Depression

Rationale

Depression is a very common problem in adults that results in significant morbidity and mortality. Often the internist is the first health professional to see a depressed patient. Frequently, the initial presentation is associated with somatiform complaints that bring the patient to the internist or with serious underlying medical illness. There is significant evidence that primary care physicians commonly fail to diagnose major depression. With recent improvements in available treatment, it is even more important for internists to screen for depression and to know the common presenting symptoms. The internist should also be familiar with available therapeutic options and be prepared to treat selected patients including those who decline consultation with a mental health professional.

Prerequisites

1. neurochemistry of depression
2. mechanism of action of the major classes of anti-depressants
3. major characteristics of bipolar disorder, major depression, dysthymia, depressive reaction (brief and prolonged), dementia, and delirium
4. know how to perform the mental status examination

Specific Learning Objectives

1. Knowledge: Students should be able to define and describe:
   1. the prevalence of depression in the general population and the impact of major illness on the prevalence of depression
   2. the impact of depression on the outcome of medical illness
   3. the nine symptoms of major depression (see Appendix A), and name the minimum number of them (five) that makes a diagnosis of major depression likely
   4. common somatic symptoms associated with major depression (insomnia, restlessness, anhedonia, decreased cognition, memory loss, weight gain, weight loss, fatigue)
   5. basic principles of brief psychotherapy (see Appendix B) and its application to dysthymia, depressive reactions, and major depression
   6. the sedative, anticholinergic, and cardiac effects of the major classes of anti-depressant drugs, and common interactions with other medications
   7. the medical indications and contraindications to electroconvulsive therapy
2. Skills: Students should demonstrate specific skills including:
   1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiologies of disease, in order to:
      1. determine an individual patient’s potential risk for subsequent depression
      2. determine the presence or absence of underlying dementia, anxiety disorder, adverse drug effect, and grief in any patient suspected of having depression
      3. determine a patient’s risk for suicide
      4. obtain a complete drug history (including illicit drugs)
   2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease, including:
      1. a complete screening neurologic examination
      2. a screening mental status examination
      3. a complete mental status examination
   3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest depression more than grief reaction, dementia, anxiety disorder and adverse drug effect
   4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences
      1. laboratory and diagnostic tests, when appropriate, should include:
         • blood and urine drug screening
         • screening for syphilis
         • interpretation of a lumbar puncture
         • thyroid function tests
   5. communication skills: Students should be able to:
      1. effectively communicate the diagnosis to the patient and their families, using sensitive, non-judgmental language
      2. recruit the patient into treatment
      3. advise the patient of the delay in therapeutic benefit from anti-depressant drugs
      4. communicate to the patient the need for psychiatric consultation when necessary
   6. basic procedural skills: Students should be able to:
      1. perform lumbar puncture
   7. management and treatment: Students should be able to develop an appropriate evaluation and treatment plan for patients including:
      1. selecting appropriate anti-depressive drugs with understanding of dosing and the complexities of each
      2. recommending psychotherapy for individuals with anxiety disorders suffering from grief
      3. accessing and utilizing appropriate information systems and resources to help delineate issues related to depression
3. Attitudes and Professional Behaviors: Students should be able to:
   1. understand that complaints of depression may be symptoms of potentially life-threatening disease
   2. understand the confidentiality requirements of psychiatric diagnoses
   3. understand that uncomplicated depression can be diagnosed and treated by non-psychiatrists.