Diagnóstico de Depressão

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Diagnóstico de Depressão

Mensagem  Vinícius Neves em Qua Abr 22, 2015 2:57 pm

Em visita domiciliar, visitamos uma paciente idosa, acamada, diagnosticada com Síndrome de Imobilidade, em acompanhamento com fisioterapia. Família distante, o que parece afetá-la de forma importante – relatava chorar todos os dias. Cuidada por cuidadores vizinhos, conforme disponibilidade, o que lhe causava alguns transtornos, dada sua dificuldade de mobilidade. Em aguardo de uma cirurgia no joelho que, para ela, seria talvez a grande solução para que voltasse a andar. Estivemos em sua casa por duas vezes, em ambas suspeitando de depressão, já que a paciente ficava a maior parte do dia, relatava tristeza e choro diário, além de queda importante em sua qualidade de vida. Aplicamos a Escala de Depressão Geriátrica, que contém 15 perguntas para o caso de, em pontuação maior que 5, indicar suspeição de depressão; o resultado da nossa paciente foi 11.
Segundo o Dynamed, para estabelecer o diagnóstico, devemos obedecer aos seguintes critérios:
• clinical diagnosis based on presence of depressed mood or anhedonia and associated symptoms, usually defined by either DSM-IV or ICD-10 criteria(1)
o DSM-IV criteria - at least 5 of following symptoms (including at least 1 of first 2 core symptoms) present during same 2-week period for most of day or nearly every day
• depressed mood (or irritable mood in children and adolescents)
• significantly decreased interest or pleasure in almost all activities
• significant change in weight or appetite
• insomnia or hypersomnia
• psychomotor agitation or retardation nearly every day (observable by others)
• fatigue or loss of energy
• feelings of worthlessness or excessive or inappropriate guilt
• indecisiveness or decreased ability to concentrate
• recurrent thoughts of death or suicide
o ICD-10 criteria
• symptoms must be present at least 2 weeks
• ≥ 2 of following typical symptoms required
 depressed mood
 loss of interest and enjoyment
 reduced energy and diminished activity
• ≥ 2 of following other symptoms required
 bleak, pessimistic views of the future
 reduced concentration and attention
 reduced self-esteem and self-confidence
 feelings of guilt and unworthiness
 thoughts or acts of self-harm or suicide
 disturbed sleep
 diminished apetite


Como diagnósticos diferenciais, tem-se:
Suicidal ideation:
• depression associated with 4 times higher risk of suicide than general population(2)
• ask patient directly about suicidal ideation and intent(2, 3)
o Do you ever think of hurting yourself or taking your own life? If yes, then ask
o Do you currently have a plan? If yes, then ask
o What is your plan?
• careful and ongoing evaluation of suicide risk is necessary for all patients with major depressive disorder (APA Category I)(4)
o ask about suicidal thoughts, intent, plans, means, and behaviors
o identify specific psychiatric symptoms (for example, psychosis, severe anxiety, substance use) or general medical conditions that may increase likelihood of acting on suicidal ideas
o assess past (especially recent) suicidal behavior
o ask about current stressors and potential protective factors (for example, positive reasons for living, strong social support)
o ask about family history of suicide or mental illness
Bipolar disorder:
• bipolar disorder appears under-recognized in patients being treated for depression
o based on 3 cohort studies
o 1,157 adults aged 18-70 years screened with Mood Disorder Questionnaire (MDQ) in urban general medicine clinic serving low-income population
• 10% prevalence of "positive screening" for lifetime bipolar disorder
• MDQ reported to have 28% sensitivity and 97% specificity in a community sample so would have a low-positive predictive value, that is, positive screen does not mean presence of bipolar disorder, but would be reasonable to consider further evaluation and/or extra warnings and patient education before prescribing antidepressant monotherapy
• 226 patients being treated for major depression
• 53 of 112 patients (47%) with positive screens for bipolar disorder had current depression recorded in medical record with no recording of bipolar disorder, a potential for adverse effects of antidepressant monotherapy
• Reference - JAMA 2005 Feb 23;293(Cool:956 full-text
• 23.5% (53) of 226 patients with current major depression had positive screening for bipolar disorder (Am J Psychiatry 2005 Nov;162(11):2146)
o 649 patients receiving antidepressants for depression screened with MDQ and followed up with Structured Clinical Interview
• 138 (21%) patients had positive screening for bipolar disorder on MDQ
• 65% of MDQ-positive patients had no previous history of bipolar diagnosis
• 86 MDQ-positive and 94 MDQ-negative patients completed Structured Clinical Interview based on DSM-IV
• MDQ had 76% sensitivity, 66% specificity, 52% positive predictive value and 85% negative predictive value for bipolar disorder
• Reference - J Am Board Fam Pract 2005 Jul-Aug;18(4):233 full-text
o 108 patients with anxiety or depression in family practice had semistructured interview by family physician with enhanced training in mood disorders
• 28 (25.9%) diagnosed with bipolar I, II or II disorder or cyclothymia
• Reference - Compr Psychiatry 1997 Mar-Apr;38(2):102
• review of diagnosing bipolar depression can be found in J Am Board Fam Pract 2005 Jul-Aug;18(4):271 full-text
• suggested questions to ask in differential diagnosis of bipolar disorder 1 & 2 vs. major depressive disorders can be found at Center for Quality Assessment and Improvement in Mental Health Toolkit PDF
• see Bipolar disorder or Cyclothymia for more details
Substance abuse disorders:
• Tobacco use disorder

• Alcohol use disorder
• Opiate abuse or dependence
• in alcohol use disorder, waiting 1-2 week after detoxification suggested before diagnosing depression
o based on cohort of 82 alcohol dependent inpatients
o 67% had diagnosis of major depression at time of admission
o only 13% met criteria for major depression after detoxification from alcohol
o Reference - Br J Psychiatry 1995 Feb;166(2):199
Other primary psychiatric conditions:
• other mood disorders
o postpartum depression
o seasonal affective disorder
o dysthymia
• generalized anxiety disorder
Medical conditions:
• hypothyroidism
• Cushing disease

Vinícius Neves

Mensagens : 4
Data de inscrição : 27/03/2015

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