DEPRESSION
Depression is highly prevalent and disabling. Community surveys in 14 countries have estimated that the lifetime prevalence of unipolar depressive disorders is 12%, and the World Health Organization ranks major depression as the 11th greatest cause of disability and mortality in the world.
In the United States, major depression ranks second among all diseases and injuries as a cause of disability, and persistent depressive disorder (dysthymia) ranks 20th.
In addition, major depression is highly recurrent. Following recovery from one episode, the estimated rate of recurrence over two years is greater than 40%; after two episodes, the risk of recurrence within five years is approximately 75%.
According to DSM-5 Diagnostic Criteria, major depressive disorder is diagnosed in patients who have suffered at least one major depressive episode and have no history of mania or hypomania. A major depressive episode is a period lasting at least two weeks, with five or more of the following symptoms: depressed mood, anhedonia, insomnia or hypersomnia, change in appetite or weight, psychomotor retardation or agitation, low energy, poor concentration, thoughts of worthlessness or guilt, and recurrent thoughts about death or suicide; at least one of the symptoms must be depressed mood or anhedonia.
If you are having trouble remembering all the important questions to ask your patient who is presenting with depression during your USMLE Step 2 CS patient encounter, then try this Depression Mnemonic – SIG E CAPs Mnemonic for both your USMLE Step 2 CS and when you are practicing in the real world.
Depression Mnemonic SIG E CAPS Mnemonic
PHYSICAL EXAMINATION
NOTE: Always wash your hands or wear gloves before you start physical examination. Make sure to ask for permission before you start each physical exam. Make sure to use proper draping (don’t forget to tie back patient’s gown). Make sure to explain each physical examination in layman’s term to your patient. Do NOT repeat painful maneuvers.
Although the benefit of screening physical examinations in depression has not been demonstrated, it has been suggest for new onset depression (especially if the psychosocial context or precipitant is not clear), severe depression (particularly patients with melancholic or psychotic features), or treatment-resistant depression, as well as patients who have or at risk for chronic medical conditions. More detailed physical examination should be pursued as guided by the history and review of systems.
For the sake of USMLE Step 2 CS, be sure to at least do the following, when you are doing your physical examination and also make sure to document them.
- Assess patient’s general appearance (does patient look disheveled? are they crying? do they make eye contact?)
- Evaluate their hair, skin and their thyroid gland (is the thyroid gland enlarged? are there any thyroid nodules?)
- Look for signs of self-harm or abuse.
- You can ask patient about suicidal or homicidal thoughts and if they have any ‘active’ plan to act on those thoughts.
- Mini-Mental Status Exam (MMSE)
- You may also quickly do Cardiovascular exam & Respiratory exam if time permits.
Depression Mnemonic SIG E CAPS Mnemonic
Depression Mnemonic SIG E CAPS Mnemonic
DIFFERENTIAL DIAGNOSIS
- Major depressive disorder
- Atypical depression
- Adjustment disorder
- Pseudodementia [Click here for forgetfulness/memory loss mnemonic]
- Domestic violence [Click here for domestic violence mnemonic]
- Normal Bereavement
- Schizoaffective disorder [Click here to view mnemonic for psychosis/hallucination]
- Dysthymic disorder
- Cyclothymic disorder
- Bipolar type 1
- Bipolar type 2
- Sleeping problem [Click here for sleeping problems/insomnia mnemonic]
- Erectile dysfunction [Click here for erectile dysfunction mnemonic]
- Dyspareunia (pain during sex)
- Type 2 Diabetes Mellitus , Type 1 Diabetes Mellitus [Click here for diabetes clinic follow up/medication refill mnemonic]
- Cancer
Depression Mnemonic SIG E CAPS Mnemonic
DIAGNOSTIC WORK UP
- Physical Examination as discussed above.
- Creatinine and Blood Urea Nitrogen (BUN): To assess renal function. Not only can kidney disease lead to symptoms similar to depression, but it’s also important for doctors to know if kidney function is impaired before prescribing an antidepressant. When the kidneys aren’t working well, they may not be able to metabolize certain medications properly.
- Liver Function Panel: liver disease can cause symptoms similar to depression, such as lethargy. If patient’s liver isn’t working well, it may be indicative of alcohol misuse, which can co-occur with or lead to depression. Like with the kidneys, it’s also important to know how well the liver is working before prescribing medications, as the organ’s ability to metabolize drugs properly can influence how they work.
- Complete Blood Count (CBC): check for anemia or infection, both of which can lead to fatigue.
- Urine drug screen: to rule out drug abuse.
- Thyroid stimulating hormone (TSH): to rule out thyroid disorder. If the thyroid gland is either under- or overactive, it may result in developing mood symptoms such as depression.
- HbA1C: to rule out diabetes mellitus as a potential cause for depression. Several studies have also indicated that people with diabetes have an increased risk of developing depression. Also remember that most patients with chronic medical conditions suffer from depression.
- Rapid plasma reagin (RPR): to rule out underlying syphilis/neurosyphilis, especially for those patients who have a history of high risk sexual behavior.
- Human Chorionic Gonadotropin (HcG): to rule out pregnancy, especially in women of reproductive age (15-49 years) population.
More extensive testing (eg, vitamin B12, folate, and electrocardiogram) is often indicated for patients who have chronic medical conditions, or are at increased risk for medical illnesses, including elderly or institutionalized patients, and patients with self-neglect or substance use disorders.
- Neuroimaging studies such as Heat CT are typically reserved for patients whose evaluation suggests an increased likelihood of structural brain disease. These include focal neurologic signs on physical examination or persistent cognitive impairment. However, it is reasonable to obtain neuroimaging in older depressed patients, especially patients with new onset depression in later life.
Depression Mnemonic SIG E CAPS Mnemonic
- Crisis Text Line
- International Association for Suicide Prevention (IASP)
- Befrienders Worldwide [offers global resources & hotlines]
- Suicide Prevention Lifeline
- National Alliance on Mental Illness
- The Trevor Project
- YouthSpace [emotional & crisis support chat]
- Veterans Crisis Line
- BEST Tips on how to Pass USMLE Step 2 CS
- Physical Exam Videos
- BLUE SHEET Mnemonic (.pdf file)
- CS Timer
- Official USMLE Step 2 CS Site
- Official Content Description & General Information Booklet (includes the list of abbreviation, you can use on your exam)
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Depression Mnemonic SIG E CAPS Mnemonic