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Last Updated: 1/23/2013  

Depression

Diagnosis
  • Ask patients whether they have experienced depressed mood and anhedonia during the last month using the two-question model (PHQ-2):

    • “Over the past 2 weeks, have you felt down, depressed, hopeless?”

    • “Over the past 2 weeks, have you felt little interest or pleasure in doing things?”

  • Consider using the 4 “SALSA” questions to assess for the presence of four symptoms of depression: sleep disturbance, anhedonia, low self-esteem, and change in appetite in patients with a positive PHQ-2. Two of the four symptoms can confirm depression.

  • Use additional instruments such as the PHQ-9 in patients with symptoms.

  • Recognize the elderly as a high-risk group for depression and screen them appropriately, generally using the Geriatric Depression Scale.

  • Assess the severity of depression and functional impairment using the PHQ-9.

  • Assess suicidal ideation, intent, and risk.

  • Consider screening for hypothyroidism in patients with depression; base other laboratory testing for secondary causes of depression on clinical evaluation.

  • Recognize that the syndrome of major depression can be a presenting feature of other major mental disorders and substance abuse.

Therapy
  • Refer patients to a psychiatrist when the diagnosis is uncertain or when complex comorbidities or significant suicidal ideation is present, or if a patient does not respond to treatment.

  • Offer psychotherapy to all patients with depression.

  • Consider single-agent antidepressant drug therapy in patients with major depressive disorder, dysthymic disorder, or both (“double depression”). Treat patients with severe symptoms with an antidepressant.

    • For severe symptoms, treat with an antidepressant and possibly psychotherapy.

    • For moderate symptoms, treat with an antidepressant and/or psychotherapy.

    • For mild symptoms, treat with psychotherapy (if resources are available). Also consider antidepressants.

  • Base choice of anti-depressant on side effect profile.

  • Treat first episodes of depression to achieve complete remission, and continue treatment for 4 to 9 months thereafter.

  • Treat recurrences of major depression with long-term maintenance therapy.

  • Provide patient and family education and inform patients about the expected response time. Create systems of care incorporating collaborative care and/or the chronic care model.

  • Assess patients at 1-2 weeks for medication side effects, and at 6-8 weeks and 12 weeks for therapeutic response.

DOI: 10.7326/d954
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Disclosures:
Elana Sydney, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Steven Hahn, MD is a consultant for Pfizer, received honorarium from Pfizer, received grant from Lilly. Robert McCarron, DO is Editor of Lippincott's Primary Care Psychiatry. Matthew Reed, MD, MSPH has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.
Deborah Korenstein, MD, FACP, Editor in Chief, ACP Smart Medicine, has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Richard B. Lynn, MD, FACP, Editor, ACP Smart Medicine, has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
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