At this point
youshould inquire into the patient's sleep patterns, as well as
associatedsymptoms. Also inquire into the patient's appetite, and if he
intended to loseweight.
Your HPI reveals
Mr.Bender has had difficulty sleeping for most of his adult life, but over
thepast 4 weeks has been having more trouble falling asleep and has been
wakingup three to
fourtimes per night.
Hedenies difficulty breathing, coughing or nocturia when he awakens
adecreased appetite over the past "couple of weeks" and his weight
hasunintentionally dropped from 205 pounds (93kg) to 190 pounds (86kg). You
notehis height is 5' 11" (180cm).
Psychomotoragitation or retardation精神運動性の焦燥または制止
The nine symptoms
ofdepression should be thoroughly assessed at this time, which can be
recalledusing the pneumonic *SIG E CAPS.
withsymptoms of depression must be asked, "Are you having any thoughts of
harmingyourself (suicidal ideation)?"
If the response
is"no", the patient should be asked, "If you would have thoughts of
harmingyourself, what would you do?" A patient may agree to contact a friend or
familymember if suicidal thoughts begin -- that friend or family member can
thenassist the patient in getting to his or her physician's office or the
nearestEmergency Room for evaluation. A person could also agree to call their
localCrisis Intervention number if suicidal thoughts begin -- a Crisis
Interventionworker can help arrange for an ambulance to transport the patient
to thenearest ER for evaluation.
patientswho are free of suicidal ideation do not require inpatient
hospitalizationBASED ON their self-harm risk. (Note that other factors may
supporthospitalization, such as poor physical health secondary to depression,
or apsychotic depression.)
If the patient
iscurrently having self-harm thoughts, the severity of suicidal ideation must
beevaluated. Does the patient have intent to harm himself / herself? Is there
aspecific plan of self-harm? Is there a past history of self-harm? Does
thepatient have guns in the home? In patients with suicidal ideation and a
planof action, inpatient psychiatric hospitalization is likely
required.Immediate consultation with an inpatient psychiatrist at the local
hospitalshould be the next step.
statesthat when he was in his 20's he had thought about how things would be if
he"fell asleep and never woke up." However, he clearly states that he has not
hadthose thoughts since that time, presently has no thoughts of harming
himself,presently has no plan of harming himself and will tell his wife or call
thelocal Crisis Intervention number if suicidal ideation begins. You give both
Mr.and Mrs. Bender the number for the local CrisisInterventionCenter.
Comments:Absolutely -- it is critical to document the findings with regard to
suicidalideation. This part of your note may read as follows: "patient denies
suicidalideation and will tell wife or call Crisis Intervention if self-harm
thoughtsbegin; both the patient and his wife given the number for local
CrisisIntervention in DauphinCounty(For other
counties,refer to the blue pages of the phone book). It is a good idea to
include theactual phone number that you give the patient, in the
Up to 15% ofpatients
with severe MDD (i.e., needing to be hospitalized) die from suicide.The risk of
suicide in MDD is 30 times greater than the risk of suicide in thegeneral
PsychiatricHistory and Family Psychiatric History should be obtained when a
diagnosis ofMDD is considered in a patient. Our discussion with Mr. Bender
reveals thefollowing (see case).
disorders:hypothyroidism, hyperthyroidism (particularly in the elderly),
induced:sedatives, hypnotics, antipsychotics, antiepileptics, antiparkinsonian
drugs,antineoplastics, corticosteroids and cardiac medications such as
alcoholand sedative abuse, cocaine and stimulant withdrawal
stroke, Parkinson's disease, Huntingdon's disease, dementingillnesses, multiple
sclerosis, subdural hematoma, brain tumors (particularlyfrontal), epilepsy,
closed head injuries
Other: HIV (highrisk
patients), pancreatic cancer, mononucleosis, systemic
thediagnosis of a MDD, particularly in light of the items included in
thedifferential diagnosis, a physical exam should be performed.
physicalexamination, with a thorough neurological examination, reveals the
following inMr. Bender:
BP130/82, P 74, R 14, T 37C
laboratoryevaluation for MDD includes checking for thyroid dysfunction via a
TSH andT4 level. Other laboratory studies may be considered in light of
additionalfindings during the HPI or on physical exam. Aside from a TSH and T4,
Mr.Bender requires no additional blood work at this time for evaluation of
While a diagnosis
oflung cancer is unlikely in this patient (normal chest exam, negative
pulmonaryROS and explanation of weight loss due to MDD), a chest x-ray may
Both the patient
andhis wife are quite concerned with lung cancer, and a negative CXR may
helpalleviate their fear. More importantly, however, the patient should
becounseled regarding smoking cessation at this and all subsequent clinic
visits.With this heightened fear of cancer, this may be a great opportunity for
thepatient to achieve smoking cessation
lifetimeprevalence of MDD for women has been found to be about 21%. Women are
morelikely than men to develop depression. Women are at increased risk for
mooddisorders at times of hormonal fluctuation: when premenstrual, postpartum,
andperimenopausal, and with infertility. Postpartum depression
ischaracterized by symptoms lasting for 2 weeks and occurring within 4 weeks
ofdelivery. Interestingly, pregnancy does not confer protection
againstdepression, as some might assume.
lifetimeprevalence of MDD for men appears to be as high as 13%. Overall the
prevalencein the general population is about 17%
The goal oftreatment
of MDD is to bring the patient to remission. Remission is the returnto
functional normality, not just feeling better. When evaluated with anassessment
tool, such as the Zung Questionnaire in the office or the HamiltonDepression
Rating Scale (i.e., Ham-D Scale) in clinical trials, the patient nolonger meets
the defined criteria for major depression.
responseto an antidepressant is defined as at least a 50 % improvement, but
notcomplete relief of symptoms. Remission involves a full restoration of
dailyfunctioning (e.g., resumption of hobbies), and the patient can no longer
bedistinguished from the non-depressed patient. This level of improvement,
forduration of 2 months, is required to meet the definition of remission.
Ifremission is reached within three months of MDD onset, studies show
thatpatients are three times LESS likely to go on to have a relapse or
recurrence,for up to two years. Therefore, there is an argument to treat
effectively toreach remission, as well as to treat early on in the course of
responserates for any given antidepressant can be expected to reach 60-70%,
whileremission rates for an individual antidepressant range from 35-45 %. As
such,achieving remission may require using maximal doses of a medication,
oraugmenting one antidepressant with a second one.
Mr. Bender and
hiswife seem agreeable to the treatment plan. You also offer Mr. and Mrs.
Benderreassurance that it is unlikely he has lung cancer, reminding him of the
needto quit smoking to prevent lung cancer in the future. On their way out of
theexamination room, Mr. Bender shakes your hand and says,