Major depression: Screening and treatment

Major depressive disorder (MDD) can complicate the care of patients in any clinical setting and is an issue for any PA practicing in primary care, as well as for those working in many specialty settings where depression may be common but poorly recognized. As many as 6% of pediatric patients and 16% of adult patients will meet the diagnostic criteria for MDD. Screening may be as simple as asking two questions and can provide a basis for improving the outcomes from this debilitating disorder.

WHAT ARE THE SYMPTOMS OF DEPRESSION?

MDD in adults is defined by the persistence for 2 weeks or more of five or more of the following symptoms:

• Depressed mood for most of the day, every day

• Diminished pleasure from or interest in almost all activities

• Weight loss, weight gain, or a change in eating habits

• Hypersomnia or insomnia

• Excessive or diminished physical movement/expression (psychomotor agitation or psychomotor retardation)

• Loss of energy and fatigue

• Feelings of worthlessness or inappropriate guilt

• Impaired decisiveness or inability to concentrate

• Intrusive thoughts of death or suicide.

Alcohol or drug abuse must be ruled out as a contributing factor. Other secondary causes of behavioral changes, including grief, medication, or an organic metabolic imbalance, should be addressed. In the absence of these, depression should be diagnosed and treatment should be planned.

Patients with depression may complain of mood disturbances but attribute their problems to stress or difficulties in their personal or business lives. They may schedule multiple visits to discuss vague symptoms, such as GI complaints. The history should include questions about previous episodes of depression or depressive symptoms, other mood disorders, psychotic disorders, substance abuse, and other behavioral disorders, as well as other risk factors (Table 1).

Children can experience depressive symptoms similar to those in adults,8 including feelings of hopelessness and loss of pleasure or interest in activities. Children may become anxious and exhibit turmoil in their lives. The prevalence of depression increases from 3% among children to 6% in adolescents, with up to a 20% lifetime MDD prevalence among adolescents. Depression affects a child's cognitive, physical, and behavioral function and manifests as feelings of isolation and helplessness; these can lead to a sense of guilt, preoccupation with death, or thoughts of suicide.

Children and adolescents, like adults, may demonstrate changes in eating or sleeping behaviors. They may appear sluggish, easily agitated, or fidgety. The history should include questions about the child's withdrawal from daily activities and whether the child is clinging, more demanding, or more dependent on others. Children may also appear out of control or engage in excessive or reckless behaviors, including activities that produce harm or pain. Comorbid substance abuse should be considered in childhood depression, particularly in adolescence. Preoccupation with morbid thoughts and impulsive, angry, or irritable behavior can all be warning signs.