Major depressive disorder (MDD) can complicate the care of patients in any clinical setting and is an issue for any PA practicing in primary care, as well as for those working in many specialty settings where depression may be common but poorly recognized. As many as 6% of pediatric patients and 16% of adult patients will meet the diagnostic criteria for MDD. Screening may be as simple as asking two questions and can provide a basis for improving the outcomes from this debilitating disorder.

WHAT ARE THE SYMPTOMS OF DEPRESSION?

MDD in adults is defined by the persistence for 2 weeks or more of five or more of the following symptoms:

• Depressed mood for most of the day, every day

• Diminished pleasure from or interest in almost all activities

• Weight loss, weight gain, or a change in eating habits

• Hypersomnia or insomnia

• Excessive or diminished physical movement/expression (psychomotor agitation or psychomotor retardation)

• Loss of energy and fatigue

• Feelings of worthlessness or inappropriate guilt

• Impaired decisiveness or inability to concentrate

• Intrusive thoughts of death or suicide.

Alcohol or drug abuse must be ruled out as a contributing factor. Other secondary causes of behavioral changes, including grief, medication, or an organic metabolic imbalance, should be addressed. In the absence of these, depression should be diagnosed and treatment should be planned.

Patients with depression may complain of mood disturbances but attribute their problems to stress or difficulties in their personal or business lives. They may schedule multiple visits to discuss vague symptoms, such as GI complaints. The history should include questions about previous episodes of depression or depressive symptoms, other mood disorders, psychotic disorders, substance abuse, and other behavioral disorders, as well as other risk factors (Table 1).

Children can experience depressive symptoms similar to those in adults,8 including feelings of hopelessness and loss of pleasure or interest in activities. Children may become anxious and exhibit turmoil in their lives. The prevalence of depression increases from 3% among children to 6% in adolescents, with up to a 20% lifetime MDD prevalence among adolescents. Depression affects a child’s cognitive, physical, and behavioral function and manifests as feelings of isolation and helplessness; these can lead to a sense of guilt, preoccupation with death, or thoughts of suicide.

Children and adolescents, like adults, may demonstrate changes in eating or sleeping behaviors. They may appear sluggish, easily agitated, or fidgety. The history should include questions about the child’s withdrawal from daily activities and whether the child is clinging, more demanding, or more dependent on others. Children may also appear out of control or engage in excessive or reckless behaviors, including activities that produce harm or pain. Comorbid substance abuse should be considered in childhood depression, particularly in adolescence. Preoccupation with morbid thoughts and impulsive, angry, or irritable behavior can all be warning signs.

HOW DO I SCREEN PATIENTS IN PRIMARY CARE?

Screening for depression can have a significant impact,3,5 and, in adults, can be accomplished by asking the patient two simple questions:4,5

• During the past month, have you often been bothered by feeling down, depressed, or hopeless?

• During the past month, have you been bothered by having little interest or pleasure in doing things?

A positive response to either of these questions was both sensitive and specific for MDD, while a negative response to both questions virtually ruled out MDD. Significantly more cases of depression will be identified if patients are screened in a primary care setting.4 In addition to these two questions, other screening tools and resources are available.

Depression screening instruments for children and adolescents are limited in number, and their validity is limited as well. The clinician should seek information about recent changes in the child’s behavior from the patient as well as from parents, teachers, and others in a position to observe the child.

HOW IS MDD TREATED?

A second-generation antidepressant is an appropriate treatment based on side effect profile, cost, and patient preference. A follow-up visit should be scheduled within 1 to 2 weeks of initiation of therapy and again after 6 to 8 weeks to assess the effectiveness of therapy and inquire about side effects. Patients should be asked about adherence to the prescribed regimen and whether they have intrusive thoughts of harm to themselves or to others. They should also be reassessed for whether they need to be referred for specialty care (see below). Patients with MDD should continue treatment for a minimum of 4 to 9 months, although those with a history of past episodes of MDD may need to extend treatment beyond a year or even indefinitely. In adults, there may be an associated increase in the risk for nonfatal suicide attempts; this is another reason for close followup and screening for suicidal tendencies in all patients who have begun treatment with antidepressant medicines.

Antidepressant medications currently approved for use in children and adolescents include certain selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, and limited other medications. Generally, the lowest effective dosages of SSRIs are appropriate. Children and adolescents are at higher risk for suicide than adults; the suicide risk is doubled with antidepressant use in this population. Young patients should be followed frequently and carefully.

Combined counseling and pharmacotherapy should be considered for children or adults with mild to moderate MDD in the primary care setting. Combination treatment may offer advantages over either treatment individually. Complementary medications (such as St John’s wort) and alternative treatments such as yoga, relaxation therapy, and massage may also be helpful for some patients who prefer to avoid traditional treatments.

WHEN IS SPECIALTY CARE ADVISED?

Patients should be referred for either inpatient treatment or counseling if they are at immediate risk for suicide or are overwhelmed with hopelessness. The characteristics associated with increased suicide risk in children and adolescents include depressed mood, psychomotor agitation, and especially feelings of worthlessness. Intensive inpatient treatment should be sought for these patients and for those patients with delusions or hallucinations, self- destructive behaviors, or significant comorbidities requiring frequent assessment. If symptoms remain uncontrolled by therapy, patients may need more intensive interventions.

Acknowledgment: CSAC would like to thank Rod Purdie, MD, and Phebe Tucker, MD, for commenting on early drafts of this article.

This article was written by Daniel L. O’Donoghue, PhD, PA-C, and Gilbert A. Boissonneault, PhD, PA-C. Contributors included the other members and staff of CSAC 2009-2010: Anthony E. Brenneman, MPAS, PA-C; Alison C. Essary, MHPE, PA-C; Frank Fortier, PA-C; Michelle Lynn Heinan, EdD, PA-C; Marie-Miche`le Le’ger, MPH, PA-C; Robert McNellis, MPH, PA; and Thomas Moreau, PA-C, MS. The manuscript was edited by Sarah Zarbock, PA-C.

REFERENCES

1. Qaseem A, Snow V, Denberg TD, et al. Using second-generation antidepressants to treat depressive disorders: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008;149(10):725-733.

2. Williams SB, O’Connor EA, Eder M, Whitlock EP. Screening for child and adolescent depression in primary care settings: a systematic evidence review for the US Preventive Services Task Force. Pediatrics. 2009;123(4):e716-e735.

3. Sharp LK, Lipsky MS. Screening for depression across the lifespan: a review of measures for use in primary care settings. Am Fam Physician. 2002;66(6):1001–1008.

4. Pignone MP, Gaynes BN, Rushton JL, et al. Screening for depression in adults: a summary of the evidence for the US Preventive Services Task Force. Ann Intern Med. 2002;136(10):765-776.

5. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression: two questions are as good as many. J Gen Intern Med. 1997;12(7):439-445.

6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th ed, text revision. Washington, DC: American Psychiatric Association: 2000.

7. Schulberg HC, Madonia MJ, Block MR, Couleman JL. Major depression in primary care practice: clinical characteristics and treatment implications. Psychosomatics. 1995;36(2):129-137.

8. Canino G, Shrout PE, Rubio-Stipec M, et al. The DSM-IV rates of child and adolescent disorders in Puerto Rico: prevalence, correlates, service use, and the effects of impairment. Arch Gen Psychiatry. 2004;61(1):85-93.