 mg q d |
| Paroxetine (Paxil) |
10 mg q d |
10-30 mg q d |
|
OTHERS |
|
Bupropion
(Wellbutrin) |
75 mg q am |
100-300
SR q d |
|
Trazadone |
25
mg q d |
25-200
mg q d (higher
doses divide to bid) |
|
Venlafaxine
(Effexor) |
3.75
mg (XR) daily |
75-225 mg (XR) q d |
| Duloxetin
(Cymbalta) |
20 mg q d |
30-60 mg q d |
|
Methylphenidate |
2.5
mg q d |
5
mg bid |
|
Mirtazapine
(Remeron) |
7.5
mg q hs |
15-45
mg q hs |
For
additional information see:
Website:
geriatrics.unmc.edu
Kennedy G. Depression and other mood disorders. Geriatric Review Syllabus 7th
Ed.,pp331-344.
Fitten LJ. Common psychiatric disorders. Practical Ambulatory Geriatrics 2nd
Ed
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