What are the symptoms, diagnosis, and treatment options for depression?

Depression: Symptoms, Diagnosis, and Treatment

Clinicians should select between either cognitive behavioral therapy or second-generation antidepressants to treat patients with major depressive disorder after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient. 1

Symptoms of Depression

Depression manifests through various symptoms that affect mood, cognition, and physical well-being:

Core Symptoms

• Depressed mood or loss of pleasure/interest (anhedonia)
• Significant changes in weight or appetite
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or excessive guilt
• Decreased concentration or indecisiveness
• Recurrent thoughts of death or suicide 1

Presentation Variations

• In adolescents: May present primarily as irritability rather than sadness 1
• Common presenting complaints may include fatigue, insomnia, weight changes, or declining academic/work performance 1
• 50-60% of individuals with depression will have comorbid anxiety disorders 1

Diagnosis

Diagnosis requires systematic assessment through multiple approaches:

Diagnostic Criteria

• Symptoms must last at least 2 weeks and affect normal functioning 1
• Five or more symptoms must be present, including at least one core symptom (depressed mood or anhedonia)

Assessment Tools

• Patient Health Questionnaire-9 (PHQ-9): Self-report scale assessing major depressive symptoms 1, 2
• Hamilton Depression Rating Scale (HAM-D): Clinician-administered scale where scores of 7-17 suggest mild depression, 18-24 moderate depression, and ≥25 severe depression 1
• Hospital Anxiety and Depression Scale (HADS): Self-report measure with separate scales for anxiety and depression 1

Assessment Process

• Direct interviews with patients and families/caregivers 1
• Assessment of functional impairment across domains (work/school, home, social) 1
• Screening for comorbid conditions (anxiety, substance use disorders) 1
• Safety assessment for suicidal ideation is mandatory 1
• Screen for bipolar disorder before initiating antidepressant treatment 3, 4, 5

Treatment

Treatment of depression involves three phases: acute (6-12 weeks), continuation (4-9 months), and maintenance (≥1 year) 1.

Pharmacological Treatment

First-line options:

• Second-generation antidepressants (SGAs) including:
  • SSRIs (sertraline, fluoxetine, escitalopram, citalopram)
  • SNRIs (venlafaxine, duloxetine)
  • Others (bupropion, mirtazapine) 1, 2

Medication selection considerations:

• Weight effects: Bupropion promotes weight loss; mirtazapine associated with weight gain; sertraline and fluoxetine generally weight-neutral 2
• Elderly patients: Start with lower doses (sertraline 25-50mg daily, citalopram 10mg daily) 2
• Side effect profiles: Monitor for increased suicidality, especially in young adults (18-24) during initial weeks of treatment 3, 4, 5

Monitoring and follow-up:

• Assess patient status within 1-2 weeks of starting therapy 2
• Evaluate treatment efficacy at approximately 6 weeks 2
• Continue treatment for 4-9 months after satisfactory response for first episode 2
• Consider switching strategies if inadequate response after 6-8 weeks 2

Psychotherapy Options

• Cognitive Behavioral Therapy (CBT): Strong evidence supporting efficacy comparable to antidepressants 1, 2
• Interpersonal Therapy: Effective particularly for more severely depressed patients 6
• Family-Focused Therapy: Particularly important for adolescents 1

Combined Approach

• Combination of CBT and antidepressant medication may provide additional benefits for moderate to severe depression 2
• No significant difference in response or remission rates between combination therapy and SSRI monotherapy, though some evidence suggests improved work functioning with combination therapy 2

Treatment Resistance

• Up to 70% of patients do not achieve remission during initial treatment 2
• Consider switching antidepressants or augmentation strategies (e.g., adding aripiprazole) 7
• For severely impaired patients with treatment resistance, electroconvulsive therapy (ECT) may be considered 2

Safety Considerations

• Suicide risk monitoring: All patients on antidepressants require close monitoring, especially during the first few weeks of treatment 3, 4, 5
• Age-related risks: Increased risk of suicidal thinking in children, adolescents, and young adults (18-24); reduced risk in adults over 65 3, 4, 5
• Warning signs: Monitor for anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, and mania 3
• Establish safety plan: Restrict lethal means, engage concerned third parties, develop emergency communication mechanisms 1

Patient Education

• Educate patients and families about depression, its causes, symptoms, and expected treatment outcomes 1
• Discuss the chronic, potentially recurring nature of depression 1
• Provide clear information about what symptoms warrant immediate medical attention 1
• Explain that medication benefits may take several weeks to appear 2

Depression is a serious but treatable condition that requires systematic assessment and a structured treatment approach. Early identification and appropriate intervention can significantly improve outcomes and quality of life.