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Lucy Chen: [00:00:01] Okay, picture this. You've just arrived at the first day of your psychiatry rotation in clerkship or residency. You feel a twinge of excitement and fear because a part of you wonders if you have the knowledge and expertise to perform well here. You straighten your shirt, take a long sip of your coffee, and wait in anticipation for what's to come. Just then, your family practice colleague approaches you about one of their patients. The patient's name is Aaron. Hi. My name is Aaron. She's a 25 year old first year resident in internal medicine. She presented a few weeks ago with fatigue and feeling unable to keep up with her peers at work. She wonders if there's something physically wrong with her or she could be depressed. She mentions that three months ago she broke up with her long term boyfriend, which she proposes might be the cause of all of this. Your colleague feels that she likely is depressed, but is also wondering if this might be just a normal reaction to the loss of her boyfriend. Aaron is reluctant to accept the diagnosis of depression and realising there's a psychiatric expert on the team has requested your opinion. What do you do?
Dr. Lu Gao: [00:01:20] Do we pronounce it psyched or psych ed?
Dr. Alex Raben: [00:01:23] PsychEd.
Dr. Lu Gao: [00:01:23] Okay. Got it. Got it. I see. I see. I see what's happening here.
Dr. Alex Raben: [00:01:26] It's psychEd. Yes.
Dr. Lu Gao: [00:01:29] You're listening to Psyched. The Educational Psychiatry podcast Made for Medical Learners by Medical Learners, where a group of first and second year residents at the University of Toronto in Canada who have come together to discuss important topics in psychiatry through our own research and with the help of our world class staff psychiatrists. I'm Lu Goa.
Dr. Alex Raben: [00:01:48] I'm Alex Raben.
Carrol Zhou: [00:01:50] I'm Carol Zhou.
Lucy Chen: [00:01:51] And I'm Lucy Chen. And today's show, we'll tackle the basic criteria for diagnosing depression. Tips on history taking and what to look for on physical exam in investigations, diagnostic conundrums, important rule outs, all of which are revealed with our research and the help of our own hand expert, Dr. Ilana Shawn. We sat down with Carol, one of our first year residents, to iron out the intricacies of assessing for depression.
Dr. Alex Raben: [00:02:18] But why is it so important for us to learn to assess for depression.
Carrol Zhou: [00:02:23] Depression as a significant impact on society, both on an individual level as well as on a global scale? It has an impact on the individual themselves, on their relationships, as well as on someone's employment and work future. If you think about it, the onset of depression is often in the twenties, and that's the beginning of someone's productivity in terms of their life. That's when they're gaining skills, They're starting their employment future and they're working towards a certain trajectory. If someone becomes unwell at that point, that's very much going to impact their education, their future, career prospects and relationships. When I think about disease burden, we have to think not just about the prevalence of a disorder, but also the amount of time someone spends unwell, the lifetime prevalence of depression in Canada is somewhere around 10%. And if the average depressive episode is at least three months, you can imagine that's having a significant impact on a significant portion of the population. Depression can also be chronic at times, or at least it's an episodic illness. So individuals may have more than one episode in their life, which is going to impact them at additional times.
Dr. Alex Raben: [00:03:36] A statistical measurement that's relevant to depression is called the DALY or disability adjusted life years. One value can be thought of as one lost year of healthy life. The sum of these years across the population can be thought of as a measurement of the gap between current health status and an ideal situation where the entire population lives to an advanced stage free of disease and disability. Using the DALY, unipolar major depression was classed in 1990 as the fourth leading cause of burden of disease worldwide for both sexes, just behind lower respiratory infections, diarrhoeal diseases and perinatal disorders. By 2004, it's now up to third place. The World Health Organization projects that it will be the leading cause of disease burden worldwide by 2030. There's clearly a need to explore and gain a better understanding of this highly debilitating illness. So now that we have a better understanding of the impact of depression, let's get back to Aaron. How do we begin to diagnose someone with depression?
Lucy Chen: [00:04:42] The most common diagnostic guidebook for health care providers in North America is the Diagnostic and Statistical Manual of Mental Disorders, or DSM. The fifth edition DSM five was released in 2013 and is generally accepted today as the main method for diagnosis. So a little bit of a disclaimer here. Any attempt to manualize human experience is likely to result in controversy. Despite numerous limitations, the DSM is an attempt to standardise the language of mental health professionals so that a health care professional in Vancouver can communicate with a health care provider in Halifax in a meaningful way. Since we lack strong objective criteria for disorders, things like x-rays or blood tests we diagnose based on patient report and our own descriptive observations of behaviour. It's an admitted work in progress, though research is expanding. By now you would have heard of the mnemonic for DSM criteria of depression, MSIGECAPS. It stands for mood, sleep, interest, guilt, energy, concentration, appetite, psychomotor retardation, or agitation and suicide. So the a criteria for major depressive disorder has these nine different symptoms, and the individual must have at least five of these for a period of at least two weeks to make these nine criteria easier to remember. We can break them down into three groups. First, you have the core symptoms of depression M for mood and I for interest. This means that there is no clinical depression without persistently depressed mood or anhedonia. So these two questions combined can be used as a 32nd screening tool for depression when asking about mood. It can be helpful to ask them to rate their general mood on a scale of 1 to 10 where ten is normal.
Lucy Chen: [00:06:34] For Anhadonia, you can start by asking about things they do for fun or used to do for fun and lead it into asking if those hobbies or anything else still brings them pleasure or joy.
Lucy Chen: [00:06:46] Second, there are the neuro vegetative symptoms. As for sleep. A for appetite and E for energy. In general, people describe a decrease in these functions, and it can be helpful to quantify the change. The classical sleep symptom is early morning awakening, but any form of disturbed sleep can be seen. Poor appetite can manifest in significant weight loss and reduced energy can be tied to anhedonia. With that said, the sleep and appetite criteria can also be filled if the patient describes an abnormal increase termed hyperphagia and hypersomnia. Lastly, there are the cognitive symptoms. C for poor concentration or indecisiveness? G For guilt or worthlessness, you can assess for concentration when asking about interests. Can you follow what's happening on a TV show?or do you have to read a page over and over again? In depression, people can lose their self-worth and thus confidence. And this can manifest in avoidance of going to school, work or even household chores. Guilt often appears as an exaggeration of a past misdeed, actual or imagined. Probably the trickiest question will be around suicide. A common worry is could I make a patient more suicidal by bringing it up so it's okay. And it's actually beneficial to ask patients about suicide even if they don't mention it. P is for psychomotor retardation or infrequently agitation. This is the part of the mental state exam. Other findings are often related to the other symptoms of depression.
Carrol Zhou: [00:08:34] The next question is how do you ask these questions without sounding like a checklist?
Dr. Ilana Shawn : [00:08:38] I think it's a really good question. Part of the psychiatric residency training is learning to be a skilled interviewer. We don't have CT scans or blood tests to diagnose our illnesses, so we need to learn to be as skilled as we can in interviewing, assessment and diagnosis. During an assessment. There's a conflict between doing a routine checklist and trying to understand this individual's experience and the impact it has on them. I try to balance open and closed-ended questions, so an open-ended question would be something that you can't answer with a yes or no. I will use a closed-ended question at the beginning of the screen and then I will open up more into open-ended questions to learn more. I will ask questions like. Tell me about your mood. Getting them to tell me in their own words how they might describe it. Tell me about your sleep. Tell me about your appetite. This allows the individual to really tell you what it's been like for them. I balance this out also with empathic and validating statements. This helps to build rapport with the individual, so ideally they feel heard and understood. And then I'll pepper that with summarising statement to just recap what we've covered. So what you're telling me is that for the past few months your mood has been terrible. You've been crying more, you can't get out of bed. You try and sleep, but you can't sleep.
Dr. Ilana Shawn : [00:10:01] You feel totally dragged down in the daytime. You can't concentrate, and you just don't feel like yourself. That helps the person understand that you're on the same page and they can also correct you if what you understand to be going on is not their experience at all.
Carrol Zhou: [00:10:38] Okay. The next question is about talking about the interview. What else should medical students or residents know?
Dr. Ilana Shawn : [00:10:44] I think one thing to impart on people is to enter the interview with an open stance without expectation, trying to retain a non-judgmental place. The more that the person feels heard and understood, the more they're going to feel able to tell you. There is a balance between being patient-centred and being a diagnostician, and so that's where open-ended questions can enter in. And some of the other techniques I spoke about before. So when you start open-ended, then you still may need to get into specifics and I'll tell the person now I'm going to ask some very specific questions. You said your sleep is poor. What time do you go to bed? What time do you fall asleep? What time do you wake up? Really trying to get at the specifics because we then use that as we're treating the person to get a better sense of what's improving and what still needs ongoing treatment. Remembering Part of our job is to engage the individual and help them feel heard and understood. And then it's also to ensure that we're doing a thorough and accurate diagnostic assessment.
Dr. Lu Gao: [00:11:45] Now, let's go back to Aaron's case. Take a moment and think about what kinds of questions you would ask for on your interview. Pause the podcast and write your questions down or think of some in your head.
Dr. Ilana Shawn : [00:12:06] Here's Dr. Shawn's response there in this case.
Dr. Ilana Shawn : [00:12:09] Firstly, I just want to say, in general, I sometimes think that people in the medical profession will get worse care because we don't do as thorough assessments as we should. We can often assume certain things because we feel we have a certain relationship with the patient from the get go or because we feel like they would obviously tell us. It's really important to do as thorough a diagnostic assessment as you would with anyone else, knowing that in some ways that might be frustrating, in another way that might be really appreciated by the patient. In terms of history, I would do the same thing. I always do assess for symptoms of depression and then symptoms of mania or hypomanic episodes. When I think about comorbid conditions. Definitely anxiety needs to be assessed both because it can be highly comorbid with depression as well as because anxious symptoms can be part of the depressive illness. We would want to think about other conditions that may also be associated like eating disorders. We know that individuals with eating disorders are going to be more likely to experience episodes of depression and also that, again, symptoms of poor appetite or disordered eating may be more common in depression. It can be uncomfortable to do a substance use history, especially on someone that you might feel a different relationship with. At the same time, this is very important. Substance use can be highly associated with mood disorders or may precipitate or worsen than them. You want to think about both illegal drugs as well as over-the-counter medications or prescribed medications.
Dr. Lu Gao: [00:13:45] How was your list of questions compared to hers? Was there anything you may have missed? Let's see what Erin tells you.
Erin: [00:13:53] It started about two months ago. I get tired and sad at the end of the day. I didn't want to do anything at all except eat and sleep. I thought it was just missing my ex. But nowadays I feel terrible. I can barely get out of bed and concentrating at work is impossible. I used to love seeing my patients, but now I don't think I'll ever be a doctor. I can't handle the stress and the sadness. I feel like I'm at the end of my rope. I mean, I don't want to die. I'd never kill myself, but I just don't see any hope for the future.
Dr. Alex Raben: [00:14:32] In addition to the history, you notice that although Erin is well dressed and has impeccable hygiene, her affect is sad and at points tearful what might be called dysthymic. And she has barely looked up throughout the interview. She has also repeatedly put herself down during the interview and seems fixated on her failures. So this is depression. Problem solved, right? Not quite.
Carrol Zhou: [00:15:00] When we think about conditions mimicking depression, we have to think about both conditions that may look like depression and are actually something else, as well as conditions that are associated with depression. Conditions that may mimic depression may be medical conditions like hypothyroidism, multiple sclerosis, obstructive sleep apnoea, all of which may have some similar symptoms or may actually even present as seeming to be depression. There are other conditions, such as in substance use, stimulant withdrawal. Individuals who are using either cocaine or amphetamine can look as if they're depressed when they're in withdrawal. But obviously, if you were to follow that along and get a good substance history, you may start to wonder about other factors or other diagnoses. Additionally, depression could be associated with either a unipolar illness or a bipolar illness and doing a very good assessment of bipolar affective disorder and manic or hypomanic state is going to be very important.
Lucy Chen: [00:15:57] So Erin might be depressed or her low mood may be caused by another disorder or simply a part of normal human experience. We can rule out alternative diagnoses by doing a thorough psychiatric history, which always includes screening for psychosis, anxiety, drug use, current medications, and a past medical history in addition to mood symptoms. Let's look at the differential for depression that Dr. Shawn has laid out in more detail by breaking it down into categories. The main categories are primary psychiatric disorders, including other primary depressive disorders, depressive disorders due to another medical condition, substance or medication induced depressive disorder or normal human emotion and reactions such as grief and bereavement. Let's start by going through the other primary psychiatric disorders, which can be confused as depression.
Lucy Chen: [00:16:51] Of all these disorders. As Dr. Sean mentioned, the most important rule out is bipolar affective disorder or BAD because it requires treatment with mood stabilisers rather than just antidepressants. You may be seeing a patient with bipolar disorder and a depressed episode, and this could be mistaken for unipolar depression if you don't screen for manic and hypomanic episodes in the past. For this reason, the DSM five makes it clear that if a patient has had a manic or hypomanic episode in the past, that was not the result of medication or medical illness, then the more appropriate diagnosis is bipolar in a depressive episode rather than major depressive disorder.
Dr. Lu Gao: [00:17:35] Another primary psychiatric disorder that can be mistaken for depression is adjustment disorder with depressed mood. Difference here is that in adjustment disorder, feelings of low mood and hopelessness will follow a recent stressor and be relieved soon after the stressor resolves. On top of this, the patient will not meet enough MSIGECAPS criteria to be diagnosed with depression. Of course, other depressive disorders will also appear similar to depression. One of these is persistent depressive disorder, or PDD, which was formerly known as dysthymia. A simple way to differentiate between these two disorders. To think of PDD as a milder form of depression that lasts longer, specifically two years or more.
Dr. Alex Raben: [00:18:16] Okay, Let's move on to medical causes of depression. It's difficult to sort out whether or not a disease causes depression. One of the reasons is that depression predisposes patients to developing certain diseases so they'll be more associated. Another reason is that medical illness can cause depression through psychosocial pathways rather than biological mechanisms. That said, there are certain conditions that are generally thought to cause depression through pathophysiological mechanisms. Some of the big ones to consider are neurological conditions, namely stroke, Parkinson's disease, multiple sclerosis and epilepsy. They can also be caused by endocrine disorders. The big ones here are hypothyroidism, Cushing's, Addison's and Hyperlipidaemia. Autoimmune conditions, namely lupus and sleep disorders, namely obstructive sleep apnoea, have also been linked to depression. If the depressive syndrome is truly secondary to an illness, it may be possible to reverse it by treating the underlying condition. When considering depressive syndromes that may be secondary to medical conditions, ordering investigations can also be useful for our assessment.
Dr. Ilana Shawn : [00:19:34] The past medical history might give some information, as well as the constellation of medical symptoms that are generally not explained completely by major depression. A lot of people with major depression may present with somatic symptoms, and in fact, that can be a very common presentation and family practice settings. You want to think about things like family history of a certain medical disorder or having received treatment for a medical disorder in the past and not showing improvement. That would make me think more likely about a depression. Each specific medical disorder has its own constellation of symptoms, of course, so if someone's presenting with profoundly low energy, they're losing their hair, they're cold all the time. Maybe you want to think about investigating for hypothyroidism. Major depression is a diagnosis of exclusion, after all, and medical disorders may be contributory or the etiology of the symptoms. And we need to make sure that we rule these out with investigations.
Dr. Ilana Shawn : [00:20:45] For a well, adult. Generally, the rule is you want to order tests with a specific diagnosis in mind for the example before with hypothyroidism, if the person's presenting with the complaints that we discussed about, that would be a good time to order a TSH. I might order a CBC if an individual is describing profoundly low energy, has had a history of anaemia, maybe also thinking about B12 or folate. If a person has a certain body habitus or tells you about headache in the morning, dry mouth, a history of snoring and maybe apnoea periods that their partner have identified, obviously then you want to think about ordering a sleep study and baseline electrolyte panel to ensure that there are no electrolyte abnormalities.
Dr. Alex Raben: [00:21:28] So to summarise, Dr. Shwan, the basic investigations include CBC Electrolytes, TSH, B12 and Folate, and you can also add a number of other investigations if you have other conditions in mind.
Lucy Chen: [00:21:44] Recreational drug use can also lead to depressive syndromes. A complete psychiatric assessment always screens for recreational drug use, and so this is when you will pick it up.
Dr. Ilana Shawn : [00:21:55] Diagnosing depression in the context of a substance use disorder, what you want to think about is are these symptoms persistent even when the person is not using the substances or are the symptoms significant enough even in the context of the substance use that we can't fully explain them just by virtue of the substance use? In part, we also have to think about the specific substances and the effects those may have on the person, both in terms of intoxication and withdrawal. Certain symptoms are more likely to cause symptoms that may appear like a depressive disorder. As I discussed previously, in terms of amphetamine withdrawal.
Lucy Chen: [00:22:30] Some of the most common substances that cause the depressive symptoms are alcohol as well as cocaine or stimulant withdrawal. If depressive symptoms only occurred in the context of alcohol use, then the correct diagnosis is alcohol induced depressive disorder. In terms of prescription medication. The list of prescription drugs which can cause depressive syndromes varies from textbook to textbook, and a long list can be found in the DSM five. Overall, the literature in this area is not great, but there are few drugs worth mentioning. Antiviral therapies such as interferon, used mainly for hep C and Atripla use for HIV corticosteroids and Alpha- Two adrenergic agonists such as clonidine and methyl dopa have all been shown to cause depressive symptoms. The heavy duty acne medication isotretinoin and the nicotine anti craving medication Varenicline have mixed evidence, with some trials showing an effect and others not. And although classically thought to recent literature suggests that oral contraceptives and beta blockers are not related to depressive symptoms. Finally, it is important to not mistake normal human emotion, just as grief, sadness and bereavement for depression. Some of the differences from depression are that grief and bereavement often come in waves, and the sadness griever has experienced remains in the context of the loss. Patients who are grieving also won't experience the guilt, hopelessness and worthlessness that often comes with depression. If guilt is present, it will again be in the context of some perceived failure in regards to the lost loved one or other life changing situation.
Dr. Ilana Shawn : [00:24:20] There is a tension between overdiagnosis and under diagnosis. We don't want to pathologize what is real human experience. Part of being human is having feelings, and within the diagnosis of depression and the treatment, the goal is not to take away feelings. The goal is to treat the symptoms of depression. So how do we decide what is pathologic and what's a major depressive episode and what is just part of the normal human experience? The major thing we want to look at is the impact on someone's functioning. If you think about having a profound stress like losing your partner, I think it's understandable that you may have sleep loss and appetite loss. Of course, you would feel sad. You may have difficulties with concentration and may even think about if life is worth living. Where you have to think about is can the person regain their functioning? Can they return to work? Can they still have fulfilling relationships and over time learn to enjoy things despite the loss? That's a really important discerning factor that may help us decide if this is a major depressive episode or if this is part of the normal human experience.
Dr. Lu Gao: [00:25:29] So how can we best help Erin? What's the evidence behind each treatment? And is there an algorithm? Find out next time on site where we discuss the various treatment modalities for depression.
Dr. Alex Raben: [00:25:42] This episode of Psych was written and produced by doctors Lucy Chen, Bruce Fage, Alex Raben and Lu Gao, and Carol Zhou. This podcast was made possible by the support from the Department of Psychiatry at the University of Toronto. We'd like to especially thank Dr. Ilana Shwan. Just took a lot of time out of her busy schedule to help prepare for the interview and help us work on the script. Special thanks to our colleagues Dr. Mohamed Attia, Ruxandria Besanu and Candice Kung for their generous contribution and ideas in recording equipment.
Lucy Chen: [00:26:19] Thanks for listening.
Dr. Alex Raben: [00:26:23] Concert.
Lucy Chen: [00:26:25] That's awesome. That's great.
Dr. Lu Gao: [00:26:27] Psyched.
Lucy Chen: [00:26:28] You just got signed. Are you psyched for the next one? I'm totally psyched for the next episode.
Dr. Lu Gao: [00:26:35] Yeah, we'll figure that one.
Lucy Chen: [00:26:36] Yeah, well, we'll figure it out. Okay. See you next time.