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Last Updated: 6/9/2014  

Depression

Diagnosis
  • Ask patients whether they have experienced depressed mood or anhedonia during the last month (PHQ-2).

  • Consider using the four “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, persistent depressive disorder (dysthymia), or both (“double depression”). Treat patients with severe symptoms with an antidepressant.

  • Base choice of antidepressant 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 to 2 weeks for medication side effects, and at 6 to 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 has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Matthew Reed, MD, MSPH has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.
The following editors of ACP Smart Medicine have nothing to disclose: Deborah Korenstein, MD, FACP, Editor in Chief; Richard B. Lynn, MD, FACP, Editor; and Davoren Chick, MD, Editor.
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