Depression

Background

• Depression is a risk factor for suicide, which is the leading cause of death among adolescents in the U.S.
• Depression in adolescence predicts depression & anxiety in adulthood and most affected adults had their first depressive episode during adolescence

Clinical Features

Major Depressive Disorder (MDD) - Must have 5 of the following features 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

• Evaluate suicide risk
• 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

• Psych consult or admission if high risk of suicide
• Consider consult with psychiatric team in other cases, particularly if severe symptoms and patient not already plugged into psych care
• Pharmacologic agents (typically not started in ED due to need for monitoring and adjustment)
  • Antidepressants can take up to 8 weeks to reach maximum effect, so discuss expectations to ensure adherence.
  • SSRIs (citalopram, fluoxetine, paroxetine, sertraline)
  • SNRIs (duloxetine, venlafaxine, milnacipran)
  • Serotonin modulators (trazodone)
  • Atypical (bupropion, mirtazapine)
  • TCAs (amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, trimipramine)
  • MAOIs (isocarboxazid, phenelzine, selegiline)
• Cognitive Behavioral Therapy and Interpersonal psychotherapy have been shown to be effective in treating depression in adolescents.

Disposition

• Those at risk for self-harm or harm to others should be admitted/transferred for psych evaluation.

See Also

• SAD PERSONS score

Calculators

PHQ-9 (Patient Health Questionnaire)

PHQ-9 Depression Screening

Over the last 2 weeks...	Not at all (0)	Several days (1)	More than half (2)	Nearly every day (3)
1. Little interest or pleasure	1 0	1	2	3
2. Feeling down, depressed, hopeless	1 0	1	2	3
3. Trouble falling/staying asleep	1 0	1	2	3
4. Feeling tired/little energy	1 0	1	2	3
5. Poor appetite or overeating	1 0	1	2	3
6. Feeling bad about yourself	1 0	1	2	3
7. Trouble concentrating	1 0	1	2	3
8. Moving/speaking slowly or being fidgety	1 0	1	2	3
9. Thoughts of self-harm	1 0	1	2	3
PHQ-9 Score		/ 27

Interpretation

0–4	Minimal depression
5–9	Mild depression
10–14	Moderate depression — Consider treatment plan.
15–19	Moderately severe depression — Active treatment recommended.
20–27	Severe depression — Immediate treatment, consider referral.

References

Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613. PMID 11556941.

External Links

Screening test for depression