Updated: 5/18/2019

Depression

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  • A 27-year-old female presents with insomnia of recent onset stating that she has been waking up at 3 am every day.  Upon further questioning the patient admits to feeling excessive fatigue lately and trouble focusing in school and at work.  She also admits that she is no longer interested in high speed cup stacking (sport stacking) her previous life passion. The patient states that she has had a depressed mood lately and that she has thought about suicide at times.
Major Depressive Episode
  • Diagnostic criterion
    • at least 5 of the following 9 symptoms for 2 weeks
      • "SIG E CAPS
        • Sleep disturbance
        • loss of Interest (anhedonia)
        • Guilt or feelings of worthlessness
        • loss of Energy
        • loss of Concentration
        • Appetite/weight changes
        • Psychomotor retardation or agitation
        • Suicidal ideations
        • depressed mood
      • must include depressed mood and anhedonia (inability to enjoy activities)
  • Epidemiology
    • lifetime prevalence
      • 5-12% male
      • 10-25% female
    • increased risk with low socioeconomic status
  • Biochemical changes 
    • ↓ NE, 5-HT, and dopamine 
  • Related disorders
    • major depressive disorder, recurrent
      • >/= 2 major depressive episodes
      • 2 months symptom-free
    • dysthymia 
      • milder form of depression lasting at least 2 years 
      • similar symptoms to major depressive disorder but patient can function
    • seasonal affective disorder
      • associated with winter season
      • improves in response to full-spectrum light exposure
    • atypical depression
      • see below
      • most common subtype of depression
    • bipolar disorder
      • according to the DSM-V manic symptoms can exist leading to a diagnosis with "mixed features"
      • mixed features increases the likelihood that patient's condition exists on a bipolar spectrum
Sleep Patterns of Depressed Patients
  • Depressed patients show characteristic changes in sleep patterns
    • ↓ slow-wave sleep
    • ↓ REM latency
    • ↑ REM early in sleep cycle
    • ↑ total REM sleep
    • repeated nighttime awakenings
    • early-morning awakening
    • improved symptoms with sleep deprivation
Atypical Depression
  • Characterized by
    • hypersomnia
    • overeating
    • leaden paralysis (feeling of heaviness in limbs)
    • mood reactivity
      • i.e., can feel happy when happy events occur, not persistently sad
  • Associated with
    • weight gain
    • sensitivity to rejection
  • Treatment
    • MAO inhibitors
    • SSRIs
      • combining these drugs increases the risk for serotonin syndrome
Electroconvulsive Therapy (ECT)
  • Treatment option for major depressive disorder refractory to other treatment and for pregnant women
  • Produces a painless seizure in an anesthetized patient
  • Major adverse effects
    • disorientation
    • anterograde/retrograde amnesia
      • can be minimized when ECT is performed unilaterally
Grief
  • Normal grief - normally less than 6 months with a cause but normal grief can last up to 1 to 2 years
    • shock
    • denial
    • guilt
    • somatic symptoms
    • may experience hallucinations of deceased person
    • can precipitate a major depressive episode in a vulnerable individual (history of depression, family history)
  • Pathologic grief - persistent and causes functional impairment 
    • excessively intense
    • prolonged
    • absent or inhibited grief
    • delusions
    • hallucinations
  • Considered major depression when
    • suicidal features appear
    • greater than 6 months
    • SIGE CAPS symptoms
Postpartum Depression
  • Postpartum "blues" 
    • considered "normal" 
      • 50-85% incidence
    • depressed affect, tearfulness, fatigue
    • follow up in 2 weeks if does not resolve
    • mother unlikely to hurt baby
  • Postpartum depression
    • 10-15% incidence
    • depressed affect, anxiety, poor concentration
    • lasts 2 weeks to 2 months, then it is considered major depression
    • treat with antidepressants and psychotherapy
    • be watchful - mother may hurt infant though less likely
  • Postpartum psychosis
    • 0.1-0.2% incidence
    • delusions, confusion, unusual behavior, and homicidal/suicidal ideation
    • lasts days to 4-6 weeks
    • treat with antipsychotics, antidepressants, and hospitalization if necessary
    • ensure the baby is protected - highest likelihood mother will hurt baby
 

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Questions (6)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.PY.40) A 28-year-old female reports that, for more days than not over the past 3 years, she has felt "down" and, at times, "mildly depressed." Over this period, she also endorses feeling fatigued, difficulty concentrating, and often sleeping more than in the past. The patient denies any manic or hypomanic periods and also reports that she did not have any periods of extreme worsening of her depressed mood beyond that described above. She also denies any suicidal ideation. What is the minimum amount of time this patient must exhibit these symptoms in order to meet the diagnostic criteria for dysthymia? Review Topic

QID: 100040
1

2 months

4%

(1/24)

2

6 months

12%

(3/24)

3

1 year

8%

(2/24)

4

2 years

75%

(18/24)

5

5 years

0%

(0/24)

M1

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