Depressive Disorders: Major Depression, Dysthymia, Depression NOS
Essential Concepts
Screening Questions
Have you felt down or depressed?
Have your friends noticed a change in you?
Have you lost interest in things you used to like to do?
Have you been feeling that life will never get better?
Mnemonic: SIG: E-CAPS
Our generation has had no Great War, no Great Depression. Our war is spiritual. Our depression is our lives.
—Chuck Palahniuk
Clinical Description
Rates of depression have increased over the past five decades, with younger age of onset. Many adolescents suffer from brief periods of depression when they are faced with an upsetting event or disappointment (breakup with girlfriend or boyfriend, for example). With increased rates of depressive disorders has come an increased rate of suicide attempts. However, after a marked increase, the rates of completed suicides for youth have declined since 1990, possibly due to improved detection and intervention of depression. Substance use, concomitant conduct problems, and impulsivity increase risk.
Major depressive disorder (MDD) and dysthymic disorder (DD) in children and adolescents are diagnosed in the same manner as those of adults. However, children and adolescents may present differently. Irritability, the new onset of oppositionality and angry outbursts, and failure to make expected weight
gain may be indicative of depression in children and adolescents. A rather precipitous drop in grades may be a clue to diminished interest and motivation and difficulty concentrating. Depressed mood and/or loss of interest or pleasure are key characteristics of MDD. Neurovegetative symptoms are those that suggest physical manifestations of the depression. Symptoms must be present for at least 2 weeks and must be functionally impairing to make a diagnosis of major depression.
gain may be indicative of depression in children and adolescents. A rather precipitous drop in grades may be a clue to diminished interest and motivation and difficulty concentrating. Depressed mood and/or loss of interest or pleasure are key characteristics of MDD. Neurovegetative symptoms are those that suggest physical manifestations of the depression. Symptoms must be present for at least 2 weeks and must be functionally impairing to make a diagnosis of major depression.
Key PointOne of the most difficult parts of psychiatry is asking the uncomfortable questions. Asking about suicide is one of those questions. However, put it into your repertoire of questions that you ask all children and adolescents. You may save a life.
Major Depressive Episode (MDD)
Mnemonic: SIG E CAPS
When checking for neurovegetative symptoms of depression, think of the mnemonic devised by Dr. Carey Gross at MGH which refers to what one might write on a prescription sheet for a depressed patient: SIG: Energy CAPSules
Sleep disorder (either increased or decreased)*
Interest deficit (anhedonia)
Energy deficit*
Concentration deficit*
Appetite disorder (either decreased or increased)*
Psychomotor retardation or agitation
Suicidality
Clinical Vignette
A 15-year-old adolescent girl presented for her first office visit because her parents are concerned that she is depressed. You ask about sad mood and find out that she has been crying every day since she broke up with her boyfriend over 2 weeks ago. She has not wanted to get out of bed, and her friends have
complained that she doesn’t want to go out with them anymore. She has typically been an A–B student and failed her first math test last week. You ask if she has felt as though life was no longer worth living, and she replies, “Sure, but it doesn’t do any good. I took 10 Tylenols last week and I’m still here.” You assess for acute suicidality and ask her mother to join the session. The girl tells her mother, who responds with appropriate concern. You determine the patient is safe to go home, but her mother will secure all medications. You send her to get blood drawn for liver function tests due to potential hepatoxicity of acetaminophen, and add thyroid and basic screening labs to the panel. You call her pediatrician to inform her of the patient’s depression and overdose. You set up the patient for a partial hospital program the next day.
complained that she doesn’t want to go out with them anymore. She has typically been an A–B student and failed her first math test last week. You ask if she has felt as though life was no longer worth living, and she replies, “Sure, but it doesn’t do any good. I took 10 Tylenols last week and I’m still here.” You assess for acute suicidality and ask her mother to join the session. The girl tells her mother, who responds with appropriate concern. You determine the patient is safe to go home, but her mother will secure all medications. You send her to get blood drawn for liver function tests due to potential hepatoxicity of acetaminophen, and add thyroid and basic screening labs to the panel. You call her pediatrician to inform her of the patient’s depression and overdose. You set up the patient for a partial hospital program the next day.
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