As you gear up for the NCLEX, understanding Depression and ‘Depressive Disorders’ is paramount to your success. Let’s dive in.

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In the DSM-5-TR, depressive disorders include the following:
– Major Depressive Disorder
– Disruptive Mood Dysregulation Disorder
– Persistent Depressive Disorder
– Premenstrual Dysphoric Disorder
– Substance/Medication-Induced Disruptive Disorder
– Disruptive Disorder Owing to another Medical Condition
– Other Specified Depressive Disorder
– Unspecified Depressive Disorder

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Major Depressive Disorder

Today and for the remainder of the discussion, we will focus on Major Depressive Disorder. Assessing a patient with major depressive disorder (MDD) involves gathering information about the patient’s symptoms, medical history, and psychological well-being. It typically involves key steps. The Clinical Interview begins with a comprehensive clinical interview to establish rapport and trust with the patient. Explain the purpose of the assessment and ensure that they feel comfortable sharing their thoughts and feelings. Gather a detailed Patient History, including medical, psychiatric, and family history. Inquire about any family history of mood disorders or other mental health conditions.

How do you assess severity of depression in a patient?

Hamilton Depression Rating Scale (HDRS) The HDRS is a widely used clinician-administered assessment tool designed to evaluate the severity of depressive symptoms in individuals with depression. The HDRS was developed by psychiatrist Max Hamilton in 1960 and has gone through various revisions, with the HDRS-17 and HDRS-21 being the most commonly used versions.The HDRS consists of a structured interview conducted by a trained clinician or mental health professional. During the interview, the clinician asks the patient a series of questions and assigns scores based on the patient’s responses. The total score indicates the severity of the patient’s depressive symptoms, with higher scores reflecting greater severity. The HDRS typically covers a range of symptoms associated with depression, including: Depressed Mood: The degree of sadness or low mood. Feelings of Guilt: The presence and severity of guilt or feelings of worthlessness. Suicidal Thoughts: The presence and severity of thoughts of death or suicide. Insomnia: The presence and severity of sleep disturbances, including difficulty falling asleep or staying asleep. Psychomotor Symptoms: The presence and severity of psychomotor agitation or retardation (restlessness or slowed movements). Appetite Changes: The presence and severity of changes in appetite or weight. Anxiety Symptoms: The presence and severity of anxiety symptoms, such as nervousness or tension. Retardation: The degree of slowed thinking and speech. Agitation: The degree of restlessness or physical agitation. General Somatic Symptoms: The presence and severity of general somatic (physical) symptoms associated with depression. Each item is rated on a scale of 0 to 4 or 0 to 2, depending on the version used, with higher scores indicating more severe symptoms. The total score, calculated by summing the scores for each item, provides an overall assessment of the patient’s depression severity. The HDRS is a valuable tool for clinicians to monitor a patient’s progress during treatment and to assess the effectiveness of interventions. However, it’s important to note that it is not a stand-alone diagnostic tool and should be used in conjunction with other clinical assessments and information gathered during a clinical interview. The specific version of the HDRS used, such as HDRS-17 or HDRS-21, may vary among practitioners and research settings, but the core principles and items assessed are consistent across versions. The HDRS is most often administered by trained mental health professionals in a clinical or research context. The HDRS is assessment that rates depression severity on a scale from 0 to 52.

The MADRS is another scale that assesses depression severity. The Montgomery-Åsberg Depression Rating Scale (MADRS) is a clinical assessment tool designed to measure the severity of depressive symptoms in individuals with depression. It was developed by Stuart Montgomery and Marie Åsberg in the late 1970s as an alternative to the Hamilton Depression Rating Scale (HDRS) and is widely used in both clinical and research settings.The MADRS consists of a structured interview conducted by a trained healthcare professional, such as a psychiatrist or psychologist. During the interview, the patient is asked a series of questions to assess their depressive symptoms. The answers are then scored to determine the overall severity of the depression. Like the HDRS, the MADRS evaluates various aspects of depression, including mood, feelings of sadness, anxiety, and other associated symptoms. The MADRS typically assesses the following domains: Apparent sadness Reported sadness Inner tension Reduced sleep Reduced appetite Concentration difficulties Lassitude (lack of physical and mental energy) Inability to feel Pessimistic thoughts Suicidal thoughts Each item is scored on a scale from 0 to 6, with higher scores indicating more severe symptoms. The maximum total score on the MADRS is 60. One key difference between the MADRS and the HDRS is that the MADRS places more emphasis on mood and psychological symptoms, while the HDRS also assesses somatic and physical symptoms. This makes the MADRS particularly useful for assessing changes in the emotional and cognitive aspects of depression. The MADRS is commonly used in clinical trials and research studies to evaluate the effectiveness of various treatments for depression, including medications and psychotherapies. It provides a structured and objective way to measure changes in depressive symptoms over time.

Major Depressive Disorder Symptom Profiling:

Assess the presence and severity of individual depressive symptoms. These may include persistent low mood, loss of interest or pleasure, changes in appetite, sleep disturbances, fatigue, feelings of worthlessness, difficulty concentrating, and thoughts of death or suicide. A more extensive list of symptoms typically indicates greater severity. Functional Impairment: Evaluate the impact of depression on the patient’s daily functioning, such as work, relationships, and self-care. Severe depression often leads to significant functional impairment. Duration and Recurrence: Assess the duration and recurrence of depressive episodes. Longer and more recurrent episodes are often associated with greater severity. Psychosocial Factors: Consider psychosocial factors, such as the presence of significant life stressors or lack of social support, as these can influence the severity of depression. Suicidal Ideation and Risk: Assess the presence and severity of suicidal ideation and the patient’s level of risk. Suicidal thoughts and plans indicate a higher level of severity and require immediate attention. Physical Symptoms: Pay attention to physical symptoms associated with depression, such as changes in appetite and sleep patterns, as well as physical complaints like unexplained pain or fatigue. Cultural and Contextual Factors: Consider cultural and contextual factors that may influence the patient’s experience of depression and their willingness to seek help. Patient’s Self-Report: Listen to the patient’s own perception of their depression severity. They can provide valuable insights into the impact of the condition on their life. Regular Monitoring: For ongoing treatment, it’s important to regularly monitor the patient’s depression severity to assess treatment progress and make any necessary adjustments. Assessing depression severity should be a comprehensive and ongoing process, involving both objective measurements and the patient’s subjective experience. This assessment helps guide treatment decisions and monitor progress throughout the course of therapy or medication.

What are other considerations in assessing a patient with depression?

Differential Diagnosis: Distinguish MDD from other mental health conditions, such as bipolar disorder, generalized anxiety disorder, or medical conditions that can mimic depression. The differential diagnosis of Major Depressive Disorder (MDD), also known as clinical depression, involves distinguishing it from other conditions that may present with similar symptoms. Accurate diagnosis is essential to provide the appropriate treatment and support. Conditions that can be considered in the differential diagnosis of MDD include:

• Bipolar Disorder: Bipolar disorder involves periods of depression (similar to MDD) but also includes manic or hypomanic episodes. Distinguishing between unipolar depression (MDD) and bipolar disorder is crucial, as the treatment approaches are different.Other Depressive Disorders: There are other types of depressive disorders, such as Persistent Depressive Disorder (formerly known as Dysthymic Disorder), which involves chronic, low-grade depression lasting for at least two years.
• Adjustment Disorder: Adjustment disorder is characterized by emotional and behavioral symptoms in response to a specific stressor or life change. Symptoms can mimic depression, but the onset is usually tied to the stressor, and they tend to improve once the stressor is removed.
• Generalized Anxiety Disorder (GAD): GAD can co-occur with depression and may lead to similar symptoms, such as restlessness, fatigue, and difficulty concentrating. However, GAD is primarily characterized by excessive worry and anxiety.
• Substance-Induced Mood Disorder: Substance abuse or withdrawal from certain drugs or alcohol can lead to symptoms of depression. It’s important to evaluate for substance use when diagnosing depression.
• Medical Conditions: Several medical conditions, such as thyroid disorders (hypothyroidism or hyperthyroidism), anemia, infectious diseases, and neurological conditions, can lead to symptoms of depression. A thorough medical evaluation may be necessary to rule out these conditions.
• Personality Disorders: Some personality disorders, such as Borderline Personality Disorder, can lead to mood instability and symptoms that overlap with depression.
• Schizophrenia or Psychotic Disorders: In some cases, depressive symptoms may be associated with psychosis, which can be indicative of a psychotic disorder like Schizophrenia.
• Post-Traumatic Stress Disorder (PTSD): Symptoms of PTSD can include intrusive thoughts, avoidance, emotional numbing, and mood disturbances, which may overlap with depression. A careful assessment can differentiate between the two.
• Premenstrual Dysphoric Disorder (PMDD): PMDD is characterized by severe mood and physical symptoms that occur in the premenstrual phase of the menstrual cycle and can mimic depressive symptoms.
• Somatic Symptom Disorders: Conditions like Somatic Symptom Disorder can lead to the misinterpretation of physical symptoms as evidence of a serious medical condition, which may result in feelings of hopelessness and depression.
• Mood Disorders Due to a Medical Condition: Certain medical conditions (e.g., stroke, brain injury) can directly affect mood and may be misdiagnosed as depression.

To arrive at an accurate diagnosis, consider the patient’s medical and psychiatric history, the presence and duration of symptoms, and any relevant precipitating factors or stressors. This may involve a comprehensive clinical interview, structured diagnostic interviews, self-report questionnaires, and medical evaluations. Differential diagnosis is crucial for tailoring the treatment and ensuring the patient receives appropriate care for their specific condition.

Major Depressive Disorder Psychosocial Assessment

Evaluate the patient’s social and environmental factors that may contribute to or exacerbate depression, such as relationship issues, work-related stressors, or recent life changes. Suicidality Assessment: Assess the patient’s risk of self-harm or suicide. Inquire about suicidal thoughts, plans, intent, and access to means. Assess the level of risk and take appropriate action to ensure the patient’s safety. Psychological Testing: In some cases, psychological assessments or tests may be administered to gain a deeper understanding of the patient’s cognitive and emotional functioning. Psychological diagnostic tests are commonly used in the assessment and evaluation of Major Depressive Disorder (MDD) to help confirm the diagnosis and assess the severity of symptoms. Here are some psychological diagnostic tests and assessments that can be performed to evaluate major depression:

• Patient Health Questionnaire-9 (PHQ-9): The PHQ-9 is a self-report questionnaire that assesses the severity of depressive symptoms. It includes nine items that correspond to the criteria for MDD in the DSM-5. Patients rate the frequency and severity of their symptoms over the past two weeks. Scores range from 0 to 27, with higher scores indicating greater symptom severity.Hamilton Depression Rating Scale (HDRS): The HDRS is a clinician-administered assessment tool used to evaluate the severity of depressive symptoms. It includes a structured interview covering various aspects of depression, and the clinician assigns scores based on the patient’s responses. The total score reflects the severity of depression.Beck Depression Inventory (BDI): The BDI is a self-report questionnaire that assesses the presence and severity of depressive symptoms. It consists of 21 items, each scored on a scale from 0 to 3. The total score indicates the level of depressive symptomatology. Montgomery-Åsberg Depression Rating Scale (MADRS): The MADRS is a clinician-administered scale used to assess the severity of depressive symptoms. It includes 10 items that focus on mood, vegetative symptoms, and cognitive aspects of depression. Scores indicate the level of symptom severity. Zung Self-Rating Depression Scale (SDS): The SDS is a self-report questionnaire that measures the severity of depressive symptoms. It consists of 20 items, and patients rate the frequency and intensity of their symptoms. The total score reflects the level of depressive symptoms.Center for Epidemiologic Studies Depression Scale (CES-D): The CES-D is a self-report assessment that measures the frequency and severity of depressive symptoms in the general population. It includes 20 items, and the total score indicates the level of depressive symptomatology.
• Quick Inventory of Depressive Symptomatology (QIDS): The QIDS is a self-report questionnaire that evaluates the severity of depressive symptoms. It includes 16 items that cover various domains of depression. Scores range from 0 to 27, with higher scores indicating more severe symptoms.
• Children’s Depression Inventory (CDI): The CDI is a self-report questionnaire designed to assess depressive symptoms in children and adolescents. It includes items covering mood, physical symptoms, and interpersonal relationships. Scores reflect the severity of symptoms.
• Geriatric Depression Scale (GDS): The GDS is a self-report questionnaire designed for older adults. It consists of 15 or 30 items and assesses the presence and severity of depressive symptoms specific to the geriatric population.

These psychological diagnostic tests and assessments can be valuable tools for mental health professionals to screen for and assess major depression.

Physical Examination

Perform a general physical examination to rule out medical conditions that may contribute to depressive symptoms. This is especially important if the patient presents with physical complaints, such as unexplained fatigue or changes in appetite. Several medical conditions can mimic the symptoms of Major Depressive Disorder (MDD) and may lead to a misdiagnosis if not properly evaluated. It is essential for healthcare providers to consider and rule out these medical conditions when assessing individuals with depressive symptoms. Some medical conditions that can mimic major depression include: Thyroid Disorders: Both hypothyroidism (underactive thyroid) and hyperthyroidism (overactive thyroid) can lead to mood changes, fatigue, and cognitive disturbances that may mimic depressive symptoms. Anemia: Anemia, especially if it is severe, can result in symptoms such as fatigue, weakness, and pale skin, which may be mistaken for depression. Infectious Diseases: Certain infections, such as mononucleosis, HIV/AIDS, and Lyme disease, can lead to symptoms like fatigue, malaise, and cognitive changes that can resemble depression. Neurological Conditions: Conditions like multiple sclerosis, Parkinson’s disease, and brain injuries may result in mood disturbances, cognitive impairment, and fatigue, which can be confused with depression. Chronic Pain and Chronic Illnesses: Individuals with chronic pain conditions, such as fibromyalgia, may experience depression-like symptoms, including fatigue and changes in sleep patterns. Autoimmune Disorders: Conditions like systemic lupus erythematosus (SLE) and rheumatoid arthritis can lead to fatigue, cognitive changes, and mood symptoms that may mimic depression. Vitamin Deficiencies: Deficiencies in essential nutrients, such as vitamin B12, folate, or vitamin D, can contribute to symptoms resembling depression. Hormonal Changes: Hormonal imbalances, such as in polycystic ovary syndrome (PCOS) or during menopause, can lead to mood changes and other symptoms that may be misinterpreted as depression. Medications and Substance Use: Certain medications and substance use or withdrawal can lead to symptoms resembling depression. For example, alcohol or benzodiazepine withdrawal can cause mood disturbances. Cardiovascular Conditions: Some heart conditions, like congestive heart failure, may result in fatigue and cognitive changes, which can be mistaken for depressive symptoms. Cancer: The diagnosis and treatment of cancer can be accompanied by mood changes, fatigue, and cognitive challenges, which can be misconstrued as depression. Sleep Disorders: Conditions like sleep apnea, insomnia, or hypersomnia can lead to fatigue and changes in mood, which may mimic depression. Other Endocrine Disorders: Conditions like Cushing’s syndrome, Addison’s disease, or diabetes can lead to mood disturbances and fatigue that may resemble depression. Epilepsy: Some individuals with epilepsy may experience mood symptoms, including depressive features, as a result of seizure activity or medication side effects. Chronic Kidney Disease: Individuals with advanced kidney disease may experience mood changes and fatigue due to metabolic imbalances. Pregnancy and Postpartum Conditions: During pregnancy and the postpartum period, some women may experience mood disturbances, including postpartum depression, which can resemble MDD. It is important for healthcare providers to conduct a thorough evaluation and medical workup to rule out underlying medical conditions that may contribute to depressive symptoms. Accurate diagnosis is crucial to ensure that individuals receive appropriate treatment and support for their specific condition, whether it is MDD, a medical condition, or a combination of both.

Laboratory Tests:

Consider ordering blood tests to check for conditions like thyroid dysfunction or anemia, as these can sometimes manifest with depressive symptoms.

Medication and Substance Use Assessment:

Inquire about the use of medications, drugs, or alcohol, as these substances can influence mood and contribute to depressive symptoms.

Treatment Planning:

Based on the assessment findings, collaborate with the patient to develop a personalized treatment plan, which may include psychotherapy, medication, lifestyle changes, or other interventions.

Follow-up and Monitoring:

Establish a plan for follow-up and ongoing assessment to monitor the patient’s progress and adjust the treatment plan as needed. Assessing a patient with Major Depressive Disorder is a comprehensive process that involves not only diagnosing the condition but also understanding the patient’s unique experiences, challenges, and needs. It is crucial to approach this assessment with sensitivity and empathy, and to involve the patient in the treatment planning process to optimize their chances of recovery.