Screening for Depression and Anxiety

Week 3 Psychiatric Screening

Depression and anxiety are the most common psychiatric problems affecting patients in primary care. Data from the National Alliance on Mental Illness (NAMI) places the prevalence of depression among American adults at 7.8 percent (representing 19.4 million people), and that of anxiety disorders at 19.1 percent (representing 48 million people) (NAMI, 2021). This week’s assignment focuses on administering relevant screening tools to detect symptoms of depression and anxiety on the presenting client, a 56-year-old Caucasian female. The Beck Depression Inventory (BDI) was selected to screen for symptoms of depression, while the Generalized Anxiety Disorder (GAD-7) scale was selected to screen for anxiety symptoms.

The BDI is a 21-item questionnaire that assesses the intensity of symptoms associated with psychoanalytic aspects of depression including social withdrawal, suicidal ideas, guilt, feelings of failure and sadness (Park et al., 2020). It measures the severity and frequency of depression symptoms experienced in the past 2 weeks on a 4-point scale. It is one of the most widely studied measures for assessing depression, with well-established psychometric properties (Garcia-Batista et al., 2018). The 21 items are scored from 1 to 3, yielding a maximum score of 63 and a minimum score of zero. Scores between 1 and 10 indicate normal ups and downs, scores of 21 to 30 indicate moderate depression, 31-40 indicate severe depression, and over 40 indicate extreme depression. The BDI was selected not just for its high validity and reliability, but also because it can be used both as a screening tool and as a measure of severity of depressive symptoms (Park et al. 2020). As such, the clinician does not have to administer a different tool to measure the effect of prescribed medication on symptoms at the time of review. Further, the BDI allows for self-rating, allowing the client to regularly measure the progression of their symptoms.

KF’s BDI Score

Question Content

Score

Implication

Rationale

Sadness

I feel sad

The client reports feeling sad mostly in the morning, but snaps out of it as the day progresses

Pessimism

Not present

Sense of failure

As I look back on my life, I see a lot of failures

Client feels like a failure for losing her son’s custody to her abusive husband and not playing an active role in bringing him up

Dissatisfaction

I do not enjoy things the way I used to

She no longer enjoys yoga and meditation

Guilt

I feel guilty most of the time

Reports feeling ‘very’ guilty about divorcing and leaving her son in France

Expectation of punishment

Not present

Self-dislike

I am disappointed in myself

Client is disappointed in herself for leaving her son in France

Self-accusations

I am critical of myself for my weaknesses

Suicidal ideas

I do not have thoughts of killing myself

Crying

Not present

Irritability

Not present

Social withdrawal

I have lost most of my interest in other people

The client tries to engage in at least one social activity weekly, meaning that she has not completely lost her interest in others

Indecisiveness

Not present

Body image change

Not present

Work retardation

I have to push myself hard to do anything

She has difficulty completing work projects and cannot stay focused

Insomnia

I wake up several hours earlier, and cannot go back to sleep

The client has to take pills in order to sleep

Fatigue

I get tired from doing anything

Activities that were previously enjoyable such as attending social events are now really exhausting

Anorexia

I have no appetite at all

Client reports not feeling hungry

Weight loss

I have lost more than 5 pounds

Client reports losing between 4 and 5 pounds of weight.

Somatic preoccupation

Not present

Loss of libido

Not present

The BDI yields a total score of 22, signifying moderate depression (Park et al., 2020). The client was not scored on 8 items including crying, irritability, indecisiveness, body image change, somatic preoccupation, and loss of libido – as there is no specific information that provides answers to these questions. As such, if the client were to avail more information, one would expect the depression score to be even higher.

The GAD-7 scale is a self-administered questionnaire used to check for the presence and severity of anxiety symptoms over the past two weeks (Johnson et al., 2019). It is scored by assigning scores of 0 to 3 to the response categories of ‘not at all’, ‘several days’ ‘nearly every day’ and ‘more than half the day’, and then summing up the scores to obtain the total anxiety score (Johnson et al., 2019). Scores of 5, 10, and 15 are the cutoff points for mild, moderate, and severe anxiety. The GAD-7 was selected for its proven psychometric properties, including specificity of 82 percent and sensitivity of 89 percent of GAD (Johnson et al., 2019). Further, like the BDI, the GAD-7 can be used both as a screening tool and as a measure of severity for anxiety symptoms (Johnson et al., 2019). As such, it provides an invaluable means for not only identifying whether a patient has anxiety, but also assessing the effectiveness of treatment plans (Johnson et al., 2019).

KF’s GAD-7 Scores

Feeling anxious, nervous or on edge – 3

Not being able to control or stop worrying – 2

Worrying too much about different things – 0

Trouble relaxing – 0

Being so restless that it is hard to sit still - 0

Being easily irritable or annoyed – 0

Feeing afraid as if something awful might happen - 0

The client is employed as a full-time consultant and mentions that she cannot stay focused anymore and is unable to complete projects for work. The inability to stay focused was interpreted as a sign of anxiety or nervousness and since she works full-time, the effect is felt nearly every day. However, it is not every day that she is unable to control worrying – at least once a week, she takes part in social events, although she finds these activities really exhausting. She has no means to control the worry the rest of the days, which are more than half the days of the week. The client was not scored on the remaining 5 items because there is no information to support such scoring. As such, her total GAD- 7 score is 5, signifying mild anxiety. The GAD-7 assesses symptoms of anxiety over the past two weeks, implying that the anxiety reported four months earlier, when the client felt nervous about leaving her son in France, cannot be subjected to assessment using this scoring tool.

Evaluation and Treatment for KF

Several laboratory tests could be ordered to determine the patient’s physical health needs. First, a complete blood count (CBC) may be necessary to rule out infections and medical conditions such as anemia, which could be potential causes of the client’s fatigue and mood affects (Tang et al., 2019). Further a TSH may be necessary to rule out hypothyroidism as the cause of the client’s depressive symptoms and poor adherence to activities (Tang et al., 2019). Studies have shown that anxiety in adults could be caused by the presence of life stressors related to finances, work, family, or poor health (Bhui, et al., 2016). For this reason, it may be necessary to carry out lipid assessment and fating glucose (CMP) tests to check for underling chronic conditions such a hyperlipidemia and diabetes, which could also be underlying causes of the depression and anxiety.

Diagnosis and Treatment

KF’s diagnosis based on the BDI and GAD-7 scores would be moderate depression with mild anxiety. Selective Serotonin Reuptake Inhibitors (SSRIs) are the recommended first-line treatments for depression and other conditions such as anxiety disorders (Harmer, Duman & Cowen, 2017). Depression is known to reduce the concentration of serotonin in the brain. SSRIs work by increasing serotonin levels in the brain, thus reducing depressive symptoms (Harmer et al., 2017). Serotonin is one of the neurotransmitters or chemical messengers that carry signals between the post-synaptic and pre-synaptic nerve cells of the brain (neurons) (Harmer et al., 2017). SSRIs’ mode of action involves blocking the reuptake or reabsorption of serotonin into the neurons, thus making more of it available to improve the transmission of messages between neurons (Harmer et al., 2017). SSRIs are referred to by the term ‘selective’ because they only act on serotonin and no other neurotransmitters.

The clinician prescribes Sertraline (Zoloft) tablets to be taken orally twice daily. Sources advise that in selecting the most appropriate SSRIS, the clinician considers the efficacy, cost, and the risk of adverse effects (Cipriani et al., 2018). Although it is slightly costlier than other SSRIs such as Pazil and Prozac, Zoloft has been shown to be more tolerable, with a lower risk of adverse effects (Cipriani et al., 2018). Adverse effects of Zoloft are often mild and include gastrointestinal symptoms such as dyspepsia, nausea, and diarrhea (FDA, 2016). A lower risk of adverse effects is associated with greater adherence to the treatment plan.

KF’s Prescription

Rx: Sertraline (Zoloft) 50mg tablets