Depression

Sickle Cell Information Center Guidelines

Edited by James Eckman, M.D. and Allan Platt, PA-C

Depression

Marietta H. Collins, Ph.D. and Nadine J. Kaslow, Ph.D.

Persons diagnosed with chronic medical illnesses, such as the sickle syndromes, may be at risk for depression. The day to day stresses associated with the illness may contribute to feelings of helplessness, a feeling of not being in control, and create a vulnerability to develop depressive symptoms.

Depression should be differentiated from normal mood fluctuations. A major depression or any of the depressive or mood disorders interferes significantly with daily functioning and, if this is suspected, the physician or family member is urged to seek help from the SCD multidisciplinary team, as well as the help of a trained mental health professional. The establishment of a support system of family, friends, community members, and medical and mental health personnel has been found to aid individuals in coping with both depression and sickle cell.

It is important to note that depression looks different at different ages and stages of development. For the young child and adolescent, depression may evidence itself as extreme irritability and anxiety, rather than sadness and melancholy that often is observed in adults. Depression is more common in females than males, and the risk for suicide should not be overlooked.

Clinical Findings

Subjective data

Depressed individuals may have feelings of sadness or irritability, an inability to experience pleasure or have fun, decreased energy, sleep problems (this may include sleeplessness, increased sleep, interruption in normal sleeping patterns), appetite changes (lack of appetite or an increase in appetite), low self-esteem (negative feelings about one's own appearance, intelligence, and personality), feelings of hopelessness and helplessness, social isolation, and suicidal ideas or attempts. These problems may interfere with social relationships and functioning at school or work. Some people who are depressed also may be anxious and worry a lot, and even may experience panic attacks. Alcohol or drug abuse may occur.

Objective data

Depressed individuals also may exhibit significant weight loss or weight gain, and psychomotor retardation or agitation. They often look sad and may neglect their appearance, and may evidence tearfulness and crying spells. They often verbalize a very negative view of themselves, the world, and the future.

Clinical and Laboratory Evaluation

When a person is evaluated for depression, a medical work-up should be conducted to look for underlying organic causes. This should include a complete physical examination..

The laboratory work up for the individual who presents with depression should be designed to rule out various medical conditions that may cause depression. A hematologic profile with differential should be obtained to look for signs of infection or anemia. Thyroid function tests, an electrolyte panel, liver function tests, BUN and creatinine all are indicated to evaluate for potential metabolic abnormalities, such as thyroid and parathyroid disease, renal dysfunction, and kidney disorders. Because depression may be substance induced, a drug screen for commonly abused substances may be indicated. Further, many prescription medications have been associated with depression, including but not limited to corticosteroids, anticonvulsants, and some antibioticsOther tests may include an EEG to look for seizures, and an EEG if a tricyclic antidepressant trial is likely.

Differential Diagnosis:

For details, refer to DSM-IV. This section will only include key criteria for each diagnosis. For all diagnoses discussed, the impairments must not be due to medical illnesses.

1. Major Depressive Episode or Major Depressive Disorder, Single Episode or Recurrent

Specifically, five (or more) of the following symptoms must be present nearly everyday during the same 2-week period and represents a change from previous functioning; at least one of the symptoms is either (1) depressed mood (depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). In children and adolescents, mood can be irritable (2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others); (3) significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day. In children, there may be failure to make expected weight gains; (4) insomnia or hypersomnia; (5) psychomotor agitation or retardation as observed by others; (6) fatigue or loss of energy; (7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional); (8) diminished ability to think or concentrate, or indecisiveness, ( or that life is not worth living); (9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt, or a specific plan for committing suicide.

2. Dysthymic Disorder -

A. Depressed mood during a significant portion of most days, as indicated either by subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.

B. Presence, while depressed, of two (or more) of the following: (1) poor appetite or overeating; (2) insomnia or hypersomnia; (3) low energy or fatigue; (4) low self-esteem; (5) poor concentration or difficulty making decisions; (6) feelings of hopelessness.

C. During the 2 year period (1 year for children and adolescents) of the disturbance, the person never has been without the symptoms in Criteria A or B for more than 2 months at a time.

D. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

3. Adjustment Disorder with Depressed Mood -

A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s) in which the predominant manifestation are symptoms such as depressed mood, tearfulness, or feelings of hopelessness.

B. These symptoms or behaviors are clinically significant as evidenced by either of the following: (1) marked distress that is in excess of what would be expected from exposure to the stressor(s); (2) significant impairment in social or occupational (academic) functioning.

C. Once the stressor or its (consequences) has terminated, the symptoms do not persist for more than an additional 6 months.

4. Generalized Anxiety Disorder -

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

B. The person finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some of the symptoms present for more days than not for the past 6 months): (1) being easily fatigued; (2) restlessness or feeling keyed up or on the edge; (3) difficulty concentrating or mind going blank; (4) irritability; (5) muscle tension; (6) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep); Note: Only 1 item is required in children.

Treatment

The current treatment of choice for depression involves both psychotherapy and pharmaceutical treatment. Cognitive-behavioral therapy is the most efficacious form of therapy for treating depression. Cognitive-behavioral therapy is short-term in nature (approximately 12-20 sessions) and incorporates a self-help and empowerment philosophy. This form of therapy may include techniques as: substituting positive thoughts for negative thoughts, blocking the development of negative thoughts, keeping a journal to chart increase or decreases in depressive symptomology and any associated stimuli, focusing attention to the good, practice in taking credit for the positive, encouragement to set more realistic and attainable goals, less attention to negative self-fault cognitions, and a reward system for elimination or reduction in the occurrence depressive behaviors.

Cognitive-behavioral therapy can be done with just the individual present, or it can include the spouse, or family members. This form of therapy also can be done within therapeutic groups, which is especially useful when addressing depression and interpersonal/relational issues.

There is evidence that exercise can help reduce depression. Also, involvement in supportive organizations, such as the church, also is recommended.

The current medications being used to treat depression are: tricyclics, monoamine oxidase inhibitors (MAOIs), and specific serotonin reuptake inhibitors (SSRIs). Since the SSRIs tend to have the fewest side effects and be very helpful in alleviating depressive symptoms, they have become the medications of choice. Common SSRIs include Prozac, Paxil, Zoloft, and Effexor. Some anti-anxiety medications have been found to work for depression and anxiety, however, many anxiolytic medications are addictive, and thus they must be used with caution.

Prevention

The adaptive coping of stress as relates to both sickle syndromes and other nondisease factors is essential in preventing the development of depression. Such coping would promote the development of a positive pre-disposition or attitude towards life, and include an emphasis on self-esteem, with appropriate rewards and praise, positive attributions for successes and disappointments, and developing feelings of empowerment and of being in control of one's life as opposed to being controlled by external sources. Utilization of the patient's support system also is of primary importance.

Patient and Parent Education

Patients and parents should be encouraged to become educated about depressive symptoms, the possible precipitants of depression, and how to best cope with depression. Information should be available on normal moods and feelings associated with chronic illnesses as the sickle cell syndromes and as well on the appearance of any sequelae suggesting the need to seek professional help. Finally, many self-help books on depression are available at libraries and bookstores today, and patients and family members should be encouraged to seek them out.

References

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition. Washington: American Psychiatric Association.