Diagnosing Mood Disorders Part 1

Screening for Depression

The primary care physician’s most powerful screening tool for depression is patient observation and active listening skills.  Most depressed patients do not realize they are depressed – and this is especially true in elderly patients. A physician should consider that a patient may have depression in the setting of unexplained physical symptoms or complaints. The higher the number of somatic complaints that a patient has, the higher the risk that they may have a mood disorder. Other clues may be a patient with persistent worries or concerns about medical illness, complaints that do not respond to typical interventions, or complaints outright of anxiety or panic attacks.  Patients with substance abuse issues may also suffer from a mood disorder. A careful history of present illness, past medical history, social and family history, and review of systems may yield more important information for making the diagnosis.

The primary care physician should ask open-ended questions of the patient about normal patterns as well as variations to determine baseline function and mood.  Mood is a range of emotions that a person feels over a period of time, while affect is how a person displays his or her mood.  The presence of a mood disorder may affect a person’s concentration, attention, motivation, interest, and sleep, as well as energy level, hunger and satiety levels, sexual pleasure, and pain sensation. These patients also frequently lose interest and lose pleasure (anhedonia) in things, people, or activities that they used to enjoy. Interruption in personal relationships with others can be a side effect due to increasing anger and conflicts, lower frustration tolerance, or from apathy and lack of enthusiastic feelings towards other people. Patients with depression may become emotionally constricted and lose their emotional flexibility.

Depression can impair cognitive function.  Cognitive dysfunction is common and patients may state that when they watch television they lose the point of the story; they read the same page of a book over and over again without comprehension; or lose the point of conversations with other people. A depressed patient’s memories may amount to more of selective recall, and normal perceptions may become distorted. Severe cognitive impairment due to depression is known as pseudodementia, and may be seen in elder populations or patients with central nervous disorders. 

Psychomotor activity is usually decreased in depressed patients. Psychomotor retardation is present when thoughts, motor movements, or speech are slowed down. Psychomotor agitation can also occur and is present when patients experience unintentional and purposeless movements – such as unstoppable crying, pacing around a room, or hand-wringing. Frequently patients may complain of insomnia. In addition to having difficulty falling asleep, depressed patients typically wake up in the middle of the night or early in the morning with feelings of sadness, anxiety, or thoughts of dread or doom. They may also sleep excessively or stay most of the day in bed.

Depressed patients may also have self-worth that goes through turbulent fluctuations. For depressed patients, past events may be viewed with extreme guilt and self criticism, and feelings of worthlessness. Patients may view themselves and their world as hopeless. Suicidal ideation or a history of suicidal attempts from the patient should be assessed. Asking depressed patients about recent bereavement is also important to note.

A past medical history of prior episodes of depression is a very important question because you may be observing a relapsing episode. In addition, the physician should inquire about a previous history of bipolar disorder because inappropriate treatment with an antidepressant-therapy alone in these patients may precipitate a manic episode.  It is also important to inquire about a family history of depression or bipolar disorder.

When to think about screening adults for depression
  • Personal previous history of depression or bipolar disorder
  • First-degree biologic relative with history of depression or bipolar disorders
  • Patients with chronic diseases
  • Obesity
  • Chronic pain (e.g., backache, headache)
  • Impoverished home environment
  • Financial strain
  • Experiencing major life changes
  • Pregnant or postpartum
  • Socially isolated
  • Multiple vague  and unexplained symptoms (e.g., gastrointestinal, cardiovascular, neurological)
  • Fatigue or sleep disturbance
  • Substance abuse (e.g., alcohol or drugs)
  • Loss of interest in sexual activity
  • Elderly age

Adapted from Sharp, LK, Lipsky MS. “Screening for depression across the lifespan: a review of measures for use in primary care settings.” American Family Physician. 2002; 66: 1001-1008

Question 2:

Which are the current recommendations of United States Preventive Screening Task Force for screening adults for depression in primary care settings?(Choose the best answer.)

  1. No recommendation for or against routine screening for depression in primary care settings
  2. Screen only adults with positive risk factors for major depression, such as those with a positive family history or chronic pain
  3. Screen in all primary care practices because it is highly effective
  4. Screen only when the primary care practice has a psychiatrist on staff
  5. Screen only when systems are in place to ensure adequate treatment and follow up
Show answer >>
The correct answer is e. The United States Preventive Screening Task Force recommends “screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow up” (USPSTF, 2006). The system in place to assure follow up and monitoring can be the primary care physician, their primary care colleagues, or properly trained staff such as nurses. Access to mental health services, outside the practice, is important should referrals be necessary for complicated cases (e.g., psychiatrists, therapists, emergency departments, etc.). The USPSTF recommends that clinicians provide depression screening to eligible patients because of fair evidence that screening improves important health outcomes and concludes that benefits outweigh harms. The existing literature suggests that screening tests perform reasonably well in adolescents and that treatments are effective, but the clinical impact of routine depression screening has not been studied in pediatric populations in primary care settings. (Source: United States Preventive Screening Task Force. Screening for depression: Recommendations and rationale. November 2006 Recommendations. http://epss.ahrq.gov/PDA/index.jsp)

There are many formal screening tools available such as the Zung Self-Assessment Depression Scale, Beck Depression Inventory, General Health Questionnaire (GHQ), Center for Epidemiologic Study Depression Scale (CES-D), and the Patient Health Questionaire-2 (PHQ-2). The USPSTF does not recommend one screening test over another and the interval for screening that is considered optimal is unknown. Recurrent screening in patients with a history of depression, unexplained somatic symptoms, substance abuse, chronic pain, or co-morbid psychological conditions may be the most useful. Any screening test that is positive requires a full diagnostic interview that uses standard diagnostic criteria, Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV) to determine the presence of major depressive disorder and/or dysthymia.

The Patient Health Questionnaire - 2 (PHQ-2) is a validated primary care tool for depression screening, and is favored because of the relative ease of using a two question tool and because the USPSTF believes that with current available evidence it is as effective as longer screening tools.

Patient Health Questionnaire – 2  (PHQ-2)
Screen for depression by asking the following 2 questions:
Over the past 2 weeks, have you been bothered by:

  • little interest or pleasure in doing things?
  • feeling down, depressed, or hopeless

A “no” response to both questions is a negative screen.

A “yes” response to either question OR if the physician is still concerned about depression, then the physician  should ask more thorough assessment questions using the Patient Health Questionnaire – 9 (PHQ-9).

The Patient Health Questionnaire – 9 (PHQ-9) is a nine item questionnaire that can be completed by the patient before or during a primary care office visit. It is available in several languages. The PHQ-9 can reliably detect and quantify the severity of depression using the DSM-IV criteria for major depressive episode. The PHQ – 9 was created by Dr. Robert Spitzer, et al. at Columbia University and is copyright protected by Pfizer Inc. The PHQ – 9 is also useful for patient follow up visits to assess symptom management.

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