Depression

Clinical Features

Must have 5 of the following features for major depressive disorder for >2 wks

• 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
  • Delirium
  • Dementia
  • Overdose
• Psychiatric causes
  • Depression
  • Anxiety
  • Conversion disorder
  • Bipolar disorder
  • Acute psychosis
  • Panic attack
  • Schizophrenia

Evaluation

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

• Consult with psychiatric team
• Pharmocologic agents, typically not started in ED due to need for monitoring and adjustment
  • SSRIs (citalopram, fluoxetine, paroxetine, sertraline)
  • SNRIs (duloxetine, venlafaxine, milnacipran)
  • Serotonin modulators (trazodone)
  • Atypical (bupropion, mirtazpine)
  • TCAs (amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, trimipramine)
  • MAOIs (isocarboxazid, phenelzine, selegiline)

Disposition

• See Sad person's score

External Links

Screening test for depression