Depression and the
A Lecture and Case Study
Chris L. Place, MD
October 21, 2004
What does the Bible say about depression?
Places for intervention in depression
One of the most ancient and common
diseases of human race Eber’s papyrus
“Now death is to me
Like health to the sick
Like the smell of a lotus
Like the wish of a man to see his house
after year’ of captivity”
Scriptural statements about depression.
A. Use of word "depressed" in NASB
1. II Sam. 13:4 -"Why are you so depressed morning after
2. II Cor. 7:6 - "God, who comforts the depressed, comforted us
by the coming of Titus."
B. Some examples of depression, discouragement, dejection, etc.
1. Job- Job 7:3-11 -without hope, God doesn't care, bitterness
2. Moses - Numb. 11:10-15 - burden; burdensome; suicidal
3. Elijah - I Kings 19 – fearful, suicidal, self-pity
4. David - Ps. 42,43 - soul in despair; disturbed; God has
5. Asaph - Ps. 73 - envious; questions God's sovereignty;
6. Jonah - displeased, angry, suicidal
7. Jesus? - Matt. 26:37; Mk. 14:33 ("desperately depressed")
Greek word ademeneo
means "to be filled, glutted" with anguish, heaviness of heart
and emotional concern.
10 Leading Causes of DALYs in 2020 (Disability adjusted for life years) in the
Both Sexes Males Females
Disease or Injury Disease or Injury Disease or Injury
All Causes All Causes All Causes
1 Ischaemic heart disease Ischaemic heart Unipolar major
2 Unipolar major Road traffic Ischaemic heart
depression accidents disease
3 Road traffic accidents Cerebrovascular Cerebrovascular
4 Cerebrovascular disease Chronic Chronic obstructive
obstructive pulmonary disease
5 Chronic obstructive Unipolar major Road traffic
pulmonary disease depression accidents
Depression as a whole-person illness
(Physical health) Depression Affects
(Mind, Will, Emotions) (Communication, relationship with God)
Four Steps to Success in Depression
•Screening: using and interpreting the PRIME-MD® PHQ-9
as a depression screen in primary care.
•Detection: gathering relevant information from screening,
clinical interview, physical exam, and laboratory tests in order
to make an appropriate diagnosis.
•Diagnosis: evaluating gathered information, applying DSM
criteria for depression, and ruling out other possible diagnoses.
•Treatment: determining what kinds of treatment strategies
to use, when they are appropriate, and how to follow up and
Case Profile: Debra Morgan
The patient, Debra Morgan, is a 32-year-old
female who has scheduled this appointment
with her primary care physician because she
has been experiencing severe fatigue.
A Screening Tool for
• PHQ 9 from Pfizer
•Mirrors DSM-IV criteria
•Many others available
•Just pick one!
Does she have at least 1 of the 2 key items (#1-little
interest or pleasure and #2-depressed mood)
checked at least "more than half the days"?
YES. Both of these items are checked as "nearly
Does she have 5 of the first 9 items checked at least
"more than half the days"?
YES. In addition to the items on loss of pleasure and
on depressed mood, she also checked the items on
sleep, tiredness, and poor appetite (or overeating)
as problems bothering her "nearly every day."
I just don't seem to have any
energy. I feel tired all the time. I have to
drag myself through the day. It's started
to affect my work the past couple of
weeks or so -- I couldn't even make it to
work for 3 days -- I just lie in bed. I
wonder if I'm anemic.
About how long would you say you have been feeling this
level of fatigue? Has it only been in the last couple of weeks?
Right now it seems like I've been tired forever, but I guess it's
a couple of months or so -- maybe a bit longer. But it's been in the
past couple of months that it really seems to be affecting my ability to
do things every day.
I don't see anything in your chart that suggests you've had
this symptom before. Do you remember feeling this way ever
Not that I can think of -- I really don't remember ever feeling
this tired for so long.
It seems from your screening form that you've been
feeling pretty down most days and not getting much pleasure
out of things for at least the last couple of weeks. You also
mentioned feeling somewhat bad about yourself. Can you tell
me more about how often and how long you've been having
Well, I guess I've been feeling bad for a while -- maybe a
few months, and pretty much all the time. I didn't used to feel
this way. I thought it might get better once I started my new
job about a month ago, but it hasn't changed that much,
except that I feel even more tired, and I'm worried about
missing 3 days of work already.
Do you like the work at your new job?
It's fine. I really don't mind it and I'm trying to do a good job, but it
seems hard to just get through the day, and it's hard to focus. I just
can't seem to get as motivated as I used to.
Do you make time to do other things that you enjoy, like exercise or
hobbies or other activities?
I used to, but now I just seem to feel so tired that when I get home
from work I mostly just lie on the couch and watch TV until it's time
What to Ask About Next?
Stress in her life?
You indicated on the screening form that sleep is a problem. Are
you sleeping a lot more or less than usual?
Well, although I feel really tired all the time, I've been waking up
real early and just lying there -- I can't seem to get back to
Are you also having trouble getting to sleep?
It depends. Lately I seem to be having some trouble since I've
been worried about work lately, and the worry seems worse at
night. But usually I can go to sleep OK.
Do you wake up at odd hours during the night?
No, I just seem to wake up way too early, and I can't go back to
sleep even though I feel tired. Then when I get up, I don't feel
rested at all.
You also indicated some problems with your appetite.
How long has this been a problem?
At least a couple of months. I just don't have a good
appetite right now.
Have you noticed any changes in your weight lately?
I must have lost 10 pounds over the past couple of
What do you think this loss of appetite is due to?
I just don't seem to have the energy to cook, and then I
don't seem to feel like eating.
Stressors in her life…
I'm sure that starting a new job has been stressful. Is there
anything else going on in your life, good or bad, that is
causing you additional stress?
Well, I guess my husband hasn't been very supportive about
my new job, and that hasn't helped. And my mom has been
sick recently, and that has been something of a worry,
although she is better now.
Do you have supportive people you can talk to about what
you are going through -- either your husband or other
friends or relatives?
Yes, my husband is a good support in most ways, although
he didn't like the idea of me taking on this new job. I have a
few good friends that I can talk to when I need to. And I do
talk to my sister quite a bit.
I'd like to find out a little about your immediate family.
Has anyone ever been diagnosed with depression,
anxiety, or some mental illness?
No. Well, I think my mother gets really down
sometimes, but she's never been to a doctor about it.
What Next? – Suicidal Thoughts?
It sounds as if things have
been difficult for you lately.
Have you had any thoughts of
harming yourself or that you'd
be better off dead?
Oh no, nothing like that. This
has not been the best year of
my life, but that's not
something that I've thought
about. I keep thinking that the
way I am feeling now is just
What Next? Setting for therapy?
Are you feeling that you can basically cope at this
point and take care of yourself? Or do you feel that
you simply can't manage any activities at all, either at
home or work?
No, right now I'm able to manage and look after
myself -- it's mainly difficult at work.
Appearance NAD; neatly dressed, teary-eyed, appears fatigued.
Vitals P: 75 and regular; BP: 115/75; Resp: 14; T: 97.9; 5' 6", weight
= 128 lbs.
HEENT PERRLA, conjunctiva pink, tympanic membranes clear
bilaterally, oropharanyx without redness or exudates; no
cervical adenopathy, thyroid not enlarged.
Lungs Clear to auscultation bilaterally.
Heart RRR, +S1, +S2, 0 murmur.
Abdomen Nontender, nondistended, bowel sounds throughout, no
Extremities 0 C/C/E, pulses 2+ throughout; 2+ pulses throughout.
Neuro Reflexes, strength, and sensation WNL. Overall grossly
What Do We Know So Far?
The patient's PHQ-9 screen is positive for depression: Debra
indicates on the form that she has 5 of 9 symptoms
characteristic of a major depressive episode (depressed mood,
anhedonia, sleep problems, fatigue, and poor appetite) nearly
every day, and she indicates she has significant functional
Her clinical interview, guided by her screening results, confirms
5 of the 9 symptoms, an absence of family history, and identifies
some current stressors and a good support system.
Debra's chart and physical exam findings are unremarkable
except that she has lost 10 pounds since her last visit, which is
consistent with her report.
Are Debra's depressive symptoms
due to another condition?
At this point the physician must rule out the following:
•Other psychiatric disorders (e.g., bipolar disorder)
•Other medical conditions (e.g., hypothyroidism, diabetes,
•Effect of medications
(adapted from First et al., 2002)
What Would You Do Now?
More lab tests?
Trial of medication?
Offering a referral to a therapist is not the best
option at this point, even though Debra has
indicated she has some psychosocial stressors
in her life. Given that there are still plausible
medical causes for her symptoms, a good option
at this point is to rule in or rule out a medical
condition as a cause of the patient's symptoms.
More lab tests?
•Depression can result from the direct physiological effect of certain
•These include endocrinopathies (e.g., diabetes, hypothyroidism);
cardiovascular disease; nutritional deficiencies; and certain
malignancies, infections, or neurological disorders (AHCPR, 1993).
•Hypothyroidism, including subclinical hypothyroidism and
autoimmune thyroiditis, is a common cause of depression and can
be readily treated, for example, with thyroxine or adjuvant
triiodothyronine (Jackson, 1998; Kierkegaard and Faber, 1998).
•If depressive symptoms are considered secondary to a medical
disorder (as opposed to comorbid), it is advisable to treat the
medical disorder first (AHCPR, 1993).
Trial of Medication?
Starting the patient on a trial of
antidepressant medication might
also be an appropriate option when
the index of suspicion for a possible
medical cause is low, which may be
the case for Debra.
Debra's Lab Results
Urine Pregnancy Negative
WBC: 2.2 K/cu.mm; RBC: 3.6 m/cu. mm; HGB:
14 g/dL; HCT: 42%; MCV: 85 cu. µ; MCH:
30.5 µµg; MCHC: 34.0 µg/dL; Platelets 8
K/cu. mm. ( All values within normal
93 mg/dL ( within normal range of 60-140
Do you think that the patient has major
Debra's final differential diagnosis is as follows:
•Based on the information obtained from her
screening form and clinical interview, Debra has
symptoms that meet the full DSM-IV criteria for a
major depressive episode.
•Based on the clinical interview, physical exam,
and lab tests, Debra does not have evidence of
substance abuse, a general medical condition,
another psychiatric disorder (e.g. bipolar disorder)
or immediate loss or bereavement.
Results of Therapy
Based on a diagnosis of a moderate episode of major depression,
Debra's initial treatment plan proceeded as follows:
•Pharmacotherapy was initiated using venlafaxine (Effexor®) at 37.5
mg twice daily. A follow-up call was made after 1 and 2 weeks to check
on Debra's symptoms, treatment adherence, and whether she was
experiencing any negative side effects.
•Debra was reevaluated after 4 weeks of treatment. Little improvement
in her symptoms was noted, she was experiencing few side effects,
and she reported good adherence to her drug regimen.
•An increase in dosage of Effexor to 75 mg twice daily was initiated.
•Another office appointment was scheduled in 4 weeks to evaluate her
response to the increased dose.
•Debra's symptoms and side effects were monitored by phone weekly
after the change in dose.
Follow-Up With Debra
At the follow-up visit at 8 weeks, Debra's response to the increased
dose of Effexor® should be evaluated.
•If she still has not responded, a further increase in the dose could
be considered, since she has not reached the maximum
recommended therapeutic dose. Although Debra declined
psychotherapy as an initial course of action, it may be advisable to
reconsider this option with her if her depression persists.
•Debra should be evaluated for remission of the depressive
episode at about 12 weeks. If, at that point, she shows a full
remission of depressive symptoms and a return to full functionality,
the same treatment at the same dose should be continued for
another 4 to 9 months. If she does not show a full remission at 12
weeks, it is time to consider augmenting treatment with another
modality, switching to another class of antidepressant, or referring
her for more specialized treatment (AHCPR, 1993b; APA, 2002).
To enhance detection of depression, the US Preventive Services
Task Force (2002) recommends routine depression screening for
all adults in primary care.
The clinical interview should include investigation of the patient's
principal symptoms, history of depression, functional status,
family history, possible psychosocial risk factors, and medication
and supplement use.
The differential diagnosis should consider and rule out general
medical conditions, other mood disorders, psychotic disorders,
substance abuse, and recent bereavement as possible causes of
The physician should educate patients about depression and
include them in deciding on the best course of treatment; both
psychotherapy and drug therapy should be discussed as possible
treatment options (alone or in combination), along with nutrition
Patients should be monitored every week to 2 weeks and reevaluated within 4
to 8 weeks of initiating pharmacotherapy or psychotherapy. Patients given
pharmacotherapy should be monitored for the following:
Achievement of a therapeutic dose
Subjective and objective improvement in symptoms
Adherence to regimen
Patients should be reassessed at approximately 3 months for remission of the
current episode; patients in remission should continue with the same treatment
for 4 to 9 months to minimize the chance of relapse.
To overcome obstacles to successful outcomes
Help patients understand that depression is treatable and neither their fault
nor a weakness
Be prepared to refer patients to good psychotherapists when appropriate
Encourage patients to take their medications even if they don't see
improvement right away
Encourage patients to report side effects of drugs
Increase the dose if there is no response, but do not switch drugs too soon
Places for Intervention in Depression
(Mind, Will, Emotions) (Communication, relationship with God)
Soul (Mind, Will, Emotions)
Prayer (self and others)
Reading or listening to Scripture
(but don’t be depressed…)