Depression
Carla D. Edwards
Rachel Glick
Major depressive disorder is one of the most common psychiatric illnesses in the general population across global cultures and is associated with a significant degree of morbidity and mortality. The World Health Organization (WHO) has ranked major depression as one of the most burdensome illnesses for society (1) and in 2001 described the disease as a leading cause of disability worldwide (2). The WHO has also projected that major depressive disorder (MDD) will continue to play a significant role in global disease burden to the year 2020 (3,4).
The severity of major depression, as with most forms of illness, can be understood as existing on a spectrum from mild to severe. In its most severe form, major depression can affect daily function, self-care, ability to work, interpersonal relationships, subjective experience of life and emotion, susceptibility to development or worsening of medical illnesses, and increased use of health services. Studies have indicated that up to 56% of individuals with major depressive disorder attempt suicide, and 15% eventually succeed in committing suicide (5). In fact, depression is the most common diagnosis in elderly suicide attempters and completers (6). Therefore, recognition and treatment of major depression is vital to decrease burden of illness, restore function, and improve quality of life.
The emergency department (ED) is a common point of entry into the medical system for individuals with major depression. This is likely related to the degree of impairment and subjective distress that can accompany the illness. Understanding the common presenting features, immediate interventions that may be necessary, and important medical illnesses to consider as contributing or complicating factors and applying a methodical treatment approach will improve recognition and timely management of the patient with major depressive disorder.
EPIDEMIOLOGY
Numerous studies have reported the lifetime prevalence of major depressive disorder in the general adult population as 10% to 25% for women (7, 8, 9) and 7% to 12% for men (9). More than 50% of people who experience a major depressive episode suffer a recurrence (10). The prevalence of depression in community adolescents has been cited as 20% to 24% (11). Attempts have been made to quantify use of emergency services for mental health, and one study has reported an approximate national rate of 5.4% of all ED visits (12). That study also identified a trend of increased use of ED services for mental health of 15% between 1992 and 2000. Additional studies have measured the prevalence of major depression in adult patients presenting to psychiatric emergency services (PESs) at 20% to 30% (3,13,14).
Underrecognition of major depression in elderly patients who present to the ED has been described extensively. Prevalence rates of major depression in the elderly presenting to EDs have been reported as 27% to 30% (15,16); however, recognition of the illness by emergency physicians has generally been poor. One study reported that recognition of major depression by emergency physicians had a sensitivity of 27%, specificity of 75%, and positive predictive value of 32% (15). As a result, a high proportion of geriatric patients in the emergency department who fulfill criteria for major depression are not identified or referred to appropriate services.
PRESENTING FEATURES
The diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th Ed., Text Revision (DSM-IV-TR) list the cardinal symptoms
of major depressive disorder, requisite minimum duration of symptoms, features that preclude the diagnosis, and subtype specifiers of the illness (Table 17.1) (17). In general, the common presenting features of major depression can encompass emotional, cognitive, functional, behavioral, and somatic dimensions. They include subjective low mood, suicidal ideation, impaired interest, guilt, low energy, poor concentration, decreased appetite (or increased, as in atypical depression), psychomotor retardation (or agitation, as in agitated depression), impaired libido, and social isolation. Memory impairment can also be a common feature, likely related to impairment in attention and concentration. Suicidal ideation is present in a significant portion of individuals with major depression, and the rate of suicide in this population has been reported as being eight times higher than that of the general population (18).
of major depressive disorder, requisite minimum duration of symptoms, features that preclude the diagnosis, and subtype specifiers of the illness (Table 17.1) (17). In general, the common presenting features of major depression can encompass emotional, cognitive, functional, behavioral, and somatic dimensions. They include subjective low mood, suicidal ideation, impaired interest, guilt, low energy, poor concentration, decreased appetite (or increased, as in atypical depression), psychomotor retardation (or agitation, as in agitated depression), impaired libido, and social isolation. Memory impairment can also be a common feature, likely related to impairment in attention and concentration. Suicidal ideation is present in a significant portion of individuals with major depression, and the rate of suicide in this population has been reported as being eight times higher than that of the general population (18).
TABLE 17.1 DSM-IV-TR Diagnostic Criteria for Major Depressive Episode | ||||||||||||||||||
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Although depressed mood is considered a fundamental feature of major depressive disorder, patients with the illness may not present with reports of sadness or low mood. Additional common presenting features include chronic fatigue (13), agitation (19), somatic complaints (13,20,21), hypersomnia (22), hyperphagia (22), aggressiveness (23), self-harm (24), and anger attacks (25). In fact, anger attacks have been reported in 38% to 44% of individuals with major depressive disorder (25). Commonly cited somatic features of depression include chest pain (21), general pain (13,26,27), and headache (13). The heterogeneity of illness presentation can make recognition of major depression challenging, but the extensive disease burden and potentially fatal outcome make it imperative to screen all patients presenting to a PES for depression. Patients presenting to general emergency departments should also be further screened for depression when they present with several of the features just listed. Accurate diagnosis of depression is further complicated by the fact that other psychiatric illness (i.e., bipolar disorder) can pre-sent with similar symptoms (28,29). Potential consequences of failure to recognize and diagnose major depression include lack of appropriate referral and follow-up, substance abuse, declining self-care, worsening or development of medical illnesses, decreased productivity, strained interpersonal relationships, divorce, and suicide.
Both psychiatric and medical comorbidities are exceedingly common in individuals with major depressive disorder. Common comorbid psychiatric and medical illnesses are listed in Tables 17.2 and 17.3, respectively. Results from the replicated National Comorbidity Study in 2003 indicated that most lifetime and 12-month cases of major depressive disorder had comorbid DSM-IV disorders, with corresponding prevalence rates of 72.1% and 78.5% (44). According to that study, 59.2% of individuals with lifetime major depressive disorder also fulfilled criteria for anxiety disorders, 24.0% screened positive for substance abuse disorders, and 30.0% satisfied the diagnosis of impulse control disorders. These results were similar to the conclusions of the original National Comorbidity Study in 1997, which demonstrated a lifetime comorbidity of major depression with anxiety disorders at a prevalence rate of 58% and with substance use disorders at 39%. The overall prevalence rate of psychiatric comorbidities with major depressive disorder was 79% (45).
TABLE 17.2 Psychiatric Illnesses That Frequently Co-occur with Major Depression | ||||||
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TABLE 17.3 Medical Illnesses That Frequently Co-occur with Major Depression | ||||||||||||||||||||||
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Individuals with major depression and comorbid alcohol dependence have demonstrated lower global assessment of functioning (GAF) score, increased cannabis dependence, increased novelty-seeking behavior, and lower rates of
cooperation with treatment relative to depressed individuals who did not have alcohol dependence (46, 47, 48, 49). The risk of alcohol dependence is higher in depressed patients than the general population, and individuals with a history of alcohol depen-dence have shown higher rates of depression than those without alcohol dependence (48).
cooperation with treatment relative to depressed individuals who did not have alcohol dependence (46, 47, 48, 49). The risk of alcohol dependence is higher in depressed patients than the general population, and individuals with a history of alcohol depen-dence have shown higher rates of depression than those without alcohol dependence (48).
Psychotic depression is considered a severe subtype of major depressive disorder and is defined as the occurrence of delusions or hallucinations in the setting of a major depressive episode (50). Psychotic features have been reported at prevalence rates of about 15% of all depressed patients (51), and up to 25% of consecutively admitted depressed patients (30).
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