The patient is a 46-year-old man who is experiencing difficulties at work to which he attributes the symptoms he is experiencing. Presenting symptoms include feelings of depression, difficulty sleeping, loss of appetite, difficulty concentrating, anxiety, and three episodes of panic-attack. The patient's wife is very worried about her husband and reports that their communication is practically non-existent over the past three weeks.
Schema for Diagnosis, Treatment, and Management
New patient procedures include brief intake conversation, taking patient history, screening with appropriate instruments, confirmation of diagnosis, jointly establishing a treatment, and follow-up focused on lifestyle changes and treatment plan extension. The early tasks are to determine if there are any existing medical conditions or substance abuse that would contribute to the patient's symptoms. Fundamental tasks are to consider the clustering of the symptoms and symptom duration, to determine if there have been primary mood episodes at other times in the patient's life, and to provide for subsequent observations following abstinence of any substance believed to be contributing to the depression because of withdrawal or intoxication. Confirmation of the diagnosis may reasonably not occur until some passage of time, following serial evaluations, or sequential treatment trials. A detailed discussion of each element of the schema follows.
Intake and Patient Assessment
In taking the patient's history, two pivotal tasks are to review the patient's family history and to establish if any primary mood episodes have previously occurred.
Intake of caffeine and/or medication. Taking the patient's history will identify any substances that could be impacting the patient's mood. Symptoms such as breathlessness, racing heart, and anxiety could be caused by excessive caffeine intake. Some people find that coffee and other forms of caffeine (e.g., diet cola drinks, energy drinks) can impact moods and even aggravate depression. A review of medications will reveal if any over-the-counter or prescription medications are contributing to the patient's feelings of depression. In addition, it is possible that the patient could have prescriptions from other physicians or psychiatrists that include tranquilizers, sleeping pills, antihistamines, and even narcotics. And it is important to determine if there is any use of recreational drugs or controlled substances, including alcohol, marijuana, amphetamines, "downers," or ecstasy.
The primary goals of the initial session with the patient are to screen for depression. If the patient's scores on an appropriate instrument indicate that he has depression, then further diagnostic measures will be implemented. The objective then becomes to determine if the depression he is experiencing is situational or clinical, and to measure the severity of his depression. Given a choice between the Beck Depression Inventory (BDI-II) and the Center for Epidemiological Studies -Depression Scale (CES-D), the more appropriate choice appears to be the BDI-II (Beck, 1996). Though both instruments discriminate effectively between people with and without major depression, greater specificity is desired -- the BDI is a slightly better measure of specificity than the CES-D (Beck, 1996). In a study of 132 patients experiencing chronic pain, a discriminant function analysis found that an optimal cut-off score for the DBI was 21 and for the CES-D was 27 (Geisser, 1997). These scores are fundamentally comparable, though the CES-D was shown to be somewhat more sensitive at 81.8% than the BDI at 68.2%. On the other hand, specificity scores for the BDI were 78.4% and 72.7% for the CES-D. The BDI-II instrument contains 21 multiple-choice items in a self-report inventory format appropriate for patients aged 13 years and over (Beck, 1996). Each item is scored on a scale of 0 to 3 with higher total scores indicative of more severe depressive symptoms (Beck, 1996). The severity scale is represented as: Minimal depression: a score of 0 to 13; mild depression: a score of 14 to 19; moderate depression: a score of 20 to 28; severe depression: a score of 29 to 63 (Beck, 1996). The reliability of the BDI indicates that confidence in the instrument as a tool for the assessment of depression is well-placed (Richter, et al., 1998; Steer, et al., 1999).The BDI-II: (1) Manifests high internal consistency (?.=91); (2) shows high one-week test-retest reliability (Pearson r = 0.93); (3) shows positive correlation with the Hamilton Depression Rating Scale, and (4) can be separated into subscales for affective and somatic components (Richter, et al., 1998; Steer, et al., 1999).
Patient Assessment -- Diagnosis
Completion of a basic screening process and taking the patient's history provides a basis for confirmation of the suspected diagnosis. One of the important decision points inherent in confirmation of a diagnosis of depression is to determine whether the depressive state is situational or clinical. A second decision point is whether anxiety disorder is co-morbid to the depressive state. The Diagnostic and Statistics Manual 4th edition, Text Revision (DSM-IV-TR) is the foundation for diagnosis of mood disorder (First, et al., 2002). Under mood disorders, the DSM-IV-TR describes mood episodes (which include Major Depressive Episode, Manic Episode, Mixed Episode, and Hypomanic Episode) which are not independently diagnoses and do not have diagnostic codes, but they do serve as a foundation for the disorder diagnosis or diagnoses (First, et al., 2002). Mood Disorders (which include Major Depressive Disorder, Dysthymic Disorder, Bipolar I Disorder) are listed after the mood episodes (First, et al., 2002). It is important to note that the Mood Disorder criteria sets require either the presence or the absence of the mood episodes (First, et al., 2002). The last part of the Mood Disorders section covers the specifiers that describe either a course of recurrent episodes, assuming the patient history manifests more than one mood episode, or the most recent mood episode that is the focus of the patient's complaint (First, et al., 2002).
Given the presenting symptoms, three disorders are considered: Major Depressive Episode, Major Depressive Disorder and Dysthymic Disorder (First, et al., 2002). These three disorder criteria sets are a fair representation of the spectrum of mood disorders that the patient is likely to have experienced (First, et al., 2002). The rationale for delineating these as possible diagnoses is as follows: Assuming the patient and his wife are accurately portraying the patient's problems as a three-week episode, then a diagnosis of mood episode is likely (First, et al., 2002). If the patient has experienced underlying dysthymic disorder -- which is characterized by a lower symptom threshold than for Major Depressive Episode -- and his work situation has deteriorated because of it -- recently coming to a crisis point which is reflected in his present complaints which include anxiety and panic attacks -- then serial evaluations and the passage of time should provide clarity (First, et al., 2002). If the middle ground is the best fit, that, too, should become evident with follow-up (First, et al., 2002).
A Major Depressive Episode requires a "minimum duration of at least two weeks of depressed mood for most of the day, nearly every day (First, et al., 2002).Also, the depressed mood must be accompanied by at least four additional symptoms over the same period" (e.g., weight change, sleep changes, motor activity changes, and suicide ideation) (First, et al., 2002, p. 47).
A diagnosis of Major Depressive Disorder requires the inclusion of two or more major depressive episodes, and the diagnostic criteria are as follows: The patient must report or show evidence of "depressed mood and/or loss of interest or pleasure in life activities for at least two weeks and at least five of the following symptoms that cause clinically significant impairment in social, work, or other important areas of functioning almost every day." The required symptoms include: "(1) Depressed mood most of the day; (2) Diminished interest or pleasure in all or most activities; (3) Significant unintentional weight loss or gain; (4) Insomnia or sleeping too much; (5) Agitation or psychomotor retardation noticed by others; (6) Fatigue or loss of energy; (7) Feelings of worthlessness or excessive guilt; (8) Diminished ability to think or concentrate, or indecisiveness; and, (9) Recurrent thoughts of death" (First, et al., 2002, p. 356).
A diagnosis of Dysthymic Disorder requires the inclusion of two or more major depressive episodes, and the diagnostic criteria are as follows: The patient must report or show evidence of "depressed mood for more days than not, for at least two years and the presence of two or more of the following symptoms that cause clinically significant impairment in social, work, or other important areas of functioning." The required symptoms include: "(1) Poor appetite of overeating; (2) Insomnia or sleeping too much; (3) Low energy or fatigue; (4) Low self-esteem; (5) Poor concentration or difficulty making decisions; (6) Feelings of hopelessness" (First, et al., 2002, p. 380).
Once the diagnosis has been established, the next processes involve the joint establishment of a treatment plan (Rothbaum, et al., 2000). Deep participation from the patient is necessary as treatment includes defining and implementing appropriate lifestyle changes which must be initiated and sustained by the patient (Rothbaum, et al., 2000). For this reason, it is imperative to have a clear idea of…