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Depression, Emergency Medicine

Basics

Description

- 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

- 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- Subtypes: Psychotic features, melancholic, catatonic, atypical, postpartum, seasonal - May be anxious/agitated or withdrawn - Associated somatic complaints: - Weakness, malaise - Weight loss - Headache, back pain

- Vital signs - Neurologic exam: - Motor exam: Station, gait, strength, tone, abnormal movements - Cognitive exam: Orientation, attention, memory, language, executive function

- 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

- Endocrine disorders: - Hypothyroidism - Adrenal insufficiency - Diabetes mellitus - Postpartum, perimenopausal, and premenstrual syndromes

- 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

- Choice of drug determined by: - Indications, efficacy - Side-effect profile and risks - Convenience, cost, availability

- 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

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 predispositionMedical illnessMedication effectsPsychosocial 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 moodDiminished interest or pleasureChange in appetite, weight loss/gainSleep disturbanceFatigue or loss of energyDiminished concentrationFeeling of worthlessness or guiltRecurrent thoughts of death or suicidePsychomotor agitation or retardation
  • Subtypes: Psychotic features, melancholic, catatonic, atypical, postpartum, seasonal
  • May be anxious/agitated or withdrawn
  • Associated somatic complaints:Weakness, malaiseWeight lossHeadache, 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 riskRisk of violence to othersAssess 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 movementsCognitive 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 functioningChanges in sleepSocial withdrawalSomatic 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 testsUrinalysisSerum and urine toxicology screenThyroid function testsB12 and folate
  • 2nd line, guided by history and initial findings:HIV testingRPRESR/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 disorderAdjustment disorderBipolar disorderAnxiety disorders, including acute stress reactions, PTSDSchizophrenia, schizoaffective disorderPersonality disorderEating disorderSubstance-induced mood disorder
  • Medical conditions that may cause or mimic depression:Drug induced:AntihypertensivesOral contraceptivesSteroidsSedative-hypnoticsOpioidsPsychostimulants (in withdrawal phase)β-BlockersMetoclopramideEndocrine disorders:HypothyroidismAdrenal insufficiencyDiabetes mellitusPostpartum, perimenopausal, and premenstrual syndromesTumors:Neurologic disorders:Dementia (early phase or frontal type)EpilepsyParkinson diseaseMultiple sclerosisHuntington diseaseStrokeHead trauma; subdural hematomaNormal pressure hydrocephalusInfections:HepatitisHIVMononucleosisNutritional disorders:Folate deficiencyPellagraVitamin B12 deficiencyElectrolyte disturbancesEnd-stage renal, hepatic, pulmonary, and cardiovascular diseasesObstructive sleep apneaChronic 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 appropriateWork up potential medical causes

Ed Treatment/Procedures

  • Psychological management:Listen empathically to understand context and relevant stressorsReassurance 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-upUsually takes weeks for antidepressant medications to resolve major depressionLow-dose benzodiazepines or neuroleptics may be used for associated agitation, insomnia, or psychosis
  • Choice of drug determined by:Indications, efficacySide-effect profile and risksConvenience, cost, availability
  • Selective serotonin reuptake inhibitors (SSRIs: fluoxetine, paroxetine, sertraline, citalopram, escitalopram):Well toleratedSide effects may include:Mild nauseaHeadacheAnxiety, restlessness, insomniaSomnolenceSexual dysfunctionWeight gainMinimal overdose risk
  • Serotonin norepinephrine reuptake inhibitors (SNRIs: venlafaxine, duloxetine):Well toleratedMay be helpful for some pain syndromesSide effects similar to SSRIs
  • Dopaminenorepinephrine reuptake inhibitor (bupropion):Agitation, insomniaTremorDecreased seizure thresholdWell-tolerated; no sexual side effects
  • Norepinephrine serotonin modulator (mirtazapine):Weight gainSedationOrthostasisConstipation
  • Tricyclic antidepressants (amitriptyline, imipramine, nortriptyline, clomipramine):Anticholinergic effectsWeight gainPostural hypotensionSedationDecreased seizure thresholdCardiac risk; overdose can be fatalNortriptyline is best tolerated
  • Monoamine oxidase inhibitors (phenelzine, tranylcypromine, selegiline transdermal):Dietary and other medication restrictions to avoid hypertensive crisisDangerous 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.

See Also (Topic, Algorithm, Electronic Media Element)

  • Bipolar Disorder
  • Psychosis, Medical vs. Psychiatric
  • Psychiatric Commitment
  • Suicide, Risk Evaluation

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)