Depression

Welcome to PT 635 Pathophysiology of Complex Patient Problems This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Nadine Risman from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Lead Editors - Your name will be added here if you are a lead editor on this page.  Read more.

Definition/Description

Depression is defined according to Goodman and Fuller as a morbid sadness, dejection, or a sense of melancholy distinguished from grief.  Depression falls under the broader category of Major Depressive Disorders which are characterized by a single isolated episode lasting weeks to months.  Major depressive disorders are viewed as an adjustment disorder which occurs due to external circumstances such as stress, trauma or loss.  Other major depressive disorders include dysthymia and seasonal affective disorder. 

Prevalence

Depression is the most commonly seen mood disorder within a therapy practice and is often associated with other physical illnesses and psychological conditions.  In 2006, the Center for Disease Control conducted a study looking at the prevalence of depression.  They found that approximately 15.7% of people reported being told by a health care provider that they had depression at some point in their lifetime.¹  Men and women ages 25 to 44 have the highest occurance of depression with the elderly population being the next highest age group affected. 

Characteristics/Clinical Presentation

It is important to note that as many as one third of people experiencing depression do not feel sad or blue.  Many experience somatic symptoms such as fatigue, joint pain, headaches, gastrointestinal disturbances, or chronic back pain.  In Goodman and Synder, they report that 80 to 90% of the most common gastrointestinal disorders are associated with depressive or anxiety disorders.  People with depression commonly have trouble sleeping, including early morning and frequent nocturnal awakenings.  In the elderly population, sleep disturbances are the first symptom of depression especially when linked with acute confusion, falling, bowel and bladder problems or syncope.  Clinical signs and symptoms can include:

• Persistent sadness, low mood, or feelings of emptiness
• Frequent or unexplained crying spells
• A sense of hopelessness
• Feelings of quilts or worthlessness
• Problems in sleeping
• Loss of interest or pleasure in ordinary activities or loss of libido
• Fatigue or decreased energy
• Appetite loss (or overeating)
• Difficulty in concentrating, remembering, and making decisions
• Irritability
• Persistant joint pain (arthralgia)
• Headache
• Chronic back pain
• Bilateral neurologic symptoms of unknown cause (e.g., numbness, dizziness, weakness)
• Thoughts of death or suicide
• Pacing and fidgeting
• Chest pain and palpitations

There may also be associated behavior changes that can include: compulsive, reckless or violent behavior, argumentative or oppositional behavior, patients may have a preoccupation with themselves, be critical toward family members (fault finding) or be unaffectionate with their partner or spouse.  Other somatic symptoms that are associated with mood disorders in nonmedicated people includes:

• Muscle Pain (myalgia)
• Excess Perspiration
• Dry Mouth or Excessive Salivation
• Rapid Breathing
• Blurred Vision
• Constipation
• Tinnitus
• Dry Skin
• Flushing
• Slurred Speech
• Amenorrhea, Polymenorrhea
• Digestive Problems

Medications

Depression may be caused by medications a patient is taking to treat another medical problem.  Sedatives, hypnotics, cardiac drugs, antihypertensives, anticonvulsants, hormones and steriods are some drug catergories that can cause depression.  Also recreational drugs such as alcohol and illegal drugs can cause signs and symptoms of depression.  Some examples are as follows:

Psychoactive Agents: Amphetamines, Cocaine, Benzodiazepines, Barbiturates, Neuroleptics

Antihypertensive Drugs: Beta Blockers (especially propranolol), Alpha Adrenergic Antagonists, Methyldopa (Aldomet), Hydralazine (Apresoline)

Analgesics: Salicylates, Propoxyphene (Darvocet-N), Pentazocine (Talwin), Morphine, Meperidine (Demerol)

Cardiovascular Drugs: Digoxin (Lanoxin), Procainamide (Pronestyl), Disopyramide (Norpace)

Anticonvulsants: Phenytoin (Dilantin), Phenobarbital

Hormonal Agents: Corticosteroids, Oral Contraceptives, Anabolic Steroids

Miscellaneous: Alcohol, Illicit Drugs, Histamine H₂ Receptor Antagonists (especially cimetidine or Tagamet), Metoclopramide (Reglan), Levodopa (Dopar, Larodopa), Nonsteroidal Antiinflammatory Drugs (NSAIDs), Antineoplastic Agents (Vinblastine), Disulfiram (Antabuse), Cytokines (Interferons)

Diagnostic Tests/Lab Tests/Lab Values

Depression is often under diagnosed by primary care physicians due to patients complaining of somatic pain rather than feelings of sadness.  Physians tend to treat the somatic issues first through medication.  Also the criteria in the DSM-IV makes diagnosing depression difficult because many patients don't fit the diagnostic criteria.  Under the current DSM version the diagnosic criteria for a single episode of Major Depressive Disorder is:

A. Presence of a single Major Depressive Episode

B. The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode.

Note: This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects of a general medical condition.

If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status and/or features:

Mild, Moderate, Severe without Psychotic Features/Severe with Psychotic Features, Chronic, with Catatonic Features, with Melancholic Features, with Atypical Features, with Postpartum Onset

In the DSM-IV there is another category listed for the diagonosis of depressive disorders that do not meet the criteria of the other mood disorders. It is important to note that the psychosocial distress or dysfunction experienced must not be due to the physiological effects of a substance or a general medical condition.  The Depressive Disorder Not Otherwise Specified category includes disorders with depressive features that do not meet the criteria for Major Depressive Disorder, Dysthymic Disorder, Adjustment Disorder With Depressed Mood, or Adjustment Disorder With Mixed Anxiety and Depressed Mood . 

Sometimes depressive symptoms can present as part of an Anxiety Disorder Not Otherwise Specified. Examples of Depressive Disorder Not Otherwise Specified include:

1. Premenstrual dysphoric disorder: in most menstrual cycles during the past year, symptoms (e.g., markedly depressed mood, marked anxiety, marked affective lability, decreased interest in activities) regularly occurred during the last week of the luteal phase (and remitted within a few days of the onset of menses). These symptoms must be severe enough to markedly interfere with work, school, or usual activities and be entirely absent for at least 1 week postmenses (see Appendix B in DSM-IV-TR for suggested research criteria).

2. Minor depressive disorder: episodes of at least 2 weeks of depressive symptoms but with fewer than the five items required for Major Depressive Disorder (see Appendix B in DSM-IV-TR for suggested research criteria).

3. Recurrent brief depressive disorder: depressive episodes lasting from 2 days up to 2 weeks, occurring at least once a month for 12 months (not associated with the menstrual cycle).

4. Postpsychotic depressive disorder of Schizophrenia: a Major Depressive Episode that occurs during the residual phase of Schizophrenia.

5. A Major Depressive Episode superimposed on Delusional Disorder, Psychotic Disorder Not Otherwise Specified, or the active phase of Schizophrenia.

6. Situations in which the clinician has concluded that a depressive disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced.

Causes

add text here

Medical Management (current best evidence)

add text here

Physical Therapy Management (current best evidence)

add text here

Alternative/Holistic Management (current best evidence)

add text here

Differential Diagnosis

add text here

Case Reports

add links to case studies here (case studies should be added on new pages using the case study template)

Resources

add appropriate resources here

Recent Related Research (from Pubmed)

see tutorial on Adding PubMed Feed

References

see adding references tutorial.

.