Major depressive disorder: a guide for primary-care clinicians
Ruling out a physiological reason for symptoms is a good starting point for NPs and PAs caring for patients with a new psychiatric disorder.
Major depressive disorder: beyond the blues
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The Fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was released in 2013, yet there remains confusion about its implementation and use in primary care.
The update includes diagnoses moved to different categories, the elimination and addition of disorders, and changes to diagnostic criteria.1
One of the most common conditions encountered is depression, technically referred to as major depressive disorder (MDD).As access to psychiatrists can be limited by time and distance, primary care providers are often asked to prescribe medications, even for their pediatric patients.
In addition, patients often request a “quick fix” and are reluctant to pursue psychotherapy. This article is a general overview, and as with any medical article, treatment should be dictated by the individual patient.
The DSM outlines criteria that are required for making any diagnosis. It has been emphasized many times that the first step in diagnosing any mental health condition is to rule out an underlying medical condition. When a patient presents with a complaint of feeling depressed, a loss of interest in activities, or if depression is suspected even if it is not the chief complaint, screening laboratory tests may need to be considered.
A complete blood count, metabolic panel including glucose, renal, and hepatic functions, and thyroid screening is a basic place to start. This not only rules out possible sources of mood changes but sets baseline levels before starting medication. Some clinicians also recommend a urine or serum toxicology screen periodically through treatment.
Regarding diagnostic criteria for MDD, patients must have a minimum of five of nine symptoms; they are also required to have at least a depressed mood or a loss of interest or pleasure as one of the five symptoms. The other symptoms can be: alteration in sleep (hypersomnia or insomnia), feelings of worthlessness or excessive or inappropriate guilt, fatigue or loss of energy, diminished ability to think or concentrate or indecisiveness, significant change in weight or appetite, psychomotor agitation or retardation that is observable by others, and recurrent thoughts of death or suicidal ideation.
These symptoms are collectively known as Criteria A and were unchanged from DSM-IV to DSM-5. They are often remembered by the acronym “SIG E CAPS”, for Sleep, Interest, Guilt, Energy, Concentration, and Appetite, Psychomotor, and Suicidal ideation.
The other criteria include the following: the condition must cause clinically significant distress or impairment (criterion B), it cannot be attributed to substance use or another medical condition (criterion C), it cannot be better explained by another mental health condition (criterion D), and the patient must never have had a manic or hypomanic episode (criterion E).2
DSM-IV had a “bereavement exclusion,” which stated that a patient could not be diagnosed with depression if the symptoms occurred within two months following the loss of a loved one. In DSM-5, this exclusion was removed, allowing the practitioner to decide if the level of sadness following a loss was significant enough to warrant a diagnosis of MDD as opposed to simply adjustment reaction.1
Consideration for culturally appropriate grieving must be taken into account, as well as the level of impairment before deciding on an “official” diagnosis of depression instead of adjustment reaction.