SIU School of Medicine

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Department of Internal Medicine

Depression

Rationale

Approximately 30,000 people die each year in the United States from suicide, and of these, sixty percent had a mood disorder. (Gibbons, Hur et al., 2005). Lifetime estimates of the prevalence of mood disorders in the United States are 28.8%, with median age of onset at age 30. Delay in seeking treatment for mood disorders among the 88% of those who seek treatment is 6 to 8 years. (Wang, Bergland, et al., 2005)

Primary care providers deliver up to 70% of the mental health care needs in United States. The treatment of mental illnesses evolved dramatically during the last half of the 20th century. This evolution is in part due to scientific advances in treatment technology such as pharmaceutical innovation, new methods of organizing elements of treatment, and improved approaches to brief psychotherapy (USDHHS, 1999). Despite FDA warnings on the use of antidepressants in children, treatment has demonstrated a reduction in suicide rates and associated morbidity. (Gibbons, Hur, et al., 2005). Primary care physicians’ usual treatment of depression has lagged behind specialty treatment. Uses of algorithm treatments such as the Texas Medication Algorithm Project have demonstrated a means of closing that gap in treatment effect. (Trivedi MH, Rush AJ, Crismon L, et al., 2004)

Prerequisites

Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should include:

  • Understanding of neuroanatomy
  • Understanding of neurophysiology involving
    • Synaptic activity
    • Neurotransmitter production
    • Neurotransmitter inactivation
    • Glial cell function
  • Knowledge of pharmacokinetics and pharmacodynamics
  • Knowledge of classes of antidepressants
    • Mechanisms of action
    • Potential side effects
    • Potential genomics involved in selection
  • Appreciation of the stigma of mental illness and its impact on patients seeking treatment

Knowledge

Students should be able to define, describe and discuss:

  • Current epidemiology of depression in the United States
  • Current treatment modalities for treatment of major depression
  • The role of primary care physician in delivering mental health care
  • How to identify suicidal ideation in a patient
  • When to refer a patient to mental health specialists, when appropriate

Skills

Students should demonstrate specific skills, including:

  • History-Taking Skills: Students should be able to obtain, document, and present an age-appropriate medical history, that differentiates among etiologies of disease including:
    • Onset of symptoms
    • Degree of impairment from symptoms
    • The nine DSM-IV symptoms of depression
    • Use of substances of abuse
    • Symptoms of mania
    • Adherence to prior treatment regimens
  • Physical Exam Skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including:
    • A mental status examination that assesses for suicidality
    • A neurologic examination that assesses for focal findings
    • A general examination that assesses for findings in hypothyroidism
      • Goiter, delayed relaxation phase of DTRs, bradycardia, hair and skin changes
  • Differential Diagnosis:Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology:
    • Bipolar disorder
    • Substance induced mood disorder
    • Adrenal disease
    • Thyroid disease
    • Ovarian failure, including menopause
    • Infectious etiologies
    • Oncologic (pancreatic cancer, brain tumor)
    • Neurologic disease (Wilson’s, Parkinson’s, Multiple sclerosis)
    • Medications creating depressive symptoms
      • Antihypertensives – beta blockers, reserpine, methyl dopa
      • Gastrointestinal agents – metoclopramide, H2 blockers
      • Anti-parkinsonian agents – amantadine, carbidopa
      • Anti-seizure agents – primidone, depakote
      • Chemotherapeutic agents – vincristine, vinblastine, interferon
      • Hormonal agents – corticosteroids, oral contraceptives, progestins
    • Nutritional sources (B12, Thiamine, Folate)

  • Laboratory Interpretation: Students should be able to recommend when to order the following diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences.
    • TSH
    • B12 level
    • Serum or RBC folate levels
    • HIV serology
    • RPR
      Students should be able to define the indications for and interpret (with consultation) the significance of the results of:
    • CNS imaging studie
  • Communication Skills: Students should be able to:
    • communicate the diagnosis, treatment plan, and subsequent follow-up to patients
    • demonstrate empathy during the encounter
  • Management Skills: Students should be able to develop an appropriate evaluation and treatment plan for patients that includes:
    • determining when to obtain consultation from a mental health professional (psychiatrist, psychologist, licensed clinical social worker, licensed clinical professional counselor, or clinical nurse specialist)
    • a cost-effective approach based on the differential diagnosis
    • patient preferences

Attitudes and Professional Behaviors

Students should be able to:

  • recognize the importance of patient preferences when selecting among diagnostic and therapeutic options for depressive disorders
  • respond appropriately to patients who are nonadherent to treatment for depression disorders
  • appreciate the impact depressive disorders have on a patient’s quality of life, well-being, ability to work, and the family
  • recognize the importance of and demonstrate a commitment to the utilization of other healthcare professions in the treatment of depression

Resources

  • Clerkship Seminar, “Depression in Clinical Practice,” D. Resch, MD
  • The Medical Management of Depression, J. John Mann, M.D., N Engl J Med 2005;353:1819-34.
  • Clerkship Website Article, Managing Depression in Medical Outpatients, NEJM 343:26, pp 1942-1950
  • Internal Medicine Clerkship Guide, Paauw, et al, Mosby 2003, pp 435-442, and 487-495
  • Williams, J, Noel, P, Cordes, J, et al. Is This Patient Clinically Depressed? JAMA, 287:9, pp 1160-1170
  • Gibbons RD, Hur K, Bhaumik DK and Mann JJ. (2005) The relationship between antidepressant use and suicide. Archives of General Psychiatry, 62, 165-172.
  • Texas Medication Algorithm Project.
  • Trivedi MH, Rush AJ, Crismon L, et al. (2004)Clinical results for patients with major depressive disorder in the Texas Medication Algorithm Project. Archives of General Psychiatry; 61, 669-680.
  • USDHHS. (1999). Mental Health: A report of the surgeon general. Washington, DC. Government Printing Office.
  • Wang PS, Berglund P, Olfson M, Pincus HA, et al. (2005) Failure of delay and initial treatment contact after first onset of mental disorders in the National Comorbidity Study Replication. Archives of General Psychiatry; 62, 603-613.

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