Depression: Difference between revisions
(15 intermediate revisions by 7 users not shown) | |||
Line 1: | Line 1: | ||
==Background== | ==Background== | ||
*Depression is a risk factor for suicide, which is the leading cause of death among adolescents in the U.S.<ref>Miller, Leslie, and John V. Campo. “Depression in Adolescents.” New England Journal of Medicine, edited by Allan H. Ropper, vol. 385, no. 5, 2021, pp. 445–49. Crossref, doi:10.1056/nejmra2033475.</ref> | |||
*Depression in adolescence predicts depression & anxiety in adulthood and most affected adults had their first depressive episode during adolescence<ref>Miller, Leslie, and John V. Campo. “Depression in Adolescents.” New England Journal of Medicine, edited by Allan H. Ropper, vol. 385, no. 5, 2021, pp. 445–49. Crossref, doi:10.1056/nejmra2033475.</ref> | |||
==Clinical Features== | ==Clinical Features== | ||
Major Depressive Disorder (MDD) - Must have 5 of the following features for >2 wks<ref>American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.</ref> | |||
*Depressed mood or anhedonia (must be present) | |||
*SIGECAPS | |||
**Sleep decreased (Insomnia with 2-4 am awakening) | |||
**Interest decreased in activities | |||
**Guilt or worthlessness (Not a major criteria) | |||
**Energy decreased | |||
**Concentration difficulties | |||
**Appetite disturbance or weight loss | |||
**Psychomotor retardation/agitation | |||
**[[suicide|Suicidal thoughts]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Psych DDX}} | {{Psych DDX}} | ||
== | ==Evaluation== | ||
*Evaluate [[suicide|suicide risk]] | |||
*Depression screening with PHQ-9, the PHQ-2, the Beck Depression Inventory for Primary Care, and the WHO-5 | |||
{{General ED Psychiatric Workup}} | {{General ED Psychiatric Workup}} | ||
==Management== | ==Management== | ||
*Psych consult or admission if high risk of [[suicide]] | |||
*Consider consult with psychiatric team in other cases, particularly if severe symptoms and patient not already plugged into psych care | |||
*Pharmacologic agents (typically not started in ED due to need for monitoring and adjustment) | |||
**Antidepressants can take up to 8 weeks to reach maximum effect, so discuss expectations to ensure adherence.<ref>Miller, Leslie, and John V. Campo. “Depression in Adolescents.” New England Journal of Medicine, edited by Allan H. Ropper, vol. 385, no. 5, 2021, pp. 445–49. Crossref, doi:10.1056/nejmra2033475.</ref> | |||
**SSRIs (citalopram, fluoxetine, paroxetine, sertraline) | |||
**SNRIs ([[duloxetine]], [[venlafaxine]], milnacipran) | |||
**Serotonin modulators ([[trazodone]]) | |||
**Atypical ([[bupropion]], [[mirtazapine]]) | |||
**TCAs ([[amitriptyline]], clomipramine, desipramine, [[doxepin]], imipramine, [[nortriptyline]], trimipramine) | |||
**MAOIs (isocarboxazid, phenelzine, selegiline) | |||
*Cognitive Behavioral Therapy and Interpersonal psychotherapy have been shown to be effective in treating depression in adolescents.<ref>Miller, Leslie, and John V. Campo. “Depression in Adolescents.” New England Journal of Medicine, edited by Allan H. Ropper, vol. 385, no. 5, 2021, pp. 445–49. Crossref, doi:10.1056/nejmra2033475.</ref> | |||
==Disposition== | ==Disposition== | ||
* | *Those at risk for self-harm or harm to others should be admitted/transferred for psych evaluation. | ||
==See Also== | ==See Also== | ||
*[[SAD PERSONS score]] | |||
==External Links== | ==External Links== | ||
[http://emedicine.medscape.com/article/1859039-overview#a1 Screening test for depression] | |||
== | ==References== | ||
<references/> | <references/> | ||
[[Category: | [[Category:Psychiatry]] |
Latest revision as of 01:57, 9 August 2021
Background
- Depression is a risk factor for suicide, which is the leading cause of death among adolescents in the U.S.[1]
- Depression in adolescence predicts depression & anxiety in adulthood and most affected adults had their first depressive episode during adolescence[2]
Clinical Features
Major Depressive Disorder (MDD) - Must have 5 of the following features for >2 wks[3]
- Depressed mood or anhedonia (must be present)
- SIGECAPS
- Sleep decreased (Insomnia with 2-4 am awakening)
- Interest decreased in activities
- Guilt or worthlessness (Not a major criteria)
- Energy decreased
- Concentration difficulties
- Appetite disturbance or weight loss
- Psychomotor retardation/agitation
- Suicidal thoughts
Differential Diagnosis
General Psychiatric
- Organic causes
- Psychiatric causes
Evaluation
- Evaluate suicide risk
- Depression screening with PHQ-9, the PHQ-2, the Beck Depression Inventory for Primary Care, and the WHO-5
General ED Psychiatric Workup
- Point-of-care glucose
- CBC
- Chem 7
- LFTs
- ECG (for toxicology evaluation)
- ASA level
- Tylenol level
- Urine toxicology screen/Blood toxicology screen
- EtOH
- Urine pregnancy/beta-hCG (if female of childbearing age)
- Consider:
- Ammonia (see Hepatic encephalopathy)
- TSH (hypo or hyperthyroidism may mimic mental illness)
- CXR (for Tb screen or rule-out delirium in older patient)
- UA (for rule-out delirium in older patients)
- Head CT (to rule-out ICH in patients with AMS)
- Lumbar puncture (to rule-out meningitis or encephalitis)
Management
- Psych consult or admission if high risk of suicide
- Consider consult with psychiatric team in other cases, particularly if severe symptoms and patient not already plugged into psych care
- Pharmacologic agents (typically not started in ED due to need for monitoring and adjustment)
- Antidepressants can take up to 8 weeks to reach maximum effect, so discuss expectations to ensure adherence.[4]
- SSRIs (citalopram, fluoxetine, paroxetine, sertraline)
- SNRIs (duloxetine, venlafaxine, milnacipran)
- Serotonin modulators (trazodone)
- Atypical (bupropion, mirtazapine)
- TCAs (amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, trimipramine)
- MAOIs (isocarboxazid, phenelzine, selegiline)
- Cognitive Behavioral Therapy and Interpersonal psychotherapy have been shown to be effective in treating depression in adolescents.[5]
Disposition
- Those at risk for self-harm or harm to others should be admitted/transferred for psych evaluation.
See Also
External Links
References
- ↑ Miller, Leslie, and John V. Campo. “Depression in Adolescents.” New England Journal of Medicine, edited by Allan H. Ropper, vol. 385, no. 5, 2021, pp. 445–49. Crossref, doi:10.1056/nejmra2033475.
- ↑ Miller, Leslie, and John V. Campo. “Depression in Adolescents.” New England Journal of Medicine, edited by Allan H. Ropper, vol. 385, no. 5, 2021, pp. 445–49. Crossref, doi:10.1056/nejmra2033475.
- ↑ American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
- ↑ Miller, Leslie, and John V. Campo. “Depression in Adolescents.” New England Journal of Medicine, edited by Allan H. Ropper, vol. 385, no. 5, 2021, pp. 445–49. Crossref, doi:10.1056/nejmra2033475.
- ↑ Miller, Leslie, and John V. Campo. “Depression in Adolescents.” New England Journal of Medicine, edited by Allan H. Ropper, vol. 385, no. 5, 2021, pp. 445–49. Crossref, doi:10.1056/nejmra2033475.