Depression, Emergency Medicine

Basics

Description

Major depression:

Depressed mood and associated signs and symptoms lasting more than 2 wk
Significant morbidity and mortality, including risk of suicide
Often coexists with other medical illness

Etiology

Biologic illness associated with derangements in several neurotransmitter systems including serotonin, norepinephrine, and dopamine
Contributing factors:
- Genetic predisposition
- Medical illness
- Medication effects
- Psychosocial stress: Depression may follow adverse life event, trauma, loss of important relationship, or life role
Higher prevalence in women. (Woman make more suicide attempts; men are more likely to complete suicide successfully)

Diagnosis

Signs and Symptoms

5 or more symptoms for at least 2 wk. (One of the symptoms must be depressed mood or loss of interest or pleasure):
- Depressed mood
- Diminished interest or pleasure
- Change in appetite, weight loss/gain
- Sleep disturbance
- Fatigue or loss of energy
- Diminished concentration
- Feeling of worthlessness or guilt
- Recurrent thoughts of death or suicide
- Psychomotor agitation or retardation
Subtypes: Psychotic features, melancholic, catatonic, atypical, postpartum, seasonal
May be anxious/agitated or withdrawn
Associated somatic complaints:
- Weakness, malaise
- Weight loss
- Headache, back pain

History

Time course, acuity, stressors
Review depressive symptoms (see above)
Past medical history
Past psychiatric history
Medications (prescribed and over-the-counter)
Substance use
Family history
Social and occupational history; losses, transitions, trauma, and other major life events
Safety assessment:
- Suicide risk
- Risk of violence to others
- Assess ability to care for self, nutrition
Collateral from family or outpatient providers
Cultural and language differences may complicate evaluation; use interpreter when appropriate

Physical Exam

Vital signs
Neurologic exam:
- Motor exam: Station, gait, strength, tone, abnormal movements
- Cognitive exam: Orientation, attention, memory, language, executive function
Mental status exam: Affect and mood, thought form and content

Depression may be difficult to diagnose in children and adolescents. Indicators of major depression in children may include:
- Changes in school, home, and social functioning
- Changes in sleep
- Social withdrawal
- Somatic complaints
Consult with a child psychiatrist

Rule-out bipolar disorder: May require different treatment (mood stabilizers, antipsychotics), also antidepressants may precipitate mania in bipolar patients

Essential Workup

Identify signs and symptoms of major depression (see "Signs and Symptoms"¯)
Use history and physical exam to guide further workup
Rule-out associated or coexisting psychiatric and medical conditions, substance use
Safety assessment

Diagnosis Tests & Interpretation

Lab

1st line:
- CBC; chemistries including electrolytes, BUN/creatinine, glucose, calcium, liver function tests
- Urinalysis
- Serum and urine toxicology screen
- Thyroid function tests
- B12 and folate
2nd line, guided by history and initial findings:
- HIV testing
- RPR
- ESR/CRP/ANA

Imaging

Brain imaging: Recommended for atypical presentation or if focal neurologic findings
MRI brain preferred over CT for detecting tumors, cerebrovascular accident, white matter changes

Differential Diagnosis

Psychiatric illnesses:
- Dysthymic disorder
- Adjustment disorder
- Bipolar disorder
- Anxiety disorders, including acute stress reactions, PTSD
- Schizophrenia, schizoaffective disorder
- Personality disorder
- Eating disorder
- Substance-induced mood disorder
Medical conditions that may cause or mimic depression:
- Drug induced:
  - Antihypertensives
  - Oral contraceptives
  - Steroids
  - Sedative-hypnotics
  - Opioids
  - Psychostimulants (in withdrawal phase)
  - β-Blockers
  - Metoclopramide
- Endocrine disorders:
  - Hypothyroidism
  - Adrenal insufficiency
  - Diabetes mellitus
  - Postpartum, perimenopausal, and premenstrual syndromes
- Tumors:
  - Pancreatic
  - Lung
  - Brain
- Neurologic disorders:
  - Dementia (early phase or frontal type)
  - Epilepsy
  - Parkinson disease
  - Multiple sclerosis
  - Huntington disease
  - Stroke
  - Head trauma; subdural hematoma
  - Normal pressure hydrocephalus
- Infections:
  - Hepatitis
  - HIV
  - Mononucleosis
- Nutritional disorders:
  - Folate deficiency
  - Pellagra
  - Vitamin B12 deficiency
- Electrolyte disturbances
- End-stage renal, hepatic, pulmonary, and cardiovascular diseases
- Obstructive sleep apnea
- Chronic pain syndromes

Treatment

Pre-Hospital

Ensure safety of patient and providers
Understand local laws for involuntary commitment to hospital

Initial Stabilization/Therapy

Safety: Assess risk of suicide, violence
General medical evaluation
Management:
- 1-to-1 observation and suicide precautions when appropriate
- Work up potential medical causes

Ed Treatment/Procedures

Psychological management:
- Listen empathically to understand context and relevant stressors
- Reassurance and education (e.g., depression is a treatable condition)
Initiate medications:
- Antidepressant medication may be initiated for some patients with clear diagnosis and established follow-up
- Usually takes weeks for antidepressant medications to resolve major depression
- Low-dose benzodiazepines or neuroleptics may be used for associated agitation, insomnia, or psychosis
Choice of drug determined by:
- Indications, efficacy
- Side-effect profile and risks
- Convenience, cost, availability
Selective serotonin reuptake inhibitors (SSRIs: fluoxetine, paroxetine, sertraline, citalopram, escitalopram):
- Well tolerated
- Side effects may include:
  - Mild nausea
  - Headache
  - Anxiety, restlessness, insomnia
  - Somnolence
  - Sexual dysfunction
  - Weight gain
- Minimal overdose risk
Serotonin norepinephrine reuptake inhibitors (SNRIs: venlafaxine, duloxetine):
- Well tolerated
- May be helpful for some pain syndromes
- Side effects similar to SSRIs
Dopaminenorepinephrine reuptake inhibitor (bupropion):
- Agitation, insomnia
- Tremor
- Decreased seizure threshold
- Well-tolerated; no sexual side effects
Norepinephrine serotonin modulator (mirtazapine):
- Weight gain
- Sedation
- Orthostasis
- Constipation
Tricyclic antidepressants (amitriptyline, imipramine, nortriptyline, clomipramine):
- Anticholinergic effects
- Weight gain
- Postural hypotension
- Sedation
- Decreased seizure threshold
- Cardiac risk; overdose can be fatal
- Nortriptyline is best tolerated
Monoamine oxidase inhibitors (phenelzine, tranylcypromine, selegiline transdermal):
- Dietary and other medication restrictions to avoid hypertensive crisis
- Dangerous in overdose

Medication

Medication dosage ranges are for adults.
Dose may be titrated over weeks as indicated.

Amitriptyline: Initial 25-50 mg/d PO
Bupropion: 75-400 mg/d PO
Citalopram: 20-40 mg/d PO
Desvenlafaxine: 50 mg/d PO
Duloxetine: 30-120 mg/d PO
Escitalopram: 10-20 mg/d PO
Fluoxetine: 20-60 mg/d PO
Imipramine: Initial 25-50 mg/d PO
Mirtazapine: 15-45 mg/d PO
Nortriptyline: Initial 25 mg/d PO
Paroxetine: 20-40 mg/d PO
Phenelzine: 15-90 mg/d PO
Sertraline: 50-200 mg/d PO
Tranylcypromine: 10-60 mg/d PO
Venlafaxine: 75-300 mg/d PO

First Line
SSRIs, SNRIs, bupropion, mirtazapine
Second Line

Tricyclics and monoamine oxidase inhibitors
Use with caution in geriatric or medically ill
Consider ECT for severe or treatment-resistant depression, psychotic depression, or catatonia

Older patients may require lower dose; pay careful attention to potential drug interactions
Caution with orthostatic hypotension and cholinergic blockade

FDA "Black box"¯ warning: Antidepressants may increase risk of suicidal thinking and behavior in some children, adolescents, or young adults with depression
In pregnant or breast-feeding women pay special attention to risks and benefits of medication treatments-consider consultation with a specialist in perinatal psychiatry

Follow-Up

Disposition

Admission Criteria

Patient is suicidal or at high risk for suicide. See "Suicide, Risk Evaluation"¯
Minimal or unreliable social supports
Symptoms so severe that continual observation or nursing supportive care is required
Psychotic features
Civil commitment for psychiatric hospitalization is necessary if the patient is refusing treatment and is at risk to harm self or others

Discharge Criteria

Low suicide risk
Adequate social support
Close follow-up available

Issues for Referral

Outpatient mental health appointments and/or partial (day) hospital for patients not admitted
Insurance carrier may determine inpatient disposition and options for other levels of care
Case management or social services in ED may be helpful for disposition issues
Communicate and coordinate care with other providers including primary care

Followup Recommendations

Follow-up depends on severity of illness and risk:

If not admitted, patients with significant symptoms should follow up in 1-2 wk
When medication is initiated, patient should be seen in follow-up in 1-2 wk
More stable patients or those with minor symptoms may be seen with less urgency

Pearls and Pitfalls

Patients with depression experience significant morbidity and may present a risk of self-harm
Consider other conditions that mimic depression; also coexisting psychiatric and medical conditions, substance use
Know hospitalization and involuntary commitment criteria in your area

Additional Reading

American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder, third edition. Am J Psychiatry. 2010;167(suppl 10):1-152.
Belmaker RH, Agam G. Major depressive disorder. N Engl J Med. 2008;358:55-68.
Cassem NH. Mood disordered patients. In: Stern TA, Fricchione GL, Cassem NH, eds. MGH Handbook of General Hospital Psychiatry. 6th ed. St. Louis, MO: Mosby; 2010.
Stewart DE. Clinical practice. Depression during pregnancy. N Engl J Med. 2011;365:1605-1611.

Codes

ICD9

296.20 Major depressive affective disorder, single episode, unspecified
296.24 Major depressive affective disorder, single episode, severe, specified as with psychotic behavior
296.30 Major depressive disorder, recurrent episode, unspecified degree
648.40 Mental disorders of mother, unspecified as to episode of care or not applicable
V62.84 Suicidal ideation

ICD10

F32.3 Major depressv disord, single epsd, severe w psych features
F32.9 Major depressive disorder, single episode, unspecified
F33.9 Major depressive disorder, recurrent, unspecified
F53 Puerperal psychosis
R45.851 Suicidal ideations

SNOMED

35489007 Depressive disorder (disorder)
370143000 major depressive disorder (disorder)
73867007 Severe major depression with psychotic features (disorder)
58703003 postpartum depression (disorder)
267073005 Suicidal (finding)
320751009 Major depression, melancholic type (disorder)

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