Depressive disorders are a set of clinical pictures in which the subjective symptom of depressed mood predominates (may not be manifest) and a reduction in interest. They occur in the course of uni- or bipolar (affective) mood disorders, somatic disorders, adjustment disorders caused by conflict or difficult situations, poisoning, adverse effects of medications, other psychiatric disorders such as schizoaffective disorders, postpsychotic depression, mixed depression and anxiety disorders, neurasthenia or withdrawal syndromes.
CLINICAL PICTURE AND DIAGNOSIS
1. The preliminary diagnosis of depressive disorders can be made by asking two questions:
1) Have you frequently experienced sadness, depressiveness or feelings of hopelessness during the last month?
2) Have you frequently experienced in the last month a loss of interest in doing different activities or have you been unable to enjoy them?
A positive answer to one of these questions has a sensitivity of 97% and a specificity of 67% for identifying a depressive episode.
2. Assessing the risk of suicide start the diagnostic process for depressive disorders → above.
3. In the differential diagnosis it is necessary to find out if it is:
1) a depressive episode in the course of recurrent depression or bipolar affective disorder
2) the depressive form of an adjustment disorder
3) dysthymia or cyclothymia
4) affective organic disorders in the course of a somatic illness.
Diagnostic criteria for depressive episode (major depression according to DSM-5)
Depressed mood almost daily (for most of the day), for ≥2 weeks and from a precise and recognizable time, together with the presence of ≥5 of the following symptoms, including ≥1 of the first 2:
1) depressed mood
2) significant decrease in interest in almost all activities and / or in the pleasurable sensations associated with them
3) increased or decreased appetite, or significant loss (not related to diet) or increase in body weight (eg, ≥5% in one month)
4) insomnia or hypersomnia
5) psychomotor agitation or inhibition
6) feeling of fatigue or loss of energy
7) feeling of worthlessness or feeling of unfounded guilt
8) decrease in cognitive dexterity, difficulties in attention or decision-making
9) recurring thoughts of death (not just fears of death)
10) Recurring suicidal thoughts without a certain plan, suicide attempts or a suicidal plan.
The major depressive episode is the most common form of depressive disorders. It occurs in the course of a recurrent unipolar depression or bipolar disorders, in which episodes of mania or hypomania also occur (in which the elevated mood does not cause severe disturbances in the perception of reality and in the decision making with serious consequences). Accurate and correct diagnosis of the depressive episode is of essential importance for long-term treatment. Therefore, in addition to establishing the form of the depressive episode, it is necessary to consider the frequent comorbidity with anxiety disorders, which frequently coexist.
Diagnostic criteria for the depressive form of adjustment disorders, according to DSM-5 (simplified)
1. Dominate: depressed mood, easy crying, feeling of hopelessness.
2. Symptoms:
1) present as a response to stress up to 3 months after its origin
2) considerably exceed the expected reaction to stress
3) significantly impair social and work functioning
4) are maintained ≤6 months after the action of stress ceases.
Adjustment disorders are distinguished from the depressive episode by the close association of the current mood with the causal problem. If the patient can avoid the repeated and painful memory (rumination) about the original causes of the disorder, he may be able to function normally again.
Diagnostic criteria for persistent depressive disorder (dysthymia) according to DSM-5 (simplified)
1. Estado de ánimo deprimido que se mantiene durante casi todo el día y durante la mayoría de los días, en un período de ≥2 años.
2. Se registran ≥2 de los siguientes síntomas: disminución o aumento del apetito; insomnio o hipersomnia; sentimiento de fatiga o falta de energía; baja autoestima; dificultades para tomar decisiones, para concentrarse y para la atención; sentimientos de desesperanza.
3. En un período de 2 años, los síntomas no remiten durante >2 meses seguidos.
El diagnóstico requiere excluir una causa orgánica, así como que se trate de síntomas de una depresión mayor (síntomas crónicos, remisión parcial).
Summary
1. Recordar que la depresión no es una tristeza común ni un síntoma de falta de voluntad o de un carácter débil. El paciente no podrá liberarse de ella “poniéndose las pilas”: hay que aplicar un tratamiento antidepresivo.
2. Escuchar con atención y comprensión al paciente, sin minimizar sus quejas. Se deben tratar muy seriamente las declaraciones del paciente que indiquen ideas o tendencias suicidas y evaluar siempre dicho riesgo →más arriba.
3. Animar al paciente a que intente llevar a cabo actividades que le resultaban placenteras con anterioridad. No mostrar reprobación en el caso de que el paciente no haya podido aprovechar los consejos del médico. Esto indica que aún no se encontraba preparado para acometerlos.