_______________________________________________________________________ Depression and Suicide
Mood and Thought Process Patients may appear tearful or sad and often report a dysphoric mood state expressed as sadness, heaviness, numbness, or irritability and mood swings, as well as a loss of interest or pleasure in their recreational or leisure activities, difficulty concentrating, or loss of energy and motivation. Feelings of worthlessness, hopelessness, helplessness, or other negative thoughts may pervade their thinking, and ruminative thinking is not uncommon in MDD. Eye contact may be absent [10]. In the context of MDD, psychotic thought processes are con- gruent in content with the patient’s mood state, examples being delusions of worthlessness or progressive physical decline. Evidence of psychotic symptoms requires careful assessment to rule out other contributing conditions such as bipolar disorder, schizophrenia or schizoaffective disorder, substance abuse, or organic brain syndrome [10; 22]. Cognition and Sensorium Poor memory or concentration is a frequent complaint of patients with MDD, but actual cognitive deficits are infrequent and when present may represent pseudodementia. A fluctuat- ing or depressed sensorium suggests delirium, and the patient should be evaluated for organic contributors [21; 22]. Speech Speech in patients with MDD may be normal, slow, mono- tonic, or lacking in spontaneity and content. Pressured speech and racing thoughts are suggestive of mania, and disorganized speech may reflect psychosis [10; 21; 22]. Thought Content, Suicidality, and Homicidality The thought content of patients with depression is usually consistent with the dysphoric mood and should always be assessed for hopelessness, suicidal ideation, or homicidal/ violent ideation or intent. Previous suicide attempts or violence predicts future behavior, and command hallucinations are associated with increased suicidal and homicidal actions [21]. SCREENING As of 2023, the U.S. Preventive Services Task Force recom- mends depression screening in the adult population, including pregnant and postpartum women and older adults (i.e., 65 years of age or older). Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up [63].
According to the Institute for Clinical Systems Improvement, clinicians should routinely screen all adults for depression using a standardized instrument. (https://www.icsi.org/wp-content/ uploads/2019/01/Depr.pdf. Last accessed
July 6, 2023.) Strength of Recommendation/Level of Evidence : Strong Recommendation, Low Quality Evidence
The recommendation applies to adults 19 years of age or older who do not have a diagnosed mental health disorder or recog- nizable signs or symptoms of depression or suicide risk. The recommendation focuses on screening for MDD and does not address screening for other depressive disorders (e.g., minor depression, dysthymia) [63]. Depression screening instruments are used to identify patients who should undergo a fuller assessment for depressive disor- ders [64]. The Patient Health Questionnaire-2 (PHQ-2) is a two-question screen widely recommended for use in primary care [65]: • ‘‘In the past two weeks, have you been bothered by little interest or pleasure in doing things?’’ • ‘‘In the past two weeks, have you been feeling down, depressed, or hopeless?’’ An answer of ‘‘yes’’ to either question requires a more detailed assessment. The Patient Health Questionnaire-9 (PHQ-9) is the most- recommended instrument following a positive screen. It consists of nine questions that ascertain depressive symptoms and symptom severity in the past two weeks and takes two minutes to complete. The PHQ-9 is recommended for use to measure severity before treatment and for periodic use during therapy to help assess response [64; 66]. Positive response to the last item (“Thoughts that you would be better off dead or of hurting yourself in some way?”) is associated with increased risk for suicide attempt [67]. Other screening and assessment tools are more complex, and others have extensive use in research. Some may be useful in assessing comorbid conditions or in differential diagnosis. They include [21; 64; 68; 69; 70]: • Zung Self-Rating Depression Scale: A widely used depression measure. • Beck Depression Inventory II (BDI-II): Widely used as a depression outcome measure in research and practice.
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