Major Depression in Adults in Primary Care

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Source:  Institute for Clinical Systems Improvement (ICSI). Major depression in adults in primary care. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2007 May. 87 p. Major Depression in Adults in Primary Care Suspect Major Depression: (see also box #1a). A. Presentations (in addition to obvious sadness) - multiple somatic complaints and visits (i.e. greater than 5 visits; more than 1 organ system with the absence of physical findings); weight gain/loss, mild dementia. - fatigue/sleep disturbances. - changes in work and/or interpersonal relationships. The two-question screen: Over the past month have you been bothered by: 1. Little interest or pleasure in doing things? 2. Feeling down, depressed, or hopeless? B. Risk Factors - history of major depression and/or substance abuse. - dysthymia. A Diagnose and characterize major depression with clinical interview to include: A. DSM-IV TR criteria (see box #2a, 2b). B. History of present illness. (Onset and severity of symptoms, functional impairment, past episodes and psychosocial stressors). DSM-IV TR Criteria for Major Depressive Episode: Must have a total of 5 symptoms for at least 2 weeks. One of the symptoms must be depressed mood or loss of interest. 1. Depressed mood. 2.   Markedly diminished interest or pleasure in all or almost all activities. C. Pertinent medical history, especially illness that can cause depression. D. Assess for current substance abuse, withdrawal or medications that can cause depression. E. Psychiatric comorbidity. A Greater than or equal to 5 DSM-IV TR criteria present? A Consider other mood and anxiety disorders or somatoform disorders. A 3. Significant (greater than 5% body weight) weight loss or gain, or increase or decrease in appetite. 4. Insomnia or hypersomnia. 5. Psychomotor agitation or retardation. 6. Fatigue or loss of energy. 7. Feeling of worthlessness or inappropriate guilt. *Consider hospitalization. *Out of guideline. Is patient unsafe to self or others?. A 8. Diminished concentration or indecisiveness. 9. Recurrent thoughts of death or suicide. Involve behavioral/chemical health. A Assess need for additional resources: substance abuse or psychiatric comorbidity, especially bipolar disorder? A Subtypes *Atypical Major Depressive Disorder. *Major Depression Disorder with Psychotic Features. *Seasonal Affective Disorder. *Melancolic. *Catatonic. *Postpartum. Additional considerations? *Medical comorbidity. *Cultural beliefs. *Special population. A Address secondary causes and/or adapt a plan for the special population. A Treatment Plan *Educate and engage patient. *Discuss treatment options (if a subtype exists, specific therapy may be indicated). *Establish follow-up plan. A Is patient responding adequately? A Continuation and maintenance treatment for 6-12 months. A Evaluate dose, duration, type and adherence with medication and/or psychotherapy. Reconsider accuracy of diagnosis or impact of comorbidities. A Consider other strategies: *Switch therapy. *Augmentation therapy. *Other therapies. *Add and/or modify psychotherapy. *More intense or higher level of psychotherapy. A A = Annotation All copyrights are reserved by the Institute for Clinical Systems Improvement, Inc.